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Surgery has traditionally been the standard of care for early-stage (T1–T2 N0) NSCLC and lung metastases as local control with conventionally fractionated EBRT was clearly inferior to surgical resection. However, the emergence of SBRT (1–5 fractions of >5 Gy/fx) for lung lesions is challenging this standard as local control rates of >80–95% can be achieved with either modality. Less extreme hypofractionation (15–25 fractions of 2.5–3.5 Gy/fx) regimens have also been utilized in an attempt to escalate the BED of radiation for more advanced (stages III–IV) NSCLC. Clinical experience has demonstrated that while these approaches can produce encouraging tumor control rates, they are not without the risk of severe, even fatal complications as a result of damage to the many critical structures located in the thorax. This chapter will review the sizeable literature for lung SBRT and hypofractionation regimens and highlight the technical considerations that are necessary to properly utilize these techniques.

Purpose: To evaluate the patient positioning accuracy and reproducibility of two commercially available immobilization systems for Stereotactic Body Radiotherapy(SBRT) treatment. Methods: Forty one patients with lung (n=21) or liver (n=20) malignancies were assigned to one of the two immobilization devices: Elekta stereotactic body frame (SBF) with built‐in stereotactic coordinate system and Civco modular indexing based frame (MIF) without stereotactic reference. All patients underwent the same simulation and planning procedure followed by cone beam CT(CBCT) guided treatment setup. A total of 151 CBCTimages were analyzed. The systematic and random isocenter setup errors of the two systems were calculated and compared based on the daily setup corrections under CBCT guidance. Results: There was not statistically significant difference between the two systems in terms of systematic setup errors in all three translational directions, for both lung and liver patients. The random errors for the lung patients under SBF setup were 1.8mm, 2.0mm and 2.9mm for the vertical, longitudinal and lateral directions, respectively compared to 3.6mm, 4.1mm, and 4.2mm for MIF. A similar trend was also observed for liver patients. The random errors of liver MIF setup reached 3.5mm, 6.1mm and 5.7mm for the vertical, longitudinal and lateral directions, respectively, with relatively smaller errors 1.7mm, 3.4mm and 2.6mm with SBF setup. Repeated CBCTs occurred for MIF system in 42.4% and 40.7% of the lung and liver treatment to verify couch corrections based on the institutional tolerance, resulting in prolonged setup time. Only 25% and 13.6% of the lung and liver treatment with SBF required with repeated CBCT.Conclusions: Without stereotactic coordinate reference, the body frame system tended to have larger random setup errors and patient positioning accuracy inevitably relies on the volumetric imaging guidance. Patient comfort and reproducibility should be clearly considered for selecting a system.

Objective This study examined barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients (N = 165) at two medical centers in the Midwestern United States. Methods Lung cancer patients completed an assessment of anxiety and depressive symptoms, mental health service use, barriers to using these services, and preferences for addressing emotional concerns. Results Only 45% of distressed patients received mental health care since their lung cancer diagnosis. The most prevalent patient-reported barriers to mental health service use among non-users of these services (n = 110) included the desire to independently manage emotional concerns (58%) and inadequate knowledge of services (19%). In addition, 57% of distressed patients who did not access mental health services did not perceive the need for help. Seventy-five percent of respondents (123/164) preferred to talk to a primary care physician if they were to have an emotional concern. Preferences for counseling, psychiatric medication, peer support, spiritual care, or independently managing emotional concerns also were endorsed by many patients (range = 40–50%). Older age was associated with a lower likelihood of preferring to see a counselor. Conclusions Findings suggest that many distressed lung cancer patients underuse mental health services and do not perceive the need for such services. Efforts to increase appropriate use of services should address patients' desire for autonomy and lack of awareness of services. Copyright © 2014 John Wiley & Sons, Ltd.

BACKGROUND: Stereotactic body radiotherapy (SBRT) is an alternative to surgery for clinical stage I non–small cell lung cancer (NSCLC), but comparing its effectiveness is difficult because of differences in patient selection and staging. METHODS: Two databases were combined which contained patients treated from 1999 to 2008 by lobectomy (LR, n 5132), sublobar resection (SLR, n 548), and SBRT (n 5137) after negative staging. Univariate and multivariate analysis were performed for survival (OS), total recurrence control (TRC comprises local-regional and distant control), and locoregional control (LRC) in our entire population. A matchedpair analysis was also performed that compared surgery and SBRT results. Median follow-up for the entire study population was 25.8 months. RESULTS: On univariate analysis, OS was significantly worse with SBRT and also correlated with histology, the Charlson comorbidity index, tumor size, and aspirin use; TRC correlated only with histology; and no variable significantly correlated with LRC. OS was significantly poorer for SBRT in the matched-pair analysis than for patients treated with surgery, but TRC and LRC were not significantly different between these groups. Multivariate analyses including propensity score as a covariate (controlling for all factors affecting treatment selection) found that OS correlated only with Charlson comorbidity index, and TRC correlated only with tumor grade. LRC correlated only with tumor size with or without propensity score correction. CONCLUSIONS: This retrospective study has demonstrated similar OS, LRC, and TRC with SBRT or surgery after controlling for prognostic and patient selection factors. Randomized clinical trials are needed to better compare the effectiveness of these treatments. Cancer 2013;119:2683–91. V C 2013 American Cancer Society.