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MTE 16 - Technical Issues after Neoadjuvant Chemoradiation - Surgeon's Perspective (Sign Up Required) (ID 565)
- Event: WCLC 2017
- Type: Meet the Expert
- Track: Surgery
- Presentations: 1
- Moderators:
- Coordinates: 10/17/2017, 07:00 - 08:00, Room 311 + 312
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MTE 16.01 - Difficulties of Surgery After Induction of Chemoradiotherapy (ID 7797)
07:00 - 07:30 | Presenting Author(s): Eric Vallieres
- Abstract
- Presentation
Abstract:
Difficulties of surgery after induction chemoradiotherapy (CRT) Surgery after induction therapy can be very challenging. From my own observations, this may particularly be an issue when the patient had nodal involvement at presentation and experienced a good response to the induction treatment (induction CRT or even induction C alone) where fibrosis of the responding lymph nodes may make the hilar vascular mobilization more difficult. The following lines will describe some tips on how to minimize the risks of such resections. Preoperatively: One should always take advantage of the induction therapy period (12 weeks or more) to achieve absolute smoking cessation in these patients. After induction therapy, one should obtain a fresh set of PFTs including a DCO measurement as both radiation and some of the induction chemotherapy agents may have caused significant pneumonitis with resulting altered lung function. If there is a possibility that a pneumonectomy will be required, prepare yourself. (QVQ, stress echo). Radiation esophagitis may have brought some nutritional issues, consider an alimentary “boost” when a significant weight loss has occurred during the induction phase of therapy. If there may be a risk that the SVC will be clamped, repaired or replaced, discontinue the port-o-cath preoperatively. Finally, make sure to review all imaging, particularly the pre-induction therapy CT. Surgery Personally, I approach these cases via open thoracotomy, though some have reported successful resections on MIS platforms. All patients get an epidural catheter preop. If one anticipates, issues with the SVC with a R upper lobar resection, get infra diaphragmatic IV access preop. Emphasize w anesthesia, in the preoperative area, the absolute need to keep these patients dry: an irradiated mediastinum cannot handle excess fluid. At entry, I prepare/ harvest the intercostal muscle, without dividing it. (I now keep the omentum for “later”, if needed to manage for a complication, and spare the serratus anterior in all cases). If accessible, I usually clear zone 7 first, with frozen section read. (The frozen section information/ feedback during this type of surgery can be very useful to have when one gets into a tough surgical corner…) If one is attempting a lobectomy and anticipates possible difficulties in the hilum, one should consider obtaining early circumferential control of the main veins and main PA (if possible), and even do so intrapericardially if needed. Similarly, early division of the azygos vein on the right, may help when one anticipates difficulties accessing the main R PA and surrounding structures. One may have to alter their “routine” sequence of dividing the central structures. With both upper lobes, when bulky fibrotic changes are present in the suprahilar areas, proceeding retrograde, from the fissures up is often very helpful. As well, dividing open the upper lobe bronchi from the back can help access and control the often fibrosed and foreshortened proximal lobar PA branches. On the left, I will identify the vagus nerve low down, away from the fibrotic field and follow it up into the AP window to minimize the risks of inadvertently injuring the recurrent nerve. During the case, I constantly remind anesthesia to keep these patients dry. For pneumonectomies, we give a steroid bolus before dividing the main PA , similarly we initiate amiodorone prophylaxis by infusion. In a R pneumonectomy, when we have stapled the bronchial stump, I add an additional non resorbable monofilament stitch to reinforce both ends of the bronchial stapled line. Finally, we cover all of our bronchial stumps with the IC muscle flap. POSTOP Remember to keep the patient dry. We give amidorone prophylaxis for 72 hours after pneumonectomies’ or other patients considered at elevated risk of going into atrial fibrillation post op. Beware of possible left vocal cord palsy after L pneumonectomy and left upper lobectomy: we keep these patients NPO until we are confident that their cords are OK. If there are any concerns, we get an immediate laryngoscopy. If the left cord is found to be paretic, we immediately get VC medialization (not negotiable)
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P1.05 - Early Stage NSCLC (ID 691)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Early Stage NSCLC
- Presentations: 1
- Moderators:
- Coordinates: 10/16/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P1.05-012 - Treatment Planning in Non-Small Cell Lung Cancer Shows Variable Utilization of Multidisciplinary Tumor Board (ID 10115)
09:30 - 09:30 | Author(s): Eric Vallieres
- Abstract
Background:
With competing treatment options for early stage non-small cell lung cancer (NSCLC), and controversies over patient selection and management of later stage disease, multidisciplinary tumor board (MDTB) is a critical decision-making forum for management plans. Studies encompassing several cancer domains have shown the benefit of MDTBs on operative mortality, 5-year survival, and patient satisfaction. We aimed to determine the timing and utilization of MDTBs, relative to the initiation of treatment, for patients with NSCLC within a large community healthcare system.
