What are the alternative treatment options for an adult patient with stage pT2b N1 R0 invasive squamous cell non-small cell lung cancer (NSCLC) and a history of smoking who declines chemotherapy?

Alternative Treatment Options for Stage pT2b N1 R0 Squamous NSCLC Without Chemotherapy

For a patient with resected stage pT2b N1 R0 squamous NSCLC who declines adjuvant chemotherapy, postoperative radiotherapy should be strongly considered, particularly given the R0 resection with N1 nodal involvement, followed by intensive surveillance and aggressive smoking cessation interventions. 1

Postoperative Radiotherapy

Postoperative radiotherapy represents the primary alternative therapeutic intervention when chemotherapy is declined. 1

• In cases where adjuvant chemotherapy is not administered, postoperative radiotherapy should be considered for patients with N1 disease, as it may provide locoregional control benefits 1
• The 2014 ESMO consensus specifically addresses that when both chemotherapy and radiotherapy are indicated but chemotherapy is declined, radiotherapy can still be administered 1
• Definitive-dose thoracic radiotherapy should be no less than 60 Gy in 1.8- to 2-Gy fractions for adequate disease control 2

Critical caveat: The evidence for postoperative radiotherapy alone (without chemotherapy) in N1 disease is not as robust as the combination approach, but it remains a reasonable option when systemic therapy is refused 1

Intensive Surveillance Strategy

A structured surveillance program becomes paramount when active adjuvant treatment is declined, as early detection of recurrence may allow for salvage interventions. 1

Surveillance Schedule:

• Every 6 months for 2-3 years: History, physical examination, and contrast-enhanced spiral chest CT at 12 and 24 months 1
• After 3 years: Annual visits with history, physical examination, and chest CT to detect second primary tumors 1
• Avoid routine PET-CT for surveillance, as it has high sensitivity but relatively low specificity leading to false-positive findings 1

Symptom-Directed Imaging:

• CT scan of chest/abdomen, brain MRI, bone scan, and laboratory studies should only be performed when clinically indicated by new symptoms, not routinely in asymptomatic patients 1
• This approach prevents unnecessary interventions while maintaining vigilance for treatable recurrence 1

Smoking Cessation Interventions

Smoking cessation is the single most impactful intervention for patients treated with curative intent, as it reduces the risk of second primary NSCLC and improves overall outcomes. 1

• Combining behavioral techniques with pharmacotherapy represents the preferred approach for smoking cessation 1
• In curatively treated patients, smoking cessation has substantial impact on preventing second primary cancers, which is a major cause of mortality in this population 1
• Avoidance of occupational and environmental carcinogenic exposures should also be emphasized 1

Management of Potential Recurrence

If recurrence is detected during surveillance, treatment options depend on the pattern and extent of disease:

Oligometastatic Recurrence:

• Resection of solitary metastases (brain, adrenal, contralateral lung) can be considered in highly selected fit patients 1, 3
• Stereotactic body radiotherapy (SBRT) for isolated lesions represents a minimally invasive option 4

Locoregional Recurrence:

• Definitive radiotherapy with curative intent may be feasible depending on prior radiation exposure 2
• Palliative radiotherapy for symptomatic control of pain, hemoptysis, cough, dyspnea, or superior vena cava syndrome 1

Systemic Recurrence:

• Platinum-based chemotherapy becomes the standard approach if the patient's performance status and preferences change 1
• For squamous histology, pembrolizumab plus carboplatin and paclitaxel or nab-paclitaxel is recommended if PD-L1 testing is available and immunotherapy is not contraindicated 1

Supportive Care Measures

Proactive symptom management and quality of life optimization are essential components of care when curative-intent adjuvant therapy is declined. 1

• Regular assessment of performance status, as this determines eligibility for future therapeutic interventions if disease recurs 1, 5
• Early palliative care referral should be considered, as it improves quality of life and can be delivered alongside surveillance 5
• Management of comorbidities, particularly cardiovascular and pulmonary conditions common in smokers with squamous NSCLC 6

What NOT to Do

Avoid chemopreventive agents and antioxidants, as their use for NSCLC prevention is investigational and not recommended in clinical practice 1

Do not perform routine PET-CT surveillance, as the high false-positive rate leads to unnecessary anxiety and interventions without survival benefit 1

Do not delay discussions about treatment preferences for potential recurrence, as establishing goals of care early allows for more timely intervention if disease progression occurs 1, 5