1. SURGEONS ROLE AND INVOLVEMENT IN SBRT PROGRAM Stephen R. Hazelrigg, M.D. Professor and Chair, Cardiothoracic Surgery Southern Illinois University, School of Medicine

2. LUNG CANCER TREATMENT  Early Stage  What we agree upon:  Good risk early stage cancers should have surgery (lobectomy)  Non-surgical patients can benefit from SBRT

3. LOBECTOMY VERSUS SBRT  Hamaji etal. ATS April 2015 Kyoto University Hospital  Retrospective single institutional study  All biopsy proven and PET/CT negative with respect to nodes  413 lobectomies, 104 SBRT  Same mean size (2.5 cm)  Mean follow up 55 months

4. SBRT  Video-Assisted Thoracoscopic Lobectomy Versus Stereotactic Radiotherapy for Stage I Lung Cancer  Hamaji, April 2015

5. LOBECTOMY VS. SBRT  Incidental satellite lesion 2.66%  Node positive with negative clinical evaluation (PET)  N1= 7%  N2= 7%

6. SBRT PROBLEMS  Competitive environment  Expensive equipment  Marketing done to attract patients  Suggestions made that “SBRT may by the choice of treatment even in good risk patients for surgery”  Look on-line at video’s and “ads”.

8. SBRT  Can stereotactic fractionated radiation therapy become the standard of care for early stage non-small cell lung carcinoma  Stereotactic body radiation therapy carries little morbidity and provides local control comparable to lobectomy for early stage NSCLC. Prospective studies should be performed to recruit operable patients for SBRT to determine whether this therapy may be an alternative option for surgery because of low complication risks.

10. LUNG CANCER TREATMENT  Gray Area:  1. High risk patients  2. Lung metastasis  Problems:  1. Who defines high risk  2. Some need for better data/science  3. Lack of accrual in prospective trials

11. SBRT  How do we define recurrence?  Do all patients get tissue diagnosis?  Variables in dose of SBRT and techniques.

16. SBRT  Results worse and complications (hemoptysis, death) higher for deeper more central tumors  Challenges to surgery even for operable early stage lung cancer

18. SBRT PROGRAM/SURGEON INVOLVEMENT  Even many variables for surgery in high risk patients  Arguments about who can tolerate lobectomy  Wedge  +/- radiation (I ¹²⁵, postage stamp)  Segmentectomy  Other modalities (i.e. RFA, etc.)

19. SURGICAL ADVANTAGE  1. Better local control (removes the cancer)  2. Better staging  3. For lobectomy, occasionally resects satellite lesions

20. WHAT SURGEONS WANT  Non-surgical patient (inoperable) can only be decided by a thoracic surgeon  Multidisciplinary clinics and/or conferences  Participate in treatment planning for SBRT (if surgeon wants)  Honest longitudinal follow-up and results  Best treatment for our patients

21. SBRT PROGRAM/SURGEON INVOLVEMENT  “All politics are local”  Who controls referrals  Who sees pulmonary nodules  Relationship with radiation therapy  Ability to offer minimally invasive surgery with good results

23. OUR APPROACH  1. Try to maximize our exposure to lung cancer patients early.  Run pulmonary nodule clinics  Work-up all patients including their diagnostic studies  2. Establish good relationships with our radiation therapy colleagues  3. Offer excellent surgical results  VATS procedure  Careful follow-up  4. Multidisciplinary clinics  5. Multidisciplinary conferences  Discuss difficult patients  Intermittently evaluate results for surgery and SBRT  6. Patients deemed unfit for surgery are evaluated by a surgeon