David Spigel, MD: Jaspal, one thing that comes up sometimes is where I see a patient with stage I cancer, and somebody—maybe the internist—has said to me, “She’s not a surgical candidate. We want her to see a medical oncologist.” Who makes the call on whether a patient is a surgical candidate?

Jaspal Singh, MD, MHS: I think you’ve uncovered one of the major issues right now in thoracic oncology. The idea of what biases go into that decision, how important it is to think about the education of all people that person touches, and not just touches, but also with social media proliferation, a lot of our patients now have done an internet search on lung cancer. They immediately, despite having a curative situation, potentially, get very upset. They start thinking a lot of different things and ask a lot of questions.

I think that’s our job. This webinar is one example of trying to get the message out in public that, timeout, let’s get the information, let’s think through this space more methodically. Let’s not rule out a surgical candidacy based on what we know. Just like medical oncology has become much more sophisticated, the surgeons have done a tremendous job in their innovations and all the advances in surgical treatments. Now they’re getting outstanding outcomes [versus] traditionally like when I trained back in the day at Duke [University]. [With] people who are being operated on now, it’s pretty impressive.

We also see it in the pulmonary community, “People are too high risk for a bronchoscopy.” We treat oxygen-dependent [patients], people who are very frail, very debilitated, and we have incredible outcomes despite all the comorbidities. The medical science has advanced. It has done it for all phases of the thoracic oncology world. I would say to err on the side of assuming your patient wants the best chance of survival.

David Spigel, MD: David, we’ll finish this case with your thoughts about that very question. Obviously, you’re a little biased. What would it take for you not to operate on a patient? I presume it’s the obvious: cardiac and pulmonary status.

David H. Harpole Jr, MD: I’ll throw this out there; I’m a co-PI [principal investigator] of the VALOR trial with Drew Moghanaki, [MD, MPH,] from [the University of California Los Angeles] who’s a radiation therapist. We’re looking at normal-risk patients being randomized to lobectomy or SBRT [stereotactic body radiotherapy]. I think that this may be changing. I always remind people that I am a modality person, but I am an oncologist first and a surgeon second, so I want my patient to get the best therapy possible, which may or may not be surgery. It’s pretty rare for us to have people who aren’t surgical candidates for something. But the point of putting our heads together as a multidisciplinary team is deciding, is that the best treatment for this individual patient? I think that’s the key question here.

David Spigel, MD: What is the future for stage I cancers besides surgery alone? This is a subject of ongoing investigation. It has not been the most attractive area initially for our pharmaceutical and biotechnology partners, but I think it’s changing. Particularly with, as we mentioned, the TKIs [tyrosine kinase inhibitors], but also immunotherapy finding its way into stage II and III adjuvant care and neoadjuvant care, I think we can imagine a future where there might be some high-risk stage I cancers where hopefully in randomized trials an intervention shows benefit in terms of OS [overall survival]. That may be immunotherapy, but who knows? We have to wait on those data to come out. You guys know well that stage I has a bit of variation in terms of risk for recurrence, so we shouldn’t just treat it as 1 entity. There can be very low risk and very high risk in stage I.

Transcript edited for clarity.