Percy Lee, MD, is vice chair of Clinical Research in the Department of Radiation Oncology, medical director of Orange County & Coastal Region Radiation Oncology, and a professor in the Department of Radiation Oncology at City of Hope

Dr Lee on the Importance of Multidisciplinary Collaboration in NSCLC Management

“The collaboration between medical oncologists, radiation oncology, and surgeons, enables us to have a cohesive plan for the patient.”

Percy Lee, MD, vice chair of Clinical Research in the Department of Radiation Oncology, medical director of Orange County & Coastal Region Radiation Oncology, and a professor in the Department of Radiation Oncology at City of Hope, discussed the critical nature of multidisciplinary collaboration in oncology. He also highlighted questions that remain regarding the optimal use of stereotactic ablative body radiotherapy (SABR) in patients with NSCLC.

Multidisciplinary collaboration facilitates the development of a unified and cohesive treatment plan for patients with NSCLC, Lee began. This essential cooperation involves medical oncologists, radiation oncologists, and surgeons, he noted. When patients receive consistent information—for example, when an initial oncologist suggests radiation and a radiation oncologist confirms the appropriateness of the treatment based on favorable anatomical considerations and the ability to safely deliver SABR doses—patients’ level of reassurance increases, according to Lee. The patient often recognizes that the proposed therapy is the result of a consensus reached by a coordinated team, rather than a collection of separate therapies offered independently by individual providers, Lee summarized.

The radiation oncology field has substantially improved its ability to treat a greater number of lesions safely due to continuous advancements in treatment technology, Lee reported. However, a major hurdle remains, which is the difficulty in precisely identifying the specific patient population that will derive the most profound benefit from SABR, he added. To address this challenge, Lee emphasized the future necessity of incorporating advanced molecular tools. Specifically, using circulating tumor DNA (ctDNA)–based biomarkers will be helpful, he said. These biomarkers, which could function as prognostic or predictive markers and be assessed both before and after treatment, would be instrumental in making treatment decisions, he continued. Integrating ctDNA assays into the decision-making process would allow oncologists to select appropriate candidates for SABR in the context of oligometastatic disease, moving beyond the current reliance on merely counting the number of lesions that can be treated at a given time, he concluded.

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Percy Lee, MD, discusses the critical nature of multidisciplinary collaboration and notes lingering questions about the optimal use of SABR in NSCLC.  

Dr Lee on the Role of SABR in Non–Small Cell Lung Cancer Management

“In most places [in the body], SABR can be used with regular radiation technology, but in special situations when the isolated tumors are in difficult-to-treat parts [of the body], that's where proton therapy [or] MRI-guided SABR would be beneficial.”

Percy Lee, MD, vice chair of Clinical Research in the Department of Radiation Oncology, medical director of Orange County & Coastal Region Radiation Oncology, and a professor in the Department of Radiation Oncology at City of Hope, discussed the applications of stereotactic ablative body radiotherapy (SABR) for the treatment of patients with non–small cell lung cancer (NSCLC).

The fundamental utility of SABR in radiation is its status as a noninvasive treatment, Lee began. This modality is significant because traditional surgery may not be safely executed in every location, or it may involve a level of complexity that is undesirable for the patient or the clinical team, he explained. Lee confirmed that, for the most part, SABR can be effectively employed across major anatomical regions, including the brain, chest, abdomen, and pelvis. The successful deployment of this technique, however, depends heavily on both the available technology and the specialized expertise of the clinical facility, he noted.

Lee further emphasized that although SABR can often be used effectively with regular radiation technology in most anatomical regions, special situations demand advanced technological approaches. For instance, certain advanced technologies are required to safely treat more complicated regions, particularly those located near highly sensitive tissues, such as the bowel, he continued. When an isolated tumor is situated in a particularly difficult part of the anatomy, specialized tools like proton therapy or MRI-guided SABR become significantly beneficial, he added. As an example of institutional capability, Lee reported that City of Hope uses MRI-guided technology.

This paradigm of managing limited metastatic NSCLC with local therapies like SABR has been formally recognized within the oncology community. The ESTRO-ASTRO Consensus defines the standard requirements for oligometastatic disease that is eligible to undergo such local treatment. This consensus requires that patients have 5 or fewer metastatic lesions in total, confirmed through radiological assessment. Furthermore, a critical stipulation is that all identified lesions must be technically treatable using local therapy modalities, which include SABR, surgery, or ablation.

Percy Lee, MD, discussed the use of SABR within the larger radiation therapy paradigm for the management of non–small cell lung cancer.

Dr Lee on the Optimal Patient Population to Receive Proton Therapy for Advanced NSCLC

“Proton therapy is [ideal to use in] a special subset of patients [who] are challenging to deliver that radiation dose to, based on anatomy, location of the tumor, [or tumor] size.”

