Drew Moghanaki, MD, MPH "Can Stereotactic Ablative Radiotherapy Improve Patient Selection for Lung Cancer Surgery and Reduce Perioperative Mortality"

1. Can Stereotactic Ablative Radiotherapy
Improve Patient Selection for Lung Cancer
Surgery and Reduce Perioperative Mortality?
Drew Moghanaki, MD, MPH
Hunter Holmes McGuire Veterans Affairs Hospital
Virginia Commonwealth University
Richmond, Virginia, USA
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH

2. I have no financial conflicts to disclose
I am an employee of the U.S. Department of Veterans Affairs
This IRB-approved study was supported by the Hunter Holmes McGuire
Veterans Affairs Medical Center
The contents neither represent the views of the U.S. Department of Veterans
Affairs, nor the United States Government
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH

3. 1930’s
Surgery
Conventional RT
SABR
1895
1990’s
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH
Treatment Options for Stage I NSCLC

4. Lobectomy
Sub-Lobar
(24%)
(73%)
Pneumonectomy
(3%)
All Lobectomy Wedge Pneumonectomy
90 day mortality 3.2% 1.4% 4.4% 0%
1993 2014
Operable Stage I NSCLC (n=284)
6 month mortality 7.0% 7.3% 7.4% 0%
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH

5. 5
pre-SABR
Surgery pre-SABR post-SABR
90 day mortality 3.2% 2.7% p=0.47
1993 2014
6 month mortality 7.0% 7.1% p=0.36
post-SABR
2007
surgeries (n=171)
Inoperable SABR
90 day mortality 0%
6 month mortality 0%
surgeries (n=113)
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH

6. Surgery (n=284) SABR (n=27)
Median f/u 49.2 mo 21.6 mo
2-year Overall Survival 63.1% 69.4% p=0.52
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Pubmed Citations
"lung stereotactic radiotherapy"
ROSEL
STARS
ACOSOG
RTOG
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH

7. MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH
STABLEMATES Trial Schema
*Anticipated (actual assignment rate will be monitored)
N = 218
Arm 1:
Sublobar
Resection
Arm 2:
SAbR
Defined
High Risk
Stage I
NSCLC
Screen
Eligible
Patients/
Pre-
Randomize
N = 272
A
c
c
e
pt
R
ej
e
ct
Consent to
Accept
Randomization
Assignment
N = 54*
Follow for OS,
Toxicity, and
Patterns of
Failure
Failure to
Consent(
Off
Study)
Follow for OS,
Toxicity, and
Patterns
of Failure
Consent to Be
Observed After
Standard of
Care Therapy
A
c
c
e
pt
R
ej
e
ct
N = 48
N = 6*
N = 109
N = 109

8. Surgery
Stereotactic
Radiotherapy pNx
Operable
Stage I NSCLC
n=676
5 year Overall Survival
Adjuvant Tx
when indicated
pN0
pN1
pN2
pN3
2 Endpoints
Quality of Life
Respiratory Function
Tumor Control & LCSM
VALOR
Veterans Affairs Lung cancer Operation vs stereotactic ablative Radiotherapy
A Department of Veterans Affairs Cooperative Study – CSP #2005
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH

9. TAKE HOME POINTS
1. Surgical mortality for stage I NSCLC has not declined following
availability of SABR
2. Improved selection of patients for surgery might improve survival
- likely short-term
- potentially long-term
3. A phase III trial appears necessary to influence referring physicians to
consider SABR as an alternative to surgery, even for frail patients
MINI 18.13 - Can SABR Improve Patient Selection for Lung Cancer Surgery – Drew Moghanaki, MD, MPH