active surveillance of lung subsolid nodules (ggo's) reduces overtreatment - 1294898

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onthemark
active surveillance of lung subsolid nodules (ggo's) reduces overtreatment - 1294898

Dr. West and other's here have made the point for a long time that lung cancers with ggo's (pure and mixed), or what some people called BAC in the past, is often over treated. The results of a long term study about this issue have been published, confirming this view.

"ACTIVE SURVEILLANCE OF LUNG SUBSOLID NODULES REDUCES UNNECESSARY SURGERY AND OVERTREATMENT"

https://www.iaslc.org/news/active-surveillance-lung-subsolid-nodules-red...

It's a summary that links to a medical paper which was just accepted for publication in the Journal of Thoracic Oncology:
"Long-term Active Surveillance of Screening Detected Subsolid Nodules is a Safe Strategy to Reduce Overtreatment "

https://www.jto.org/article/S1556-0864(18)30764-0/pdf

The upshot is that having pure or mixed ggo nodules ups the risk for lung cancer appearing elsewhere in the lungs. On the other hand these nodules can be safely watched for a decade or more without requiring surgery or any other intervention in almost all cases.

"In conclusion, the majority of subjects with SSN who were diagnosed with lung cancer in the MILD cohort had developed a cancer elsewhere in the lungs. Lung cancers that arose from the SSN never represented the cause of death within the nearly 10-year follow-up period. Therefore, SSN can be considered a biomarker of cancer risk, and should be managed by active surveillance until signs of growth of the solid component. "

catdander
Thanks onthemark for the

Thanks onthemark for the links. It's good to know that info is getting out to the general onc population in such a relevant way.

Congratulations on the good scan. You're now on yearly scans, that's remarkable. Don is just now moving to yearlys because of the various problems he's had with his lungs but never did the problems lead to a recurrence and that's the goal. Yay for us. :)

onthemark
Hi Janine,

Hi Janine,

Glad you to hear your Don is also going to one year scans. My oncologist gave me the option of 6 months or one year, so I went for one year.

So glad to see this long term study which has overwhelming evidence that ggos can be safely watched. They are an indication of an underlying predisposition for not only lung cancer but also other extrapulmonary cancers. Indeed 11% of subjects with a subsolid nodule in the lung experienced cancer outside of lung cancer after their SSN was detected.

That was something I was not aware of.

Dr West
I think this is a valuable

I think this is a valuable contribution, and it's absolutely true that these data just corroborate what I have been seeing and doing literally for years. Here is an algorithm I wrote that basically says "if the nodules aren't growing at a very readily visible pace, just monitor them but don't DO anything based on them":

http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

That said, I think we may never see this level of wisdom and experience practiced broadly. The Journal of Thoracic Oncology is read primarily by people who are already devoted to careful, deliberate management of lung cancer, which includes not reflexively over-treating it. Unfortunately, most lung cancer is managed by people who are far less reflective, so I fear that it won't be any time soon that most patients with ground-glass opacities (GGOs) (also referred to as sub-solid nodules) are treated with a minimalist approach that is likely the optimal strategy here. But I would love to be wrong, to see this information more broadly disseminated, and to see fewer patients being treated as if multifocal GGOs/SSNs should be managed the same way as having multifocal invasive cancer.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

onthemark
Dr. West,

Dr. West,

Thank you for your contributions to this area. I was hoping you would comment and find it interesting.

I'm a bit more optimistic about reducing overtreatment for indolent SSN or ggo.

One reason is the ability of patients to educate themselves using the internet at sites like GRACE, or to access all the other information you have made available on the web through twitter, youtube and other places.

[I am one example of overtreatment and that is why this issue interests me so much.

I was originally staged 2b after finding a tiny additional AIS nodule in the completion lobectomy of my invasive adenocarcinoma. The overtreatment was not surgery but adjuvant chemo I had afterward as protocol for stage 2b. From reading this site and posting on the forum, I asked my oncologist's whether AIS would really upstage to 2b rather than stage 1 based on the dominant tumour. He took it to the local tumour board and they still came back with 2b.

A year later I showed my onc a paper defining IASLC's new staging of multifocal, lepidic type lung cancer, where my situation was clearly now 1b. My doc restaged me in the system from 2b to 1b. ]

Another reason I am optimistic is the 2018 NCCN guidelines explicitly have a different algorithm for dealing with subsolid than solid nodules. It describes a conservative management protocol totally in line with yours. I believe these guidelines define a precise standard of care in North America.

The National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer are publicly available (after creating an account) at:
https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf