An Algorithm to Guide through Options for Advanced Bronchiol

[NikoleV]

An Algorithm to Guide through Options for Advanced Bronchioloalveolar Carcinoma

January 25th, 2013 - by Dr. Jack West

http://expertblog.lungevity.org/2013/01 ... -algorith/

I’m editing a late draft of a chapter I’m writing for a lung cancer textbook on management of multifocal bronchioloalveolar carcinoma (BAC). This is a clinical entity and in fact a field that is really in flux. In fact, the term BAC is in the process of being re-labeled lepidic predominant adenocarcinoma (LPA) (lepidic meaning scale-like, which is the classic way that the cells are defined as spreading when looked at under a microscope). Despite the potential name change, I suspect that it will continue to be called multifocal or advanced BAC for a long time by practicing clinicians.

I found in the process of developing this chapter that I faced the challenge of there being very little actual hard data on managing multifocal BAC. Many lung cancer experts have a very similar approach, but in truth this is based more on on expertise, good judgment, and clinical experience than real published data to cite. So, with the caveat that there isn’t a lot of evidence to shape my own practice, but also noting that I see and treat a lot of BAC and am recognized for this expertise, I wanted to distill my own thought process as I shape recommendations for my patients. I don’t think anyone has ever really articulated a clear strategy in any medical paper or book chapter, so I’m hoping this will be a valuable addition to the literature.

In my review of the medical literature out there, I was struck by two points:

1) There is incredible variability in the appearance and clinical behavior of what is called advanced BAC in the clinical world. Some of it is aggressive and imminently threatening, while much of it is very slow growing and among the least threatening cases ever labeled as lung cancer. There is therefore a great potential to over-treat or under-treat patients by not recognizing the patterns of what’s going on in an individual patient and tailoring the approach to that person’s case, rather than using a “one size fits all” approach for everyone with advanced BAC.

2) People with a very slow growth rate are likely to do very, very well no matter what treatments they get, as much despite as because of those treatments. In many cases, interventions are pursued on patients who are destined to do very well, and then when their short term survival is good, the people who did that intervention write a paper saying how their approach is feasible and attractive because the patients did well — not recognizing, or at least glossing over the idea, that they were going to do very well anyway.

I would contend that in no other area of lung cancer care is it more important to distinguish between what can be done and what should be done. And the real experts know when to not intervene. However, this algorithm is designed specifically around multifocal BAC but works just as well for other slow-growing cancers.

So here is the algorithm I developed, which isn’t beautiful, but you can see that it focuses on seeing what is actually changing rather than treating reflexively based on a label on a pathology report or single a scan finding. Essentially, it argues to avoid intervening in the absence of clinically significant change (which I would consider as something that is readily apparent as progression on scans done 6 months apart or less). Then, if you see progression, clarify whether it’s limited to one lesion or progressing more diffusely in multiple areas.

Also, if patients need systemic therapy, you use the same approach that you would for another non-squamous NSCLC. BAC today should be tested for the key molecular markers that can change management, most particularly EGFR mutation and ALK rearrangement, with the decision of chemo or targeted therapy as first line treatment really dictated by the molecular profile. In essence, this is the same way we should approach an invasive lung adenocarcinoma. There is no magic different approach for BAC once you’ve decided someone should receive systemic therapy.

Finally, I’ll emphasize that the algorithm here isn’t for ALL people with multifocal BAC, but just those who have evidence of an indolent and asymptomatic (or minimally symptomatic) process, and those who have a more readily progressing disease need all of the aggressive anti-cancer treatment they can get.

But it’s really important to recognize that we treat lots of people with more therapy than is their best interests: part of that is a cultural bias among patients and doctors of ”don’t just stand there — DO SOMETHING!“, even if it’s not likely to be helpful, or at least not yet. Also, part is that the incentives, in the US health care system at least, is to give the most care that is defensible and will be paid for.

People facing this situation may or may not accept remaining untreated for months or years at a time, even recognizing in their heads that they have an indolent cancer. We know that we over-treat some other cancers, like the majority of men with prostate cancer, but lung cancer hasn’t been one that is usually thought of as requiring as much aggressive treatment as possible. The best lung cancer doctors recognize when to hold off on that instinct.

I would advise people to think about some of these slower-growing cancers like diabetes, high cholesterol, or obesity. They represent a chronic risk to survival over years and often decades, but most people don’t lose sleep over obesity or their cholesterol levels and don’t rush into a triple bypass done 10 years before it might be needed just because a paper might show that people who undergo a prophylactic cardiac bypass 10 years before they would have had a clinical issue are still doing well 3 years after the surgery.

But admittedly, I’m on one side of the exam room, and the view my be different from the other chair. Could you accept surveillance scans and no treatment if you were told that you have what is technically an advanced cancer, but one that is likely slow-growing and for which early intervention offers no clear benefit over later intervention? Do you accept the premise that the treatment might be worse than the disease?