2470 - Delphi Consensus on Managing Non-Small Cell Lung Cancer (NSCLC) in Patients with Coexisting Interstitial Lung Disease
Presenter(s)
A. Salem1, J. L. Tan2, F. Al-Samarat3, D. A. Palma4, O. Abu Hlalah5, N. Chaudhuri6, S. Senan7, S. F. M. Nijman8, C. Hiley9, E. Lim10, S. V. Liu11, G. Rodrigues12, K. Thippu Jayaprakash13, M. X. Qu14, A. Louie15, and S. Harrow16; 1Hashemite university, Zarqa, Jordan, 2University of Manchester, Manchester, United Kingdom, 3Hashemite University, Amman, Jordan, 4Division of Radiation Oncology, London Health Sciences Centre, London, ON, Canada, 5Abdali Hospital, Amman, Jordan, 6Ulster University, belfast, United Kingdom, 7Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands, 8Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Pulmonology, Amsterdam, Netherlands, 9University College London Hospitals NHS Foundation Trust, London, United Kingdom, 10Imperial College London, London, United Kingdom, 11Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, 12London Health Sciences Centre, London, ON, Canada, 13Addenbrookes Hospital, Cambridge, United Kingdom, 14Department of Radiation Oncology, London Health Sciences Centre, London, ON, Canada, 15Odette Cancer Centre, Sunnybrook Hospital, University of Toronto, Canada., Toronto, ON, Canada, 16Edinburgh Cancer Centre, Edinburgh, United Kingdom
Purpose/Objective(s): Around 5-10% of lung cancer patients have a concomitant diagnosis of interstitial lung disease (ILD). Managing NSCLC with co-exciting ILD is challenging due to the heightened risk of treatment-related toxicity and the lack of standardized guidelines and comparative clinical trials. Therefore, we conducted a Delphi study to develop consensus statements on optimal management practices, engaging a multispecialty international panel of clinicians.
Materials/Methods: A two-round Delphi study engaged 25 international physicians (chest physicians, surgeons, medical oncologists and radiation oncologists) with expertise in managing NSCLC patients with co-existing ILD (chosen based on previous limited publications or specialist interest) representing various institutions (academic, public, comprehensive cancer centers, and private institutions). The median experience was 11 years (range, 3-28 years) and the median annual case volume was 20 (range, 2-500). Round 1 included open-ended questions developed through literature review covering general management, pre-treatment, and treatment approaches across surgery, radiotherapy, systemic therapies, and follow-up care. Round 2 evaluated statements derived from initial responses, with consensus defined as =75% of respondents rating agree/strongly agree (4 or 5 on a 5-point Likert scale).
Results: The study achieved 100% and 92% response rates in rounds 1 and 2, respectively with 23 of 40 statements reaching consensus. Summary key agreements included: (1) General management: treatment decisions should be individualized, balancing the risks of treatment-related complications against potential benefits; (2) Pre-treatment: ILD specialist consultation, comprehensive pulmonary/perfusion testing, immediate initiation of cancer treatment while awaiting anti-fibrotic therapy; (3) Surgery: decisions guided by pre-operative lung function, pulmonary hypertension risk, and tumor-ILD co-location, with emphasis on minimizing parenchymal loss; (4) Radiotherapy: use of conformal techniques with meticulous review of medium/low dose spillage, prioritizing lung dose constraints over cardiac/esophageal constraints, adopting lowest acceptable doses for stage II/III cases; (5) Systemic therapy: enhanced pneumonitis monitoring during chemotherapy, careful immunotherapy risk-benefit assessment with contraindication of anti-CTLA4 agents in diffuse ILD cases; (6) Follow-up: mandatory ILD specialist involvement in routine care, immediate specialist consultation for suspected treatment-induced toxicity, and increased monitoring frequency during adverse events. Consensus was not reached on using specific ILD scoring systems, pre-treatment pulmonary rehabilitation, or standardized follow-up testing intervals.
Conclusion: This study provides healthcare providers with expert-derived recommendations for managing NSCLC patients with co-existing ILD.