Managing lung cancer in high-risk patients: what to consider

Abstract

Lung cancer patients with medical comorbidity are a challenge for care providers. As with other solid tumors, treatment is stage dependent; but a critical difference is the invasive nature of lung resections and the resulting importance of surgical risk stratification for treatment of early stage disease. External beam radiation was considered the only treatment option for early stage disease in non-operative candidates 10–15 years ago. With recent advances in image-guided technologies, robotics, and the resurgence in interest of sublobar resection there are now numerous treatment options which offer excellent local control and reasonable short and long term survival. Extensive work has been done to clarify interventional risk, and accurately describe anticipated outcomes of these varied treatments in the high risk population. The aim of this article is to review recent literature and provide a better understanding of the considerations used in the management of these patients in the current era.

Keywords::

• high risk
• minimally invasive surgery
• non-small cell lung cancer
• radiofrequency ablation
• stereotactic radiotherapy
• sublobar resection

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Treatment of choice for Stage I non small cell lung cancer (NSCLC) in 2014 remains lobectomy with systematic mediastinal lymph node evaluation, while mortality for this is low (1–2%), many patients with severe medical comorbidity are poor candidates for this procedure.

• FEV1 and DLCO inversely correlate with risk for pulmonary complications and are the primary tools for risk assessment for lung resection.

• Sublobar resection by either large wedge or segmentectomy is a surgical option for many patients with inadequate pulmonary reserve for lobectomy. In well-selected patients with small peripheral NSCLC, survival and local control after sublobar resection is similar to lobectomy.

• Minimally invasive approaches to lung resection significantly reduce morbidity and mortality compared with thoracotomy in high-risk patients. Guidelines for risk assessment for minimally invasive resections are not currently available.

• Numerous image-guided modalities for NSCLC treatment have emerged and have the advantage of generally being performed as outpatients without general anesthesia and have less procedural risk and pain, shorter recovery and faster return to normal function than resection.

• Stereotactic body radiation therapy is a form of highly precise radiation therapy in which it delivers an ablative dose of radiation in a small number of fractions. Primary tumor control is reported as high as 98% in prospective Phase II evaluation.

• Radiofrequency ablation is a percutaneous image-guided therapy that destroys tumor tissue with heat. It appears to be safe and efficacious, but long-term results are limited.

• Head-to-head prospective comparisons between treatment modalities in high-risk patients with NSCLC have proven to be very challenging. Treatment decisions are individualized and based on patient preference, extent of comorbid disease, tumor size and location and expertise of the treating physicians.