Early-stage lung cancer—what do the experts recommend?
Authors: N.B. Leighl, G. Curigliano
Journal: Annals of Oncology (2014)

In this issue of the Annals, the European Society of Medical Oncology (ESMO) presents expert recommendations from the 2nd Consensus Conference on Lung Cancer, focusing on early-stage lung cancer diagnosis, treatment, and surveillance after curative therapy [1.Vansteenkiste J. Crino L. Dooms C. et al.2nd ESMO Consensus Conference on Lung Cancer: early stage non-small cell lung cancer consensus on diagnosis, treatment and follow-up.Ann Oncol. 2014; 25: 1462-1474Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar]. The report issues recommendations based on expert discussion of 14 questions in early-stage lung cancer, complementing the recently updated (2013) ESMO Clinical Practice Guidelines (CPG) for early and locally advanced non-small cell lung cancer (NSCLC) [2.Vansteenkiste J. De Ruysscher D. Eberhardt W.E.E. et al.Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2013; 24: vi89-vi98Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar]. Similar to the guideline development process, experts graded evidence that they selected from published literature to address key questions, but did not conduct a formal systematic review of all existing evidence for each topic. How does a consensus conference report differ from an evidence-based practice guideline?The principle of a consensus conference relies on a clear distinction between those who provide the evidence (experts) and those who draw the final recommendations (the jury). The jury consists of individuals with sufficient background knowledge to cover the perspectives of all stakeholders without being involved directly in the topic under evaluation. The organizing committee, the experts, and the jury interact within three phases: preparation, the actual consensus conference, and deliberations. Each question is addressed by a panel of experts, leading to the proposition of recommendations at the conference meeting, which are challenged by the jury and the audience. Based on all available information, the jury finalizes the consensus recommendations, which are eventually published and made available to all [3.Grundahl J. Joss S. Durant J. The Danish consensus conference model.Public Participation in Science: the Role of Consensus Conferences in Europe. Science Museum, London1995Google Scholar]. There are several potential limitations in this process. First, recommendations are influenced by the opinions, clinical experience, and composition of the guideline development group. The beliefs to which experts subscribe in areas of uncertainty, often in the face of conflicting data, can be based on misconceptions and personal recollections that misrepresent population norms. Second, patients' needs may not be the only priority in making recommendations. Practices that are suboptimal from the patient's perspective may be recommended to help control costs, serve societal needs, or protect special interests (those of doctors, risk managers, or politicians, for example). What is best for patients overall, as recommended in guidelines, may be inappropriate for the individual; blanket recommendations, rather than a menu of options or recommendations for shared decision making, ignore patients' preferences [4.Joss S. Joss S. Durant J. Evaluating consensus conferences: necessity or luxury?. Science Museum, London1995: 41-49Google Scholar]. Lay versions of guidelines, if improperly constructed and worded, may mislead or confuse patients and compromise the doctor–patient relationship. The well-intentioned effort to make guidelines explicit and practical encourages the injudicious use of certain words (‘should’ instead of ‘may,’ for example), arbitrary numbers (such as months of treatment, intervals between screening tests), and simplistic algorithms when supporting evidence may be lacking. Algorithms that reduce patient care into a sequence of binary (yes/no) decisions often do injustice to the complexity of medicine and the parallel and iterative thought processes inherent in clinical judgment. The consensus conference should also prioritize areas for future research. The existence of weak recommendations or absence of recommendation in a controversial area might serve as a basis to identify key questions that require convincing answers [5.Lesurtel M. Perrier A. Bossuyt P.M. et al.An independent jury-based consensus conference model for the development of recommendations in medico-surgical practice.Surgery. 