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Table 1 Challenges and solutions for difficult SABR scenarios

From: A critical review of recent developments in radiotherapy for non-small cell lung cancer

Clinical scenario Challenges Potential solutions being explored
Pre Treatment Incorporating patient preferences for treatment Choice of SABR in operable NSCLC • Shared decision-making [19, 20] • Comparative effectiveness research (including patient-reported outcomes, QOL and cost-effectiveness analyses) with “big data” strategies to facilitate data mining • RCTs underway (NCT02629458, NCT01753414, NCT02468024, VALOR study)
Obtaining a diagnosis Risks of treating benign disease Risks of biopsy in frail patients •Use validated models for cancer risk determination in a given population [9] • Explore blood biomarkers [123]
Treatment Central tumors Multiple primary lung cancers Proximity to OARs Uncertainty in OAR location Uncertainly in OAR dose constraints • “Big data” strategies to establish more reliable OAR dose constraints • MRI-guided adaptive RT [44] • Protons [41]
Oligometastases Higher pneumonitis risk Identify molecular and clinical characteristics of patients likely to benefit from ablative local therapies Optimize sequencing of RT and new systemic treatments • Phase I-II trials, as well as randomized trials
Follow-up Detection of recurrences Distinguishing post-RT fibrosis vs recurrent disease • Radiomic approaches [24]
Survivorship issues Loco-regional recurrences and second lung tumors Smoking cessation • Survivorship clinics [124] • Patient-reported outcomes, including financial impact of treatments
  1. Abbreviations QOL quality of life, RT radiotherapy, SABR stereotactic ablative radiotherapy, NSCLC non-small cell lung cancer, OAR organ at risk, PTV planning target volume