1. Advances in Lung Cancer Treatment Stereotactic Radiotherapy
Pre-Planning Meeting - May 27, 2014
Drew Moghanaki, MD, MPH
Hunter Holmes McGuire Veterans Affairs Medical Center
Director of Clinical Radiation Oncology Research
VCU Massey Cancer Center
Associate Professor
Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

2. This talk does not represent the views of the VA, or the US Government
Disclosures
Research Funding
VA Cooperative Studies Program
Bristol Myers Squibb Foundation
Honoraria & Travel Support
Varian Medical Systems
This talk does not represent the views of the VA, or the US Government
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

3. Introduction

4. Today’s Standard of Care
Operable
Surgery
Borderline
Operable
Less Surgery
Medically
Inoperable
Stereotactic Radiotherapy
Non-Small Cell Lung Cancer
Stage I
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

5. Surgical Outcomes Rely on Size
Pathological Group Stage
0-10 mm = Stage IA1 (n=1486)
11-20 mm = Stage IA2 (n=6348)
21-30 mm = Stage IA3 (n=5415)
31-40 mm = Stage IB (n=8906)
41-50 mm = Stage IIA (n=2631)
Overall Survival
Goldstraw, J Thor Oncol 2015
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

6. Advances in Surgery - VATS
Randomized data vs Open Thoracotomy
Reduced operative time
Reduced perioperative blood loss
Reduced postoperative air leaks
Shorter duration of epidural anesthesia
Shorter hospital stay
Less postoperative pain
Improved quality of life
No improvements in long-term survival
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

7. Importance of Surgical Expertise
30-Day Mortality Rates
Depends on patient selection, range from <1% to 29%
Specialization
25% = board certified w/ focus on thoracic surgery
45% = board certified w/ focus on cardiac surgery
25% = general surgeons
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

8. Postoperative Mortality – Remains a Problem
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017
Senthi & Senan, Eur J Cancer 2014

9. Elderly Patients Concerns Limited physiological capacity to heal
Impaired vision and hearing
Urinary incontinence, falls, depression, poor baseline nutrition
Cognitive disorders such as dementia and delirium.
Recovery is occasionally prolonged, can take up to months
Discharges frequently to skilled nursing facilities
Mortality rates 4x in patients ≥75 years (5.3% v 1.3%, p<0.01).
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

10. Dilemma of Developing More Lung Cancers
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

11. Treatment Options for Early Stage NSCLC
Minimally Invasive Surgery
Minimally Invasive Radiotherapy
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

12. Stereotactic Radiotherapy

13. Conventional Radiation Stereotactic Radiotherapy
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

14. This is “large field” radiotherapy
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

15. Phase I - A Serendipitous Finding
Indiana University
Indianapolis VA Medical Center
It’s been >20 years since SBRT
The findings surprised everyone
MADE POSSIBLE: NCI, enrolled pts at VA
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017
Timmerman, Chest 2003

16. Confirmatory Findings - Dutch Series
LC rates reproduced around world
REPRODUCED with many LINACS
Fueled ENTHUSIASM in Radonc field
Figures courtesy of BJ Slotman
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

17. Post-Treatment Scanxiety & Potential Harms
18 Gy x 3
6 mo
12 mo
15 mo
Could lead to harms
MD Anderson series
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

18. Matched Comparisons Matched 251 Matched 6,295 SEER NCDB
Shirvani, JAMA Surgery 2014
Yerokun, JCTS 2017
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

19. Screened Population Buckstein , J Radiat Oncol 2014
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

20. Graveyard of Randomized Trials
Surgeon
Surgery
Pulmonologist
RadOnc
SBRT
ROSEL; NCT Randomized 22 of 960
STARS: NCT Randomized 36 of 420
RTOG: NCT Randomized 10 of 420
2012-?? Mayo Trial: NCT Randomized 0 of 96
SABRTooth: NCT Randomized 23 of 54
TOTAL Randomized 91 of 1,950 = 4.6%
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

21. The Pooled Randomized Trials
/1480 (4%)
J Chang, Lancet Oncology 2015
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

22. Yet, preferences are shifting anyway
Surgery
Radiation
SEER, Stage IA (n=32,000)
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017
Haque, AJCO 2016

23. Surgery is the standard of care if operative mortality rate <1.5%
Treatment without biopsy can be considered
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

24. Active Randomized Trials for Operable Stage I
Surgery
SBRT?
VALOR (n=670)
Borderline
Operable
STABLE-MATES (n=258)
Less Surgery
SBRT?
RTOG 3502 (n=76)
Medically
Inoperable
SBRT
Drew Moghanaki | Cancer Action Collation of Virginia | Richmond – Sept 14, 2017

25. Veterans Affairs Lung Cancer Surgery or Stereotactic Radiotherapy Trial
Surgeon
Surgery
Pulmonologist
R A N D O M I Z E
OVERALL SURVIVAL
N=670
Positive Bx
Clinical IA v IB
Central v Peripheral
SECONDARY ENDPOINTS: pt-reported QOL, changes in PFTs
PROSPECTIVELY CAPTURING
Patterns of failure with uniform def’n
Type & tolerance of secondary treatments (2nd MALIGNANCY)
Cause of death
SBRT
RadOnc

26. Take Home Points
Surgery remains a great option for early stage lung cancer
“Surgery for all” is a fading paradigm
Stereotactic radiotherapy can be considered without biopsy
Post radiotherapy scanxiety can be a problem
Salvage surgeries appear safe

27. Questions
@DrewMoghanaki