Management of Patients With Stage I Lung Cancer

The treatment of stage I non–small-cell lung cancer has advanced markedly over the past century. The transition from therapeutic nihilism with ensured mortality to radical surgery with pneumonectomy to rational oncologic-based resection has resulted in dramatically improved outcomes and reduced morbidity. The superiority of anatomic resection with lobectomy over sublobar resection for fit patients with stage I disease, where more than one half of all patients should expect to be cured, is backed by level 1 evidence. Minimally invasive approaches have further decreased morbidity and mortality, and prospective trials continue to assess whether sublobar resection is appropriate in more select circumstances for tumors < 2 cm. Interest in studying the patient at high risk for complications after lobectomy has been spurred by recent advances in surgical, radiotherapy, and ablative treatment options. In particular, provocative results with stereotactic body radiotherapy have led to rapid adoption in clinical practice with a resultant decrease in the number of untreated patients. A comparison of outcomes across studies of competing modalities remains challenging given the potential impact of selection bias in single-arm trials, and attempts to conduct randomized studies have been largely unsuccessful. Given the uncertainty in defining optimal therapy, patients are best served by a multidisciplinary team of thoracic surgeons, radiation oncologists, pulmonologists, and chest and interventional radiologists to ensure that they receive the evaluation and treatment best suited not only to their tumor and medical challenges but also to their concerns, fears, and values.