2014; 155: 390-397Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar].How does the current consensus statement add to the ESMO CPG for early-stage lung cancer? While most recommendations are unchanged, there are several areas where the experts provide additional advice for clinicians and patients. For example ESMO's overall recommendations for lung cancer screening remain similar, but experts agree that high-volume thoracic oncology centers with low-dose computed tomography (LDCT) screening experience ‘can’ offer dedicated LDCT screening programs outside a clinical trial to those at high risk, with appropriate quality control measures and integrated smoking cessation programs. Individuals seeking LDCT screening should be referred to such programs rather than undergoing ad hoc imaging. With respect to the target population and screening interval, it is recommended that these should mirror the randomized National Lung Screening Trial (NLST) until further evidence is available [6.Aberle D.R. Adams A.M. National Lung Screening Trial Research Team et al.Reduced lung cancer mortality with low-dose computed tomographic screening.New Engl J Med. 2011; 365: 395-409Crossref PubMed Scopus (6539) Google Scholar], similar to recommendations published by other groups [7.Bach P.B. Mirkin J.N. Oliver T.K. et al.Benefits and harms of CT screening for lung cancer.JAMA. 2012; 307: 2418-2429Crossref PubMed Scopus (930) Google Scholar, 8.National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: non-small cell lung cancer version.. 2014; 3 (20 May 2014, date last accessed)http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdfGoogle Scholar, 9.Roberts H. Walker-Dilks C. Sivjee K. et al.Screening high-risk populations for lung cancer: guideline recommendations.J Thorac Oncol. 2013; 8: 1232-1237Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 10.Screening for Lung Cancer, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm (20 May 2014, date last accessed).Google Scholar]. Challenges for implementation remain issues of how to minimize false positives, overdiagnosis (of adenocarcinoma in situ, for example), large-scale participation of those at risk, and costs, with a preliminary cost-effectiveness estimate from the NLST of $72 900 USD per quality-adjusted life year [11.Black W.C. Cost effectiveness of CT screening in the National Lung Screening Trial.in: 2nd Joint Meeting of the National Cancer Institute Board of Scientific Advisors & National Cancer Advisory Board2013http://deainfo.nci.nih.gov/advisory/ncab/165_0613/minutes.pdfGoogle Scholar].With respect to clinically detected lung nodules (i.e. not screen-detected), the expert panel recommends that clinicians continue to use existing guidelines for investigation of solitary pulmonary nodules, and that sole use of algorithms derived from lung cancer screening studies, nodule volume doubling time, or positron emission tomography should not be used to establish a diagnosis of lung cancer. The report also highlights the importance of confirming a lung cancer diagnosis before treatment, including the challenges for patients referred for stereotactic ablative radiotherapy (SABR), who are often not well enough for invasive procedures. In the event that obtaining tissue for diagnosis is too dangerous for the patient, the consensus statement recommends that there should be an at least 85% chance of malignancy before proceeding with SABR. The group also adds specific recommendations for preoperative cardiopulmonary function assessment to the existing ESMO guidelines, including use of the externally validated revised cardiac risk index and guidelines from the task force of the European Respiratory Society and European Society of Thoracic Surgeons on fitness for curative lung cancer therapy, similar to that proposed by other groups [12.Brunelli A. Cassivi S.D. Fibla J. et al.External validation of the recalibrated thoracic revised cardiac risk index for predicting the risk of major cardiac complications after lung resection.Ann Thorac Surg. 2011; 92: 445-448Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 13.Brunelli A. Charlous A. Bolliger C.T. et al.ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy).Eur Respir J. 2009; 34: 17-41Crossref PubMed Scopus (591) Google Scholar, 14.Detterbeck F.C. Lewis S.Z. Diekemper R. et al.Executive summary. Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.Chest. 