When treating two primary early stage lung cancers with SBRT, do you treat both at the same time or stage your treatment?

A completely non-clinical but nevertheless "real world" thought:

If you deal with Evicore, the insurance pre-auth gatekeepers for many private insurances in the U.S. (BCBS e.g.), and they "catch wind" that you're not going to treat such a patient's lesions synchronously, it's highly likely they will deny payment for a second SBRT and will argue you should do both SBRTs together. I say this from rather a lot of experience. They also argue similarly in SRS cranial cases with >1 cranial met. If your institution, practice, billers, etc., will allow a "no charge" second treatment, maybe it's not a big deal. Again, in my experience, this is usually not allowed. For non-private insurance patients this hasn't been a problem. Yet.

*per ASTRO's new lun...

This is an interesting problem. Treatment depends on where they are anatomically and patient factors...e.g. a compliant patient, location of tumors and size of tumors. Do you need to biopsy both? Ideally yes, if possible, but I am treating PET positive, growing or new lesions in high risk patients i.e. big time smokers, without biopsy. There is a growing body of literature to support treatment without biopsy. I generally try to treat two-three lesions at the same time on Tomotherapy, not so easy on Truebeam. The key is a very good vac-loc, abdominal compression for both patient immobilisation and breathing control (never gating!). I have had good success with targeting and treating more than one lesion synchronously with a very low local fa...

This is a very practical and not-uncommon scenario without clear evidence-based answers (as far as I know). Regarding biopsy, our practice has been to obtain a biopsy whenever feasible. In this scenario, I don't think you could really conclude that these are two separate primaries (as opposed to satellite lesion or mets) without biopsying both. But assuming that both lesions have been worked up and concluded to represent synchronous primary NSCLC, I have been treating both at the same time. But there's a further question of what "at the same time" means: 1) complete one course of SBRT and then start the second, 2) treat both lesions synchronously but stagger the days (Monday for lesion 1/fraction 1, Tuesday for lesion 2/fraction 1, Wednesda...

This is a pretty common scenario. I have done all three approaches: 1) treat each lesions on the same day (usually no more than 2), stagger the treatment on different but consecutive days 3) complete the course on one lesion then start the 2nd. Generally speaking, I have not noted any difference in tumor control, compliance, acute/late toxicity with any of these approaches.

It comes down to a few pragmatic and technical considerations: If the patient lives far away, have issue with access to care with transportation, then it would make sense to shorten the # of days of treatment as much as possible. If the two lesions are reasonably close together, and in the plan, the total dose per day is a contribution of the main treatment, with some do...

This is not an uncommon situation. I have treated two simultaneous primaries or metastases with SBRT at the same time, usually on the same days. For example, this week I am starting treatment on a patient with two biopsy proven adenocarcinomas of the lung (one RML and one LLL), one is poorly differentiated and one is well-differentiated, so presumably simultaneous primaries. The RML lesion is small and not adjacent to the chest wall, so I am treating with 54 Gy in 3 fractions. The LLL lesion is more central and I have decided to give 50 Gy in 5 fractions. So the first 3 treatment days there will be 2 lesions treated, and the last 2 days only the one lesion treated. I don't believe there is data to show that treating just one lesion at a tim...

Some great points...insurance "peer to peer" conferences (often retired family doctors who have no idea and sometimes cannot even pronounce the radiation jargon..my peer? I think not) are the bain of my existence. But nonetheless, my perspective is that I always try for biopsy. Kentucky is ground zero for lung cancer with among the highest rates or smoking and lung cancer but many of my patients will not tolerate invasive procedures. As we know, untreated stage I lung cancer can have a median survival of 3 years or less so I am not an advocate for observation only. Certainly for biopsy proven lung cancer with two-three nodules, there should be no question about treating all disease whether or not they are separate primaries or the only site...