What are the next steps for an adult patient with a history of invasive squamous cell carcinoma, who has undergone a bilobectomy with 2 lymph nodes containing cancer cells, indicating a stage T2B, N1 cancer, and has opted for surveillance instead of adjuvant chemotherapy?

Management of Stage T2B N1 Lung Squamous Cell Carcinoma with Patient Declining Adjuvant Chemotherapy

Adjuvant platinum-based chemotherapy is strongly recommended for this patient with completely resected (R0) stage T2B N1 lung squamous cell carcinoma, as it significantly improves survival in patients with node-positive disease, and surveillance alone substantially increases the risk of recurrence and death. 1

The Evidence for Adjuvant Chemotherapy

The American College of Chest Physicians guidelines explicitly state that in patients with resected non-small cell lung cancer (NSCLC) who were found to have N1 disease and achieved complete resection (R0) with good performance status, adjuvant platinum-based chemotherapy is recommended (Grade 1A evidence). 1 This should typically involve a doublet regimen for 3 to 4 cycles initiated within 12 weeks of surgery. 1

• The presence of 2 positive lymph nodes (N1 disease) automatically places this patient in a high-risk category where chemotherapy provides a proven survival benefit. 1
• Regional lymph node involvement by squamous cell carcinoma significantly increases the risk of recurrence and mortality. 2
• Patients with invasive squamous cell carcinomas metastatic to regional nodes constitute a group at high risk for recurrence and death, with regional nodal disease being the single most significant risk factor (hazard ratio 7.64) on multivariate analysis. 2

Understanding the Risks of Surveillance Alone

While the patient's choice must be respected, it is critical that both patient and family understand the substantial risks of declining chemotherapy:

• Surgery alone for node-positive lung cancer results in long-term survival rates that rarely exceed 25% when regional lymph nodes are involved. 1
• The presence of N1 disease means microscopic disease likely remains despite complete surgical resection, which is why adjuvant therapy exists. 1
• Without adjuvant chemotherapy, the likelihood of disease recurrence is significantly higher, and salvage treatment options become more limited and less effective. 1

Considerations for Sequential Adjuvant Radiotherapy

Sequential adjuvant radiotherapy should be considered when concern for local recurrence is high, though it should follow chemotherapy rather than replace it. 1

• Adjuvant postoperative radiotherapy reduces the incidence of local recurrence in patients with N1 disease, though its impact on overall survival is less clear than chemotherapy. 1
• If radiotherapy is pursued, adjuvant chemotherapy should be administered first, followed by radiotherapy—concurrent chemoradiotherapy is not recommended outside clinical trials in the adjuvant setting. 1
• This sequential approach may be particularly relevant given the patient has 2 positive nodes, indicating more extensive nodal involvement. 1

The Surveillance Plan If Chemotherapy Is Declined

If the patient maintains their decision to decline chemotherapy despite thorough counseling, a rigorous surveillance program is essential:

Close monitoring must include:

• CT chest imaging every 3-4 months for the first 2 years, as this is when most recurrences occur. 1, 3
• Clinical examination and symptom assessment at each visit, specifically evaluating for new respiratory symptoms, bone pain, or constitutional symptoms suggesting metastatic spread. 1
• Consideration of PET/CT imaging if any concerning findings emerge on surveillance CT, as PET has superior sensitivity for detecting recurrent disease. 1

Critical surveillance pitfalls to avoid:

• Non-compliance with the surveillance schedule dramatically worsens outcomes, as early detection of recurrence provides the best chance for salvage therapy. 3
• Any new or enlarging lymph nodes on imaging require tissue confirmation via ultrasound-guided fine needle aspiration or biopsy. 1, 3
• New pulmonary nodules or masses require prompt evaluation, as these may represent either recurrence or new primary tumors. 3

Ongoing Counseling Strategy

The oncology team should maintain an open dialogue about reconsidering adjuvant therapy, particularly as the patient recovers strength. 1

• The 12-week window for initiating adjuvant chemotherapy provides time for recovery while maintaining efficacy. 1
• Emphasize that adjuvant chemotherapy in this setting typically involves 3-4 cycles of a platinum doublet, which is time-limited and has manageable side effects in most patients. 1
• Frame the discussion around quality of life: while chemotherapy has short-term side effects, disease recurrence has far more devastating and permanent impacts on quality of life and survival. 1
• Consider involving palliative care or supportive oncology early to address concerns about treatment tolerability and optimize symptom management during therapy if the patient reconsiders. 1

Multidisciplinary Tumor Board Review

This case should be presented at a multidisciplinary tumor board to ensure consensus on the treatment plan and surveillance strategy. 3

• The tumor board can provide unified messaging to the patient about the importance of adjuvant therapy. 3
• Radiation oncology input is valuable for determining whether adjuvant radiotherapy should be part of the treatment plan. 1
• Medical oncology can discuss specific chemotherapy regimens, expected side effects, and supportive care measures. 1