2013; 143: 7S-37SAbstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar].The expert panel, recognizing lobectomy as the standard therapy for operable T1N0 lung cancer, continues to recommend this as the standard of care for tumors ≤2 cm with a solid appearance on imaging. Randomized trials are ongoing, asking the question of whether sublobar resection may be an alternative to lobectomy in small peripheral tumors 2 cm or smaller, (CALGB 140503/NCT00499330 and JCOG 0804/WJOG 4607C). The panel also recognized sublobar resection as acceptable management of ground glass opacities or in situ or minimally invasive adenocarcinoma. There is growing evidence to support excellent outcomes with minimal resection in patients with these abnormalities [15.Tsutani Y. Miyata Y. Nakayama H. et al.Appropriate sublobar resection choice for ground glass opacity-dominant clinical stage IA lung adenocarcinoma: wedge resection or segmentectomy.Chest. 2014; 145: 66-71Abstract Full Text Full Text PDF PubMed Scopus (222) Google Scholar, 16.Cao C. Gupta S. Chandrakumar D. et al.Meta-analysis of intentional sublobar resections versus lobectomy for early stage non-small cell lung cancer.Ann Cardiothorac Surg. 2014; 3: 134-141PubMed Google Scholar], but this leads to other questions. Although these noninvasive lesions can be safely removed, should they all be routinely resected even with minimal resection techniques? What is the natural history of these cases, and how many contribute to overdiagnosis, where the tumor itself will not cause morbidity or mortality, although resection may?The group also addresses a key question faced by all multidisciplinary tumor boards on a recurring basis, namely the management of multifocal carcinoma of the lung. The expert consensus recommendation is for complete resection whenever possible, followed by consideration of SABR and then systemic therapy. Some of these patients may be cured by surgical resection, most likely those with a limited number of synchronous bilateral lesions. High-quality randomized data do not exist for the population with multiple lesions, and studies are often confounded by patient selection for radical treatment. The presence of multiple unilateral lesions, advanced age, male sex, nodal involvement (N2), and involvement of three or more lobes are likely associated with worse outcome [17.Tanvetyanon T. Finley D.J. Fabian T. et al.Prognostic factors for survival after complete resections of synchronous lung cancers in multiple lobes: pooled analysis based on individual patient data.Ann Oncol. 2013; 24: 889-894Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 18.Cheung W.Y. Hwang D.M. Chung T.B. et al.Initial treatment strategies and outcomes for multifocal bronchioloalveolar carcinoma.Clin Lung Cancer. 2009; 10: 187-192Abstract Full Text PDF PubMed Scopus (3) Google Scholar]. Unfortunately, there are many remaining questions. How many resections are too many? Should other technologies be considered, such as radiofrequency ablation? Should those with EGFR mutant or ALK rearranged lung cancer receive targeted TKI therapy instead? Should lung transplantation ever be considered (and for whom)?For patients with complications or progression post-SABR, the expert consensus recommends surgical salvage be offered, acknowledging potential for more difficult surgery and higher operative risk.For adjuvant therapy, the panel offers practical advice about the sequencing of therapy in those selected patients for whom both adjuvant radiation and adjuvant chemotherapy would be offered (chemotherapy followed by radiotherapy, not concurrent delivery). Indirect data to support this recommendation come from the ANITA trial, where postoperative radiotherapy was offered after completion of vinorelbine/cisplatin chemotherapy for completely resected N2 disease and was associated with better outcome [19.Douillard J.Y. Rosell R. De Lena M. et al.Impact of postoperative radiation therapy on survival in patients with complete resection and stage I, II, or IIIA non-small-cell lung cancer treated with adjuvant chemotherapy: the adjuvant Navelbine International Trialist Association (ANITA) Randomized Trial.Int J Radiat Oncol Biol Phys. 2008; 72: 695-701Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar]. Results of the Eastern Cooperative Oncology Group trial E3590 discourage use of concurrent administration in the adjuvant setting, where investigators demonstrated that adjuvant concurrent etoposide/cisplatin plus radiotherapy was not superior to adjuvant radiotherapy alone in resected stage II and IIIA NSCLC [20.Keller S.M. Adak S. Wagner H. et al.A randomized trial of postoperative adjuvant therapy in patients with completely resected stage II or IIIA non-small cell lung cancer.N Engl J Med. 2000; 343: 1217-1222Crossref PubMed Scopus (446) Google Scholar].The other area of guidance beyond the literature provided by the consensus report addresses the question of follow-up after curative lung cancer therapy. It has been previously demonstrated that