Mark G. Kris, MD; Egbert Smit, MD, PhD


June 17, 2013

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Mark G. Kris, MD: Hello. I am Mark Kris, Chief of the Thoracic Oncology Service at Memorial Sloan-Kettering Cancer Center in New York, New York. I would like to welcome you to this edition of Medscape Oncology Insights. Today we will discuss key studies on lung cancer that caught our interest at this year's meeting of the American Society of Clinical Oncology (ASCO®) here in Chicago. Joining me today is Dr. Egbert Smit, Professor of Pulmonary Medicine at the Free University (Vrije Universiteit) Medical Center in Amsterdam, The Netherlands. Welcome.

Egbert Smit, MD, PhD: Thank you.

Dr. Kris: We look forward to hearing your opinions today, first as a lung cancer expert, but also about the differences between practice [in Europe and the United States] and what you have learned here at ASCO that might influence you. I will begin with what caught your interest. What did you think of as new information that you heard?

SBRT or Surgery for Early Disease?

Dr. Smit: Two totally unrelated subjects struck me the most. The first was an analysis[1] from the Lung Cancer Mutational Consortium (LCMC) of patients who tested positive for a target that was actionable, and were either treated or untreated. That study provided the last piece of information from a bigger cohort of patients in whom you showed[2] that patients who were treated according to their target lived longer than patients who did not receive targeted treatment. That is a very important piece of information -- for us in Europe as well, because we are a little bit behind you [in the use of targeted therapies].

The second thing that struck me was a report on very early disease. In my country, for patients with stage IA disease (small nodes with no lymph node metastases), we have a strong tradition in stereotactic radiotherapy (high-dose radiotherapy). Two abstracts were presented in a poster discussion session. One was from Timmerman and colleagues,[3] who showed that in patients with operable disease, the local control rate was in excess of 90%. The other was a second abstract in the same section about local recurrences after sublobar resections.[4]

Dr. Kris: The stage IA patients were treated with stereotactic body radiation therapy (SBRT), although these patients don't typically undergo SBRT, right?

Dr. Smit: They received SBRT in the context of study. Here in the United States, you do surgery. We do surgery as well, but we try to avoid surgery if we reasonably can. With small nodules, removing a whole lobe -- especially in younger people who are at risk for secondary lung cancers -- might not be a good idea, but we need randomized trials.

Dr. Kris: We share the same idea, however, as we have learned from other forms of cancer that doing a traditional cancer operation may not be necessary. When we are curing more people, we have to think more about the long-term consequences, and sparing the lung will ensure a quicker recovery and, frankly, more normal life for years to come.

Dr. Smit: It was a pity that in our study in The Netherlands, when we had the phase 3 study planned comparing SBRT with surgery,[5] the study was closed for slow accrual, and that also happened here in the United States. It was a pity for our patients.

Dr. Kris: Are you thinking of trying it again now that stereotactic radiation is more accepted?

Dr. Smit: It would be worthwhile to try that study again.

Dr. Kris: Do you see a different spectrum of toxicities? I was a little struck at the lung cancer meeting in Amsterdam where a high incidence of rib fractures , roughly 30%, was reported.

Dr. Smit: I didn't see that figure, but in our experience when the tumors are close to ribs, fracture is a risk, that's true, but not as high as 30%.


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