Guidelines Released for Stereotactic Radiation Use in Early-Stage Lung Cancer

The American Society for Radiation Oncology (ASTRO) has released new clinical guidelines that recommend the use of stereotactic body radiation therapy (SBRT) in early-stage lung cancer.
Currently, SBRT is the standard of care for patients with peripherally located tumors that are inoperable. The new guidelines address the use of SBRT for medically inoperable patients with high-risk clinical scenarios that require curative focused therapy.
Additionally, the guidelines offer detailed principles of SBRT directed toward centrally located lung tumors. The appropriateness of SBRT in operable patients was also addressed.
The guidelines––which drew on data from retrospective and prospective studies and randomized clinical trials­­––provides evidence-based recommendations on the appropriate use of SBRT for early-stage non-small cell lung cancer (NSCLC).
The appropriateness of SBRT as an alternative to surgery for different subsets of medically operable patients with early-stage NSCLC differs among patients who are at high risk or standard risk of surgery-related mortality.
For standard risk, SBRT is not recommended as an alternative to surgery outside of the clinical trial setting for patients with stage 1 NSCLC who have an anticipated risk of operative mortality of less than 1.5%. A lobectomy with systematic mediastinal lymph node evaluation remains the recommended treatment for these patients.
For high risk patients, discussions about SPBRT as an alternative to surgery is recommended for patients with stage 1 NSCLC who are at a greater risk of surgical morbidity or mortality, or who cannot tolerate a lobectomy but are candidates for sublobar resection. However, the guidelines note that health care providers should let patents know that although short-term treatment-related risks are lower with SBRT, long-term outcomes more than than 3 years are not well-established in studies.
To reduce potential specialty bias, a thoracic surgeon should evaluate any potentially medically operable patients with early-stage NSCLC who are considering SPRT––preferable in a multidisciplinary setting.
Recommendations for inoperable patients are varied based on tumor location, type, size, and treatment history.
SBRT is appropriate for centrally located tumors, but the associated toxicity risk depends on the total dose and fractionation schedule. Therefore, SBRT should be delivered in 4 or 5 fractions as a function of total dose, the guidelines states.
Additionally, the use of stereotactic treatment for centrally located lung tumors close to or involving specific critical structures should be considered because of the risk of rare but potentially severe adverse events after receiving high-dose treatments.
For tumors that are larger than 5 cm that cannot be surgically removed, SBRT is conditionally recommended, but patients should be counseled about the subsequent risk of locoregional and distant failure.
Although a biopsy should be used whenever possible to confirm tumor malignancy, SBRT can be considered for patients who are unable or unwilling to undergo a biopsy. Such cases should be discussed prior to treatment at a multidisciplinary tumor board.

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