up to a third of patients with resected lung cancer will experience asymptomatic relapse within the first 13 months (median) post treatment, and approximately half of these may be suitable for salvage curative therapy [21.Cho S. Lee E.B. A follow-up of integrated positron emission tomography/computed tomography after curative resection of non-small-cell lung cancer in asymptomatic patients.J Thorac Cardiovasc Surg. 2010; 139: 1447-1451Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Additional recommendations of the panel beyond the ESMO CPG include surveillance every 6 months for 2–3 years after initial therapy, spiral chest CT (preferably contrast enhanced) at 12 and 24 months post treatment, and visits and imaging annually thereafter. These guidelines are among the more conservative compared with surveillance imaging recommended by other groups [8.National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: non-small cell lung cancer version.. 2014; 3 (20 May 2014, date last accessed)http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdfGoogle Scholar, 14.Detterbeck F.C. Lewis S.Z. Diekemper R. et al.Executive summary. Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.Chest. 2013; 143: 7S-37SAbstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar]. The French Intergroup for Thoracic Oncology has completed accrual to a study (NCT00198341) of over 1744 patients with resected early-stage lung cancer, randomized to routine clinical assessment, and chest radiography with or without CT imaging and bronchoscopy. This trial will define the impact of CT imaging on survival and other key outcomes. For those undergoing SABR, the panel recommends a more intense program of CT imaging 6 monthly for the first 3 years post treatment in order to establish benchmarks for treatment-related effects and local control rates, with less intensive follow-up recommended for those not suitable for salvage therapy.In the absence of high-quality evidence, expert advice can be invaluable. The ESMO lung cancer consensus conference has successfully provided the support of expert recommendations in several areas where evidence is currently lacking, and at the same time raises more questions to be answered. Vive la consensus conference? It's your turn to be the jury.disclosureThe authors have declared no conflicts of interest. In this issue of the Annals, the European Society of Medical Oncology (ESMO) presents expert recommendations from the 2nd Consensus Conference on Lung Cancer, focusing on early-stage lung cancer diagnosis, treatment, and surveillance after curative therapy [1.Vansteenkiste J. Crino L. Dooms C. et al.2nd ESMO Consensus Conference on Lung Cancer: early stage non-small cell lung cancer consensus on diagnosis, treatment and follow-up.Ann Oncol. 2014; 25: 1462-1474Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar]. The report issues recommendations based on expert discussion of 14 questions in early-stage lung cancer, complementing the recently updated (2013) ESMO Clinical Practice Guidelines (CPG) for early and locally advanced non-small cell lung cancer (NSCLC) [2.Vansteenkiste J. De Ruysscher D. Eberhardt W.E.E. et al.Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2013; 24: vi89-vi98Abstract Full Text Full Text PDF PubMed Scopus (424) Google Scholar]. Similar to the guideline development process, experts graded evidence that they selected from published literature to address key questions, but did not conduct a formal systematic review of all existing evidence for each topic. How does a consensus conference report differ from an evidence-based practice guideline? The principle of a consensus conference relies on a clear distinction between those who provide the evidence (experts) and those who draw the final recommendations (the jury). The jury consists of individuals with sufficient background knowledge to cover the perspectives of all stakeholders without being involved directly in the topic under evaluation. The organizing committee, the experts, and the jury interact within three phases: preparation, the actual consensus conference, and deliberations. Each question is addressed by a panel of experts, leading to the proposition of recommendations at the conference meeting, which are challenged by the jury and the audience. Based on all available information, the jury finalizes the consensus recommendations, which are eventually published and made available to all [3.Grundahl J. Joss S. Durant J. The Danish consensus conference model.Public Participation in Science: the Role of Consensus Conferences in Europe. Science Museum, London1995Google Scholar]. There are several