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 ...

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...

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 sat...

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 ...

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 differe...

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 ze...