Multidisciplinary decision-making in the care of patients with lung cancer

The work performed in this thesis addresses some of the challenges facing multidisciplinary tumor boards (MDT) when assessing patients who present with a non-metastatic non-small cell lung cancer (NSCLC). Challenges in patients with early-stage NSCLC treated with stereotactic ablative radiotherapy Acute and late fibrotic changes following stereotactic ablative radiotherapy (SABR) are commonly observed, and mass-like fibrosis is sometimes difficult to distinguish from tumor recurrence. An overview of the patterns of radiological changes seen after SABR were highlighted, and high-risk radiological features (HRF’s) associated with a higher risk of tumor recurrence were presented. In addition, the incidence and patterns of change of HRF’s were studied on 747 follow-up CT scans of 88 patients who were known to have no local recurrence. More than half of these patients developed HRF’s, with (sequential) enlarging opacities being observed in most of these cases. In nearly 25% of these patients 3 or more HRF’s were present. Considerable inter-observer variability in scoring these features was observed, and multidisciplinary assessment of patients with HRF’s is therefore recommended. Another challenge is the treatment of patients with lung cancer and co-existing interstitial lung disease (ILD) as they have an increased risk on toxicity following cancer treatments. We presented our institutional experience with SABR in 19 patients with early stage NSCLC and co-existing ILD, with 42% having idiopathic pulmonary fibrosis. Grade ≥2 lung toxicity was observed in 32% of patients, with 21% of cases classified as a possible, probable or definite grade 5 radiation pneumonitis. Median overall survival was only 17 months, a finding which was predicted by a high ILD-GAP score of ≥4 in 63% of patients. Factors influencing multidisciplinary decision-making in patients with locally advanced NSCLC Treatment decision-making was studied in 197 patients presenting with locally advanced NSCLC between 2015-2017 at our regional network comprising 5 hospitals, using data from the Netherlands Cancer Registry, hospital records and weekly MDT reports. MDT assessment was performed in 95% of all patients, and radical intent treatments (RIT) including surgery or concurrent chemoradiotherapy (CCRT) were recommended in 61%. Finally, 48% actually received a RIT, and the most important factors associated with a failure to do so were an age of ≥70 years and a WHO-performance score of ≥2. The commonest cause of death for all patients was progressive lung cancer, and more comorbidity related deaths were observed in the patients who did not undergo a RIT. In a subsequent study, we extended this analysis of treatment decis