potential limitations in this process. First, recommendations are influenced by the opinions, clinical experience, and composition of the guideline development group. The beliefs to which experts subscribe in areas of uncertainty, often in the face of conflicting data, can be based on misconceptions and personal recollections that misrepresent population norms. Second, patients' needs may not be the only priority in making recommendations. Practices that are suboptimal from the patient's perspective may be recommended to help control costs, serve societal needs, or protect special interests (those of doctors, risk managers, or politicians, for example). What is best for patients overall, as recommended in guidelines, may be inappropriate for the individual; blanket recommendations, rather than a menu of options or recommendations for shared decision making, ignore patients' preferences [4.Joss S. Joss S. Durant J. Evaluating consensus conferences: necessity or luxury?. Science Museum, London1995: 41-49Google Scholar]. Lay versions of guidelines, if improperly constructed and worded, may mislead or confuse patients and compromise the doctor–patient relationship. The well-intentioned effort to make guidelines explicit and practical encourages the injudicious use of certain words (‘should’ instead of ‘may,’ for example), arbitrary numbers (such as months of treatment, intervals between screening tests), and simplistic algorithms when supporting evidence may be lacking. Algorithms that reduce patient care into a sequence of binary (yes/no) decisions often do injustice to the complexity of medicine and the parallel and iterative thought processes inherent in clinical judgment. The consensus conference should also prioritize areas for future research. The existence of weak recommendations or absence of recommendation in a controversial area might serve as a basis to identify key questions that require convincing answers [5.Lesurtel M. Perrier A. Bossuyt P.M. et al.An independent jury-based consensus conference model for the development of recommendations in medico-surgical practice.Surgery. 2014; 155: 390-397Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. How does the current consensus statement add to the ESMO CPG for early-stage lung cancer? While most recommendations are unchanged, there are several areas where the experts provide additional advice for clinicians and patients. For example ESMO's overall recommendations for lung cancer screening remain similar, but experts agree that high-volume thoracic oncology centers with low-dose computed tomography (LDCT) screening experience ‘can’ offer dedicated LDCT screening programs outside a clinical trial to those at high risk, with appropriate quality control measures and integrated smoking cessation programs. Individuals seeking LDCT screening should be referred to such programs rather than undergoing ad hoc imaging. With respect to the target population and screening interval, it is recommended that these should mirror the randomized National Lung Screening Trial (NLST) until further evidence is available [6.Aberle D.R. Adams A.M. National Lung Screening Trial Research Team et al.Reduced lung cancer mortality with low-dose computed tomographic screening.New Engl J Med. 2011; 365: 395-409Crossref PubMed Scopus (6539) Google Scholar], similar to recommendations published by other groups [7.Bach P.B. Mirkin J.N. Oliver T.K. et al.Benefits and harms of CT screening for lung cancer.JAMA. 2012; 307: 2418-2429Crossref PubMed Scopus (930) Google Scholar, 8.National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: non-small cell lung cancer version.. 2014; 3 (20 May 2014, date last accessed)http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdfGoogle Scholar, 9.Roberts H. Walker-Dilks C. Sivjee K. et al.Screening high-risk populations for lung cancer: guideline recommendations.J Thorac Oncol. 2013; 8: 1232-1237Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 10.Screening for Lung Cancer, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspslung.htm (20 May 2014, date last accessed).Google Scholar]. Challenges for implementation remain issues of how to minimize false positives, overdiagnosis (of adenocarcinoma in situ, for example), large-scale participation of those at risk, and costs, with a preliminary cost-effectiveness estimate from the NLST of $72 900 USD per quality-adjusted life year [11.Black W.C. Cost effectiveness of CT screening in the National Lung Screening Trial.in: 2nd Joint Meeting of the National Cancer Institute Board of Scientific Advisors & National Cancer Advisory Board2013http://deainfo.nci.nih.gov/advisory/ncab/165_0613/minutes.pdfGoogle