Method:
We reviewed cI-III patients who underwent work-up for primary NSCLC during 6/2013-6/2015 in a hospital network of 7 institutions. This network offers mature multidisciplinary care with dedicated thoracic oncologic services collaborating for formal, weekly MDTBs. Only patients who underwent oncologic treatment were included, and were stratified based on initial treatment type: surgical versus chemotherapy (CHT) and/or radiation therapy (RT). Stage was defined as clinical stage established prior to MDTB, or treatment initiation.
Result:
We identified 203 patients; the figure depicts MDTB timing and utilization stratified by stage for each initial treatment type. Sixty seven percent (24/36) of cI patients did not have a MDTB prior to receiving stereotactic ablative radiotherapy (SABR). In addition, 33% (2/6) of the cIII patients did not receive a MDTB prior to surgical resection. Figure 1
Conclusion:
Variable utilization of MDTB was demonstrated for all clinical stages of NSCLC. In cI NSCLC where competing treatment options of surgery and SABR exist, less than half of the patients received multidisciplinary discussion. MDTB was also underutilized in cIII where treatment controversy exists. Although time constraints, referral patterns and provider bias challenge clinical practice, greater study and quality initiatives are necessary to ensure patients have access to MDTB discussion in the rapidly evolving landscape of NSCLC care.
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P1.10 - Nursing/Palliative Care/Ethics (ID 696)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Nursing/Palliative Care/Ethics
- Presentations: 1
- Moderators:
- Coordinates: 10/16/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P1.10-008 - Palliative Care and Hospice Resources are Underutilized in Patients with Advanced Non-Small Cell Lung Cancer (ID 8656)
09:30 - 09:30 | Author(s): Eric Vallieres
- Abstract
Background:
The 2010 Temel et al. paper demonstrated a survival benefit from early implementation of palliative care (PC) in stage IV non-small cell lung cancer (NSCLC). Since this finding, medical systems have struggled with the adoption of clinical services for patients with advanced NSCLC, including PC and hospice resources for patients at the end of life. We aimed to document the utilization of PC and hospice resources in NSCLC patients within a large community healthcare system.
Method:
We reviewed a total of 406 stage cI-IV patients who were diagnosed and managed for primary NSCLC during 6/2013-6/2015, in a hospital network of 7 institutions with dedicated PC services. Patients were initially categorized according to the decision to undergo oncologic treatment (therapeutic or palliative) or to receive no oncologic treatment. Patients were further stratified into those who received PC consultation, those referred to hospice (without PC consultation), or those who received neither based on clinical stage.
Result:
We identified 182 stage cIV patients, of which 16% (30/182) received a PC consultation, 39% (71/182) were referred to hospice, and 45% (81/182) received neither. Of the stage cIV patients, those who received oncologic treatment were less likely to receive PC or hospice services (51%, 78/154) than patients without treatment (82%, 23/28); p=0.002 (figure). The figure also demonstrates services utilized by patients of all stages that were ineligible/refused oncologic treatment (48/406). Figure 1
Conclusion:
PC and hospice services were underutilized in patients with advanced disease, and in those likely to reap benefit from these resources. In addition, stage IV patients receiving oncologic treatment were less likely to receive PC or hospice services than patients undergoing no oncologic treatment. Quality improvement interventions and referral triggers targeting the implementation of PC and hospice services early in patient management are needed to meet patient’s global oncologic needs.
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P2.04 - Clinical Design, Statistics and Clinical Trials (ID 705)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Clinical Design, Statistics and Clinical Trials
- Presentations: 1
- Moderators:
- Coordinates: 10/17/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P2.04-004 - IMpower010: A Phase III Study of Atezolizumab vs Best Supportive Care Following Adjuvant Chemotherapy in Completely Resected NSCLC (ID 8896)
09:30 - 09:30 | Author(s): Eric Vallieres
- Abstract
Background:
Atezolizumab is an anti–PD-L1 mAb that blocks PD-L1 from interacting with its receptors PD-1 and B7.1 and restores anti-cancer immunity. In patients with 2L/3L advanced NSCLC, the OAK trial showed improved mOS in the atezolizumab arm (13.8 mo) vs the docetaxel arm (9.6 mo), with survival benefit observed across all PD-L1 expression levels on tumor cells (TC) or tumor-infiltrating immune cells (IC). In patients with fully resected NSCLC (stages IB [tumors ≥ 4 cm]-IIIA), adjuvant chemotherapy remains the standard of care, but survival benefit is limited. Therefore, more effective therapies are still needed for patients with early-stage NSCLC. IMpower010 (NCT02486718) is a global Phase III, randomized, open-label trial conducted to evaluate the efficacy and safety of atezolizumab vs best supportive care (BSC) following adjuvant cisplatin–based chemotherapy in patients with resected stage IB (tumors ≥ 4 cm)-IIIA NSCLC.
Method:
Eligibility criteria include complete tumor resection 4-12 weeks prior to enrollment for pathological stage IB (tumors ≥ 4 cm)-IIIA NSCLC, adequate recovery from surgery, ability to receive cisplatin-based adjuvant chemotherapy and ECOG PS 0-1. Patients with other malignancies, autoimmune disease, hormonal cancer or radiation therapy within 5 years and prior chemotherapy or immunotherapy will be excluded. Approximately 1127 patients will be enrolled regardless of PD-L1 status. Patients will receive up to four 21-day cycles of cisplatin-based chemotherapy (cisplatin [75 mg/m[2] IV, day 1] + vinorelbine [30 mg/m[2] IV, days 1, 8], docetaxel [75 mg/m[2] IV, day 1] or gemcitabine [1250 mg/m[2] IV, days 1, 8], or pemetrexed [500 mg/m[2] IV, day 1; only non-squamous NSCLC]). Adjuvant radiation therapy is not permitted. Eligible patients will be randomized 1:1 to receive 16 cycles of atezolizumab 1200 mg q3w or BSC post-adjuvant chemotherapy. Stratification factors include sex, histology (squamous vs non-squamous), disease stage (IB vs II vs IIA) and PD-L1 status by IHC (TC2/3 [≥ 5% expressing PD-L1] and any IC vs TC0/1 [< 5%], and IC2/3 vs TC0/1 and IC0/1 [< 5%]). The primary endpoint is disease-free survival, and secondary endpoints include OS and safety. Exploratory biomarkers will be evaluated, including PD-L1 expression and immune- and tumor-related biomarkers before, during and after treatment with atezolizumab and at radiographic disease recurrence or confirmation of new primary NSCLC.
Result:
Section not applicable
Conclusion:
Section not applicable
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P2.13 - Radiology/Staging/Screening (ID 714)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiology/Staging/Screening
- Presentations: 2
- Moderators:
- Coordinates: 10/17/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P2.13-019 - Attrition Rate in Community-Based Lung Cancer Screening: One and Done (ID 10310)
09:30 - 09:30 | Author(s): Eric Vallieres
- Abstract
Background:
Community-wide lung cancer screening has the potential to significantly impact lung cancer mortality. Thus, much emphasis has been placed on program development and recruitment of high-risk individuals. Lung cancer screening is a continuum, and shared decision-making focuses on the need for participants to remain engaged. Currently, little is known about screening follow-through in the community setting outside of clinical trials. Thus, we aimed to quantify the rate of attrition in our Lung Cancer Screening Program (LCSP) and identify contributing factors.
Method:
We reviewed all individuals enrolled in our LCSP, which is led by an independently practicing nurse practitioner within a multidisciplinary team, from 2012-2016. We identified all individuals who were closed out of the program, the closure date, and reason for closure. Of these, attrition was defined as declined further screening or lost to follow-up. A formal process for documentation of attrition included failure to respond to a written communication, a minimum of three contact attempts, and a clinical note forwarded to the referring provider.
Result:
Of the 520 individuals enrolled in the LCSP, 23% (122) were officially closed out. Thirteen percent (67/520) were closed out for clinical, geographic, or other identifiable reasons. Attrition from the program was identified to be 11% (55/520). Of the individuals that dropped out, 69% (38/55) were smoking upon enrollment compared to 52% (205/398) of retained individuals (p=0.014). In addition, 78% (43/55) had only one CT scan prior to attrition (Figure). Figure 1
Conclusion:
We identified an 11% attrition rate in our community-based LCSP. Individuals who failed to follow-up with the LCSP were more likely to be current smokers. The majority of individuals who failed to follow-up did not return after the initial CT scan. Future work needs to focus on promoting the continuum of screening and support the highest risk communities to minimize attrition.
