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Original Research: Lung Cancer |

When Is a Biopsy-Proven Diagnosis Necessary Before Stereotactic Ablative Radiotherapy for Lung Cancer?Stereotactic Ablative Radiotherapy for Single Node: A Decision Analysis

Alexander V. Louie, MD; Suresh Senan, PhD; Pretesh Patel, MD; Bart S. Ferket, MD, PhD; Frank J. Lagerwaard, MD, PhD; George B. Rodrigues, MD, PhD; Joseph K. Salama, MD; Christopher Kelsey, MD; David A. Palma, MD, PhD; Myriam G. Hunink, MD, PhD
Author and Funding Information

From the Department of Radiation Oncology (Drs Louie, Senan, and Lagerwaard), VU University Medical Center, Amsterdam, The Netherlands; the Department of Radiation Oncology (Drs Louie, Rodrigues, and Palma), London Regional Cancer Program, London, ON, Canada; the Department of Epidemiology (Drs Louie, Ferket, and Hunink), Harvard School of Public Health, Boston, MA; the Department of Radiation Oncology (Drs Patel, Salama, and Kelsey), Duke University Medical Center, Durham, NC; and the Department of Epidemiology and Biostatistics (Drs Ferket and Hunink), Erasmus MC, Rotterdam, The Netherlands.

CORRESPONDENCE TO: Alexander V. Louie, MD, Department of Radiation Oncology, VU University Medical Center, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands; e-mail: Dr.alexlouie@gmail.com


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(4):1021-1028. doi:10.1378/chest.13-2924
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BACKGROUND:  The practice of treating a solitary pulmonary nodule (SPN) suspicious for stage I non-small cell lung cancer (NSCLC) with stereotactic ablative radiotherapy (SABR) in the absence of pathology is growing. In the absence of randomized evidence, the appropriate prior probability threshold of lung cancer of when such a strategy is warranted can be informed using decision analysis.

METHODS:  A decision tree and Markov model were constructed to evaluate the relative merits of surveillance, a PET scan-directed SABR strategy (without pathology), or a PET scan-biopsy-SABR strategy, when faced with an SPN at different prior probabilities for lung cancer. Diagnostic characteristics, as well as disease, treatment, and toxicity parameters, were extracted from the literature. Deterministic analysis and probabilistic sensitivity analyses were performed to inform the appropriate lung cancer prior probability threshold between treatment strategies.

RESULTS:  In the reference case analysis, the prior probability threshold between surveillance and PET scan-biopsy-SABR was 17.0%; between PET scan-directed SABR and PET scan-biopsy-SABR, the threshold was 85.0%. The latter finding was confirmed on probabilistic sensitivity analysis (85.2%; 95% CI, 80.0% to 87.2%). This predicted lung cancer prior probability threshold was most sensitive to the diagnostic sensitivity of transthoracic biopsy (range, 77.2% to 94.0%) and the detection rate of false negatives on CT scan surveillance (range, 82.4% to 92.3%).

CONCLUSIONS:  This model suggests that if there are concerns about morbidity related to biopsy for an SPN, a PET scan-directed SABR strategy is warranted when the prior probability of lung cancer exceeds a point estimate of 85%.

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