Scholar]. With respect to clinically detected lung nodules (i.e. not screen-detected), the expert panel recommends that clinicians continue to use existing guidelines for investigation of solitary pulmonary nodules, and that sole use of algorithms derived from lung cancer screening studies, nodule volume doubling time, or positron emission tomography should not be used to establish a diagnosis of lung cancer. The report also highlights the importance of confirming a lung cancer diagnosis before treatment, including the challenges for patients referred for stereotactic ablative radiotherapy (SABR), who are often not well enough for invasive procedures. In the event that obtaining tissue for diagnosis is too dangerous for the patient, the consensus statement recommends that there should be an at least 85% chance of malignancy before proceeding with SABR. The group also adds specific recommendations for preoperative cardiopulmonary function assessment to the existing ESMO guidelines, including use of the externally validated revised cardiac risk index and guidelines from the task force of the European Respiratory Society and European Society of Thoracic Surgeons on fitness for curative lung cancer therapy, similar to that proposed by other groups [12.Brunelli A. Cassivi S.D. Fibla J. et al.External validation of the recalibrated thoracic revised cardiac risk index for predicting the risk of major cardiac complications after lung resection.Ann Thorac Surg. 2011; 92: 445-448Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 13.Brunelli A. Charlous A. Bolliger C.T. et al.ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy).Eur Respir J. 2009; 34: 17-41Crossref PubMed Scopus (591) Google Scholar, 14.Detterbeck F.C. Lewis S.Z. Diekemper R. et al.Executive summary. Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.Chest. 2013; 143: 7S-37SAbstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar]. The expert panel, recognizing lobectomy as the standard therapy for operable T1N0 lung cancer, continues to recommend this as the standard of care for tumors ≤2 cm with a solid appearance on imaging. Randomized trials are ongoing, asking the question of whether sublobar resection may be an alternative to lobectomy in small peripheral tumors 2 cm or smaller, (CALGB 140503/NCT00499330 and JCOG 0804/WJOG 4607C). The panel also recognized sublobar resection as acceptable management of ground glass opacities or in situ or minimally invasive adenocarcinoma. There is growing evidence to support excellent outcomes with minimal resection in patients with these abnormalities [15.Tsutani Y. Miyata Y. Nakayama H. et al.Appropriate sublobar resection choice for ground glass opacity-dominant clinical stage IA lung adenocarcinoma: wedge resection or segmentectomy.Chest. 2014; 145: 66-71Abstract Full Text Full Text PDF PubMed Scopus (222) Google Scholar, 16.Cao C. Gupta S. Chandrakumar D. et al.Meta-analysis of intentional sublobar resections versus lobectomy for early stage non-small cell lung cancer.Ann Cardiothorac Surg. 2014; 3: 134-141PubMed Google Scholar], but this leads to other questions. Although these noninvasive lesions can be safely removed, should they all be routinely resected even with minimal resection techniques? What is the natural history of these cases, and how many contribute to overdiagnosis, where the tumor itself will not cause morbidity or mortality, although resection may? The group also addresses a key question faced by all multidisciplinary tumor boards on a recurring basis, namely the management of multifocal carcinoma of the lung. The expert consensus recommendation is for complete resection whenever possible, followed by consideration of SABR and then systemic therapy. Some of these patients may be cured by surgical resection, most likely those with a limited number of synchronous bilateral lesions. High-quality randomized data do not exist for the population with multiple lesions, and studies are often confounded by patient selection for radical treatment. The presence of multiple unilateral lesions, advanced age, male sex, nodal involvement (N2), and involvement of three or more lobes are likely associated with worse outcome [17.Tanvetyanon T. Finley D.J. Fabian T. et al.Prognostic factors for survival after complete resections of synchronous lung cancers in multiple lobes: pooled analysis based on individual patient data.Ann Oncol. 2013; 24: 889-894Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 18.Cheung W.Y. Hwang D.M. Chung T.B. et al.Initial treatment strategies and outcomes for multifocal bronchioloalveolar carcinoma.Clin Lung Cancer. 