Operating in Oligometastatic Disease: Dr. Antonoff Shares Patient Selection Considerations

Mara Antonoff, MD, a thoracic surgeon at the University of Texas MD Anderson Cancer Center, joined Lung Cancers Today to discuss operating in oligometastatic lung cancer.

“Among patients with oligometastatic lung cancer, lung resection can be used as a consolidation therapy,” Dr. Antonoff said. “It may offer a therapeutic benefit, as seen by prolonged survival and progression-free survival compared with best supportive care or maintenance therapy.”

However, she explained surgery is not always presented as an option for patients who have oligometastatic disease and emphasized why it’s critical for care teams to provide information on surgery.

“That discussion, that conversation, that consultation is the most important first step, because the concern is not that enough patients are being evaluated for surgery and going to surgery; the concern is that it’s not even being considered for far too many patients,” she said.

While there are multiple nuances to consider when it comes to surgery, it’s important to recognize that there are “no hard and fast rules” about who is a candidate for surgery, Dr. Antonoff said. She explained that it’s critical to start off with considering the “big picture” issues surrounding a patient’s candidacy for surgery by addressing this set of questions:

• What is their performance status?
• What is their pulmonary function?
• Are they able to lose the amount of lung needed?
• Will they tolerate single-lung ventilation?
• Do they have any major contraindications to major surgical procedures, such as severe heart disease or other medical conditions that make surgery higher risk?

In addition, it’s important to recognize that “in this era, we do not use the number of metastases as a strict cutoff,” Dr. Antonoff explained.

“We will operate on people who have more than three sites of metastases,” she said. “We will offer surgery even to people who have had a history of a previous pleural effusion, provided that it has responded well to systemic therapy.”

When it comes to the optimal patient age range for this type of surgery, Dr. Antonoff explained that it’s a nuanced consideration.

“In the space of stage IV lung cancer, we don’t typically consider age to be a sharp cutoff or an exclusion criterion from surgery,” Dr. Antonoff said. “We’ve seen substantial benefits for local consolidated therapy, which can be performed with surgery or radiation. We need to be thoughtful about those patients and whom we offer surgery and those whom we offer radiation because as of yet, we don’t have definitive evidence comparing the two side by side.”

Retrospective comparisons can be used to evaluate outcomes with surgery versus radiation, but there are limitations to this approach.

“We understand there’s a very substantial selection bias and that the healthier, stronger patients typically get surgery, so we don’t know if one is better than the other,” she said.

However, when examining options for older patients with comorbidities, “consideration of radiation as local consolidation is very much appropriate,” she said.

With so many patient characteristics and considerations to take into account, Dr. Antonoff emphasized that “it’s important for us to acknowledge that there are definitely different subgroups of patients.”

“We don’t have strict cutoffs such as polymetastatic disease as an exclusion criterion or pleural effusion as an automatic exclusion criterion, but it’s more about the big picture and how well we think the biological control is,” she said. “I would say the best candidates are not determined by how extensive the disease was at the beginning, but that we have a window where they have really good biological control, and we can manage the primary tumor to hopefully keep drugs that are working well working for even longer.”

Dr. Antonoff spoke about the importance of identifying patients who are good candidates for surgery and offering them the option.

“We’re pushing toward surgical resection for patients who are healthy and are strong and have a targetable mutation or are on a drug that’s working well,” she said. “We tend to believe that the cells that are going to be resistant to targeted therapy, those persister cells are often also the same cells that are resistant to radiation, but you can’t be resistant to surgery.”

Disease control and treatment feasibility are critical considerations when it comes to surgery, she said.

“Some patients have drugs that they can be on for a long time that work well, and some patients don’t,” Dr. Antonoff said. “Ultimately, I think it’s important to recognize that for each patient, every site of disease that they have needs to be either addressable by some form of local consolidation or needs to be addressable by a drug therapy that they can stay on long term. And if they don’t meet those criteria, then it’s not clear there’s a benefit to operating on any portion of their lung. For example, even if a patient doesn’t have a drug therapy that they can be on for a long time, if their only site of disease is the lung area that’s going to be resected, and one other site that’s going to be radiated, then they would be a great candidate.”

She explained why it’s critical to consider multiple factors, including timing, potential outcomes, and patient and disease characteristics, when considering surgery.

“We need to be very thoughtful about the patients to whom we do offer surgery, particularly when we’re talking about those with polymetastatic disease or any patient with stage IV disease,” Dr. Anonoff.

For more insights on this topic, watch the companion video, “Operating in Oligometastatic Lung Cancer: Dr. Antonoff Discusses Key Advances.”