A Guide for Managing Patients with Stage I NSCLC: Deciding Between Lobectomy, Segmentectomy, Wedge, SBRT and Ablation-part 1: a Guide to Decision-making

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, Stereotactic Body Radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods: Based on a systematic review from 2000-2021, evidence regarding relevant outcomes was assembled, with attention to aspects of applicability, uncertainty and effect modifiers. A framework was developed to present this information a format that enhances decision-making at the point of care for individual patients.

Results: While patients often cross over several boundaries, the evidence fits into categories of healthy patients, compromised patients, and favorable tumors. In healthy patients with typical (i.e., solid spiculated) lung cancers, the impact on long-term outcomes is the major driver of treatment selection. This is only slightly ameliorated in older patients. In compromised patients increasing frailty accentuates short-term differences and diminishes long-term differences especially when considering non-surgical surgical approaches; nuances of patient selection (technical treatment feasibility, anticipated risk of acute toxicity, delayed toxicity, and long-term outcomes) as well as patient values are increasingly influential. Favorable (less-aggressive) tumors generally have good long-term outcomes regardless of the treatment approach.

Discussion: A framework is provided that organizes the evidence and identifies the major drivers of decision-making for an individual patient. This facilitates blending available evidence and clinical judgment in a flexible, nuanced manner that enhances individualized clinical care.