Of the participating 170 physicians, 24% were pulmonolog, 23% thoracic surgeon, 45% radiation oncologist and 8% medical oncologist. Eighty six percent of the participants were between 40–49 years old. Women were more than men with a rate of 56%. The smoking data is on Fig. 1.
The interest of the physicians in lung cancer was mostly between 5–15 years (45%).
In scenario 1, they were asked if they were smoker and diagnosed as non small cell lung cancer (NSCLC), what they would do? Results of this question is in Fig. 2.
Scenario 2 was to discuss single station N2 lymph node for the decision of surgery for stage T2AN2M0 (Stage IIIA). Almost half of the TS, preferred surgery at initial treatment, even the NCCN guideline recommendation of induction chemotherapy or definitive chemotherapy (NCCN).
Scenario 3 was a stage IIIB (T2a N3 M0) squamous lung cancer. A 4 cm. peripheral left lower mass, with a concomittan left supraclavicular lymph node which had an FDG uptake at PET-CT scan and proven to be malignant with a biopsy. Nearly half of the surgeons preferred to be operated even though the malignant lymph node (43.6%).
Scenario 4: “A 1.5 cm. right upper lobe tumor is detected and your lymph nodes are proven to be benign with PET/CT and EBUS (T1b N0 M0 = Stage 1A2). If you are suitable for a lobectomy with good respiratory functions what would you prefer?” Most of the participants preferred surgery while a quarter of radiation oncologists preferred stereotactic body radiotherapy (SBRT). If respiratory functions were limited and unsuitable for a lobectomy, most of the surgeons choosed sublobar resection, while others preferred SBRT. Nobody preferred chemotherapy (Table 1).
Table 1
Preferences of the participants for scenario 4, T1b tumor, but unsuitable for lobectomy.
| Sublobar resection | Stereotactic RT | CT* | No treatment | Total |
Pulmonology | %45,0 18 | %50,0 20 | %0,0 0 | %5,0 2 | %23,8 40 |
Thoracic surgery | %79,5 31 | %20,5 8 | %0,0 0 | %0,0 0 | %23,2 39 |
Medical oncology | %15,4 2 | %84,6 11 | %0,0 0 | %0,0 0 | %7,7 13 |
Radiation oncology | %10,5 8 | %89,5 68 | %0,0 0 | %0,0 0 | %45,2 76 |
Total results | %35,1 59 | %63,7 107 | %0,0 0 | %1,2 2 | 168 |
P: pulmonolog TS: thoracic surgeon RO: radiation oncologist MO: medical oncologist *CT: chemotherapy |
Scenario 5: “A centrally localized left lung tumor invading left pulmonary artery without any metastatic lymph node is detected (T4 N0 M0 = Stage 3A). Your surgeon adviced neoadjuvant therapy before a surgery. Would you choose RT, CT, or concomitant RT and CT?” Pulmologists, surgeons and medical oncologists mostly selected CT respectively (59%, 64.1%, 61.5%) whereas radiation oncologists were on the side of concomitant therapy (66.2%). The radiation dose preferences were 45 Gray for 53.4%, 60–66 Gray for the remaining radiation oncologists.
Scenario 6: “A locally advanced NSCLC is detected. You accepted to have concomitant radiochemotherapy (T3 N2 M0 = Stage IIIB). The treatment alternatives are cisplatin + etoposid, weekly paclitaxel + carboplatin, cisplatin + vinorelbin, cisplatin + gemcitabine or platin + pemetrexet.” Seventy four percent of the surgeons did not have any idea, while half of the pulmonologists preferred cisplatin + etoposid (51.3%). Weekly paclitaxel + carboplatin option was higher than other treatments for medical oncologists and radiation oncologists (46.1%, 43.4%). “What about the continuation of the therapy if you are still unresectable?” They were asked if they would get consolidation (durvalumab) therapy. The acceptance rates were as follows; pulmologists 76,9%, surgeons 56,4%, medical oncologists 92,3%, radiation oncologists 92,1%.
Scenario 7. The participant had lung adenocarcinoma. At the time of staging, brain metastasis was detected with a contrasted magnetic resonans imaging. All driver mutations were negative (EGFR, ALK, ROS-1 and PD-L1<%1). Participants were asked which treatment they would choose for the brain metastasis before the systemic therapy? Only surgery, surgery followed by a stereotactic radio surgery (SRS) for the cavity, SRS followed by surgery or SRS or whole brain RT? Most preferred option was surgery followed by SRS with a sum of 64% at all clinicians. The second part of this scenario was as follows: “Brain metastasis are 3, driver mutations positive and PD-L1 <%1. You are planned to be treated with tyrosine kinase inhibitor. Before this treatment which is your preference for brain metastasis; early cranial RT or waiting for the response of cranial metastasis to systemic treatment with close MR monitoring.” Results are at Table 2.
Table 2
Responses to scenario 7, part 2.
| Early cranial RT | Wait for the response of cranial metastasis to systemic treatment with close MR monitoring |
Thoracic Surgeons | %51,9 20 | %48,7 19 |
Pulmonologists | %79,5 31 | %20,5 8 |
Medical oncologists | %15,4 2 | %84,6 11 |
Radiation oncologists | %50,0 38 | %50,0 38 |
Scenario 7, part 3 is about 3 brain metastasis, negative driver mutations and this time PD-L1 >%1. The treatment options are;
-
Chemothreapy followed by RT
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Immunotherapy followed by RT
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RT followed by Chemotherapy
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RT, followed by immunotherapy
Most of the participants preferred answer 4 (64,1%, 43,2%, 69,2%, 64,5%).
In case of multipl brain metastasis requiring whole cranial RT, would you prefer hippocampus sparing RT to protect neurocognitive functions? Answers are at Table 3.
Table 3
Answers of the participants to the scenario requiring whole brain RT.
| Yes | No | No idea |
Thoracic Surgeons | %71,05 27 | %0,00 0 | %28,95 11 |
Pulmonologists | %69,23 27 | %2,56 1 | %28,21 11 |
Medical oncologists | %76,92 10 | %15,38 2 | %7,69 1 |
Radiation oncologists | %63,64 49 | %31,17 24 | %5,19 4 |
Scenario 8. “You were found to have NSCLC with a single adrenal gland metastasis (oligometastatic disease) and you underwent an adrenalectomy operation. There is no progression in your lung lesion. Would you consider a radical treatment for the primary lung lesion (surgery, radical RT or RCT)?” Nearly all of the participants preferred to have a radical treatment for the lung lesion (97%).