Percy Lee, MD, vice chair of Clinical Research in the Department of Radiation Oncology, medical director of Orange County & Coastal Region Radiation Oncology, and a professor in the Department of Radiation Oncology at City of Hope, discussed the differentiated application of radiation modalities, the increasing complexity of re-irradiation, and the strategic use of stereotactic ablative radiotherapy (SABR) for patients with non–small cell lung cancer (NSCLC).

Regarding the selection of fundamental radiation modalities, Lee noted that most patients with NSCLC benefit from photon therapy alone. Proton therapy, conversely, is generally considered ideal for a special subset of patients, he said. This specialized use is dictated when radiation dose delivery proves challenging due to anatomical constraints, the specific location of the tumor, or the size of the disease, he reported. The use of proton therapy is ultimately a case-by-case determination, suggesting that although it is not necessary for every patient, certain patients could benefit from its application, he emphasized.

The practice of re-irradiation is complicated, yet its prevalence is increasing, according to Lee. This rise in reirradiation rates is attributed to patients experiencing better outcomes with modern systemic therapy, he stated. A critical component of successful reirradiation is timing, he added. Time intervals of at least 1 year between the last course of radiation therapy are typically favored, as this minimizes the risk of toxicity, limits the radiation dose to healthy tissue, and maintains constraints believed to be relatively safe, he explained. Furthermore, the ability to administer chemotherapy concurrently with a definitive second course of radiation therapy appears to contribute to better patient outcomes, he reported.

SABR is defined as localized high-dose radiation for patients with a limited size of disease, Lee continued. Currently, patient eligibility for SABR often relies on the number of lesions, with 3 to 4 lesions considered optimal, he said. The clinical imperative is to accurately distinguish between patients presenting with aggressive vs indolent cancer, thereby allowing SABR to target and control specific sites of disease, he reported. Leveraging SABR in this manner in the metastatic setting enables patients to achieve a chemotherapy-free or systemic therapy–free interval, or allows for the strategic delay of subsequent lines of systemic therapy, he concluded.

Percy Lee, MD, discusses different radiation modalities for patients with NSCLC, the increasing complexity of reirradiation, and the strategic use of SABR.

Dr Lee on the Role of IMRT in Locally Advanced NSCLC Management

“Our [radiation therapy] technique has evolved, and I would consider [IMRT] standard of care because we can spare more normal tissue and reduce [adverse] effects based on a better conformal radiation therapy plan.”

Percy Lee, MD, vice chair of Clinical Research in the Department of Radiation Oncology, medical director of Orange County & Coastal Region Radiation Oncology, and a professor in the Department of Radiation Oncology at City of Hope, discussed the evolution of radiation therapy techniques for patients with locally advanced non–small cell lung cancer (NSCLC).

Lee began by explaining that current technological advancements emphasize the importance of optimizing treatment delivery through improved dose conformity and crucial organ sparing in patients with NSCLC. He considers intensity modulated radiation therapy (IMRT) to be the standard of care in modern radiation oncology practice. The primary benefit of IMRT stems from the ability to create an improved conformal radiation therapy plan, which allows radiation oncologists to spare more normal tissue and consequently reduce adverse effects associated with treatment, according to Lee. By reducing the radiation delivered to critical healthy organs—such as the esophagus, heart, and lungs—IMRT ensures that patients can better tolerate the treatment, he said. This enhanced tolerance is vital, as it allows for the subsequent addition of systemic therapy, including both chemotherapy and immunotherapy, into the overall treatment regimen, he explained.

Although IMRT remains the standard for most patients, intensity modulated proton therapy (IMPT) offers potential advantages in selected patient populations, Lee noted. Proton therapy is capable of further reducing radiation doses to healthy tissue, including the lung, heart, and esophagus, he stated. Lee emphasized that the value of proton therapy is significant in specific-use cases. These include situations where there is a large tumor bulk and the team is attempting to deliver definitive therapy, or in instances where a second course of radiation is necessary in the same area, he reported. IMPT may be particularly beneficial for patients with poor pulmonary reserve, central tumors, or those with a history of prior thoracic radiation therapy, he concluded.

Percy Lee, MD, discusses the importance of considering radiation therapy techniques like IMRT and proton therapy for patients with locally advanced NSCLC.

Percy Lee, MD

Articles

Dr Lee on the Importance of Multidisciplinary Collaboration in NSCLC Management

Dr Lee on the Role of SABR in Non–Small Cell Lung Cancer Management

Dr Lee on the Optimal Patient Population to Receive Proton Therapy for Advanced NSCLC

Dr Lee on the Role of IMRT in Locally Advanced NSCLC Management