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P2.13-021 - Community Network Lung Cancer Screening Experience Underrepresents Medically Underserved and Geographically Remote Individuals (ID 10402)
09:30 - 09:30 | Author(s): Eric Vallieres
- Abstract
Background:
The National Lung Screening Trial (NLST) demonstrated a 20% reduction in lung cancer mortality. However, it’s study centers may not have represented remote populations with low socioeconomic status and/or health care access. Previous reports on other cancers have demonstrated higher rates of screening in urban populations, with lower adoption in underserved and geographically remote communities. We aimed to quantify the proportion of screened individuals from medically underserved and geographically remote areas represented in our multi-state hospital network lung cancer screening programs (LCSPs).
Method:
We performed a multi-institution review using data from individuals enrolled in Pacific Northwest LCSPs, which form part of a multi-state hospital network. Individuals from programs spanning Washington State, Oregon, Montana, and Alaska from 2012-2016 were included. Definitions include: medically underserved area [MUA; healthcare resources deficient region], medically underserved population [MUP; area with economic/cultural/linguistic barriers to primary care services], health professional shortage area [HPSA; primary care physician shortage].
Result:
We identified a total of 2,379 screening participants. Of these, 22% (529) resided in a medically underserved area and 5% (108) were from a medically underserved population. Only 9% (216) resided in a HPSA, compared to the combined state data reporting a rate of 20% HPSA residents. Individuals lived a median of 6 miles from the screening site. Data stratified by state is shown in the figure, and demonstrates a high capture rate of individuals residing in MUAs in Montana. Figure 1
Conclusion:
All sites showed poor penetration into communities identified as MUPs and HPSAs. All sites also had poor penetration into MUAs; except for Montana, likely due to its overwhelming rural nature. However, the vast majority of screening participants lived in close proximity to screening centers. Therefore, novel approaches such as telemedicine and mobile screening clinics may be needed to reach underserved populations for LCS.
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P3.13 - Radiology/Staging/Screening (ID 729)
- Event: WCLC 2017
- Type: Poster Session with Presenters Present
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:
- Coordinates: 10/18/2017, 09:30 - 16:00, Exhibit Hall (Hall B + C)
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P3.13-029 - Imaging Guideline-Recommendations Prior to Treatment for Non-Small Cell Lung Cancer Demonstrates Variable Compliance (ID 10121)
09:30 - 09:30 | Author(s): Eric Vallieres
- Abstract
Background:
Poor adherence to the recommended guidelines in diagnosing and staging patients with non-small cell lung cancer (NSCLC), with negative downstream effects has been previously shown. In addition, studies have demonstrated benefits of staging with PET, including a reduction in number of non-curative resections performed and a higher rate of identifying M1b disease. Staging with brain MRI has demonstrated a yield up to 10% for detecting metastasis in patients with negative clinical examinations. We aimed to assess the adherence to imaging guidelines for PET and brain MRI in the staging of NSCLC patients prior to treatment within our healthcare system.
Method:
We reviewed patients who underwent initial work-up for primary NSCLC during 6/2013–6/2015, in a hospital network of 7 institutions. Clinical stage II-IV patients were stratified by imaging performed prior to the initiation of treatment. Evidence-based clinical practice guidelines referenced include the American College of Chest Physicians (ACCP) 3[rd] edition and the National Comprehensive Cancer Network (NCCN) 7[th] version. Both ACCP and NCCN recommend a PET scan for suspected cIb-III; while ACCP recommends a brain MRI for suspected cIII-IV, and NCCN for suspected cIb-IV.
Result:
The figure demonstrates compliance rates for the 283 included patients. Of cII patients, 7% (2/30) did not receive a PET scan and 43% (13/30) did not receive a brain MRI; while, 11% (6/56) of cIII did not receive a PET scan and 20% (11/56) did not receive a brain MRI. Figure 1
Conclusion:
Variable compliance with imaging guidelines for the use of PET and brain MRI imaging for the staging of our NSCLC patients was seen. Lack of appropriate imaging for NSCLC staging may lead to inappropriate management decisions resulting from incomplete staging information. Quality initiatives are necessary to ensure guideline compliance.
