Abstract
The number of pulmonary nodules identified incidentally or through lung cancer screening programs has dramatically increased. The role of radiation therapy (RT) in this patient population is not defined. Our institution established a multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) to optimize the management of these patients. In this study, we describe the role of radiation oncologists in the multidisciplinary evaluation and management of incidental and screening-identified pulmonary nodules. This study included patients referred to the PNLCSC between 10/2012 and 9/2019. Indications for referral included a Lung-RADS 4 finding on screening CT or an incidental pulmonary nodule measuring ≥6 mm. At each clinic session, a multidisciplinary team including diagnostic/interventional radiologists, pulmonologists, medical oncologists, thoracic surgeons, and radiation oncologists made recommendations regarding the work-up, management, and follow-up of each patient. Demographic and clinical characteristics as well as data on follow-up and treatments were prospectively recorded. Collection and analysis of the data was approved by institutional IRB. Of 1,150 patients evaluated by the PNLCSC, 234 (20.3%) were screening patients, and 916 (79.7%) had incidental nodules. Among screening patients, 41 (17.5%) underwent therapeutic intervention, 31 (13.2%) with surgical resection and 10 (4.3%) with RT. RT represented 24.4% of all treatments received by screening patients. Among patients with incidental pulmonary nodules, 227 underwent therapeutic intervention, with 167 (18.2%) and 60 (6.6%) receiving surgery and RT, respectively. The overall rate of patients undergoing RT was stable over time, ranging from 6.0% in 2014-2016 to 6.7% in 2017-2019. However, the rate of screening patients receiving RT increased from 1.7% in 2014-2016 to 4.3% in 2017-2019. Among the 70 RT patients, 58 (82.9%) were treated for clinically diagnosed lung cancer, while 12 (17.1%) had biopsy-proven non-small cell lung cancer. Nearly all (95.7%) patients treated with RT, and 100% of those with screening detected nodules, had stage I disease and received SBRT to a median dose of 50 Gy (range 48–50 Gy) in 5 fractions (range 4–5 fractions). Compared to patients who underwent surgical intervention, those receiving RT were older (median age 67.6 vs. 73.8 years, p < 0.001) and more likely to be current/former smokers (76.8% vs. 95.7%, p = 0.001). In this large prospective cohort, 24.4% of all screening patients with lung nodules requiring intervention were treated with SBRT. The high percentage of patients receiving RT without biopsy may reflect careful multidisciplinary evaluation. Altogether, this unique data highlights the important role radiation oncologists can play in the diagnosis and treatment of patients with screening-detected and incidental lung nodules.
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