2009; 10: 187-192Abstract Full Text PDF PubMed Scopus (3) Google Scholar]. Unfortunately, there are many remaining questions. How many resections are too many? Should other technologies be considered, such as radiofrequency ablation? Should those with EGFR mutant or ALK rearranged lung cancer receive targeted TKI therapy instead? Should lung transplantation ever be considered (and for whom)? For patients with complications or progression post-SABR, the expert consensus recommends surgical salvage be offered, acknowledging potential for more difficult surgery and higher operative risk. For adjuvant therapy, the panel offers practical advice about the sequencing of therapy in those selected patients for whom both adjuvant radiation and adjuvant chemotherapy would be offered (chemotherapy followed by radiotherapy, not concurrent delivery). Indirect data to support this recommendation come from the ANITA trial, where postoperative radiotherapy was offered after completion of vinorelbine/cisplatin chemotherapy for completely resected N2 disease and was associated with better outcome [19.Douillard J.Y. Rosell R. De Lena M. et al.Impact of postoperative radiation therapy on survival in patients with complete resection and stage I, II, or IIIA non-small-cell lung cancer treated with adjuvant chemotherapy: the adjuvant Navelbine International Trialist Association (ANITA) Randomized Trial.Int J Radiat Oncol Biol Phys. 2008; 72: 695-701Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar]. Results of the Eastern Cooperative Oncology Group trial E3590 discourage use of concurrent administration in the adjuvant setting, where investigators demonstrated that adjuvant concurrent etoposide/cisplatin plus radiotherapy was not superior to adjuvant radiotherapy alone in resected stage II and IIIA NSCLC [20.Keller S.M. Adak S. Wagner H. et al.A randomized trial of postoperative adjuvant therapy in patients with completely resected stage II or IIIA non-small cell lung cancer.N Engl J Med. 2000; 343: 1217-1222Crossref PubMed Scopus (446) Google Scholar]. The other area of guidance beyond the literature provided by the consensus report addresses the question of follow-up after curative lung cancer therapy. It has been previously demonstrated that up to a third of patients with resected lung cancer will experience asymptomatic relapse within the first 13 months (median) post treatment, and approximately half of these may be suitable for salvage curative therapy [21.Cho S. Lee E.B. A follow-up of integrated positron emission tomography/computed tomography after curative resection of non-small-cell lung cancer in asymptomatic patients.J Thorac Cardiovasc Surg. 2010; 139: 1447-1451Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar]. Additional recommendations of the panel beyond the ESMO CPG include surveillance every 6 months for 2–3 years after initial therapy, spiral chest CT (preferably contrast enhanced) at 12 and 24 months post treatment, and visits and imaging annually thereafter. These guidelines are among the more conservative compared with surveillance imaging recommended by other groups [8.National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: non-small cell lung cancer version.. 2014; 3 (20 May 2014, date last accessed)http://www.nccn.org/professionals/physician_gls/pdf/nscl.pdfGoogle Scholar, 14.Detterbeck F.C. Lewis S.Z. Diekemper R. et al.Executive summary. Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.Chest. 2013; 143: 7S-37SAbstract Full Text Full Text PDF PubMed Scopus (308) Google Scholar]. The French Intergroup for Thoracic Oncology has completed accrual to a study (NCT00198341) of over 1744 patients with resected early-stage lung cancer, randomized to routine clinical assessment, and chest radiography with or without CT imaging and bronchoscopy. This trial will define the impact of CT imaging on survival and other key outcomes. For those undergoing SABR, the panel recommends a more intense program of CT imaging 6 monthly for the first 3 years post treatment in order to establish benchmarks for treatment-related effects and local control rates, with less intensive follow-up recommended for those not suitable for salvage therapy. In the absence of high-quality evidence, expert advice can be invaluable. The ESMO lung cancer consensus conference has successfully provided the support of expert recommendations in several areas where evidence is currently lacking, and at the same time raises more questions to be answered. Vive la consensus conference? It's your turn to be the jury. disclosureThe authors have declared no conflicts of interest. The authors have declared no conflicts of interest.