Diagnosis and management of interstitial lung disease with concomitant lung cancer in Italy: Results from the ICARO clinician survey

Background: Coexistence of interstitial lung disease (ILD), particularly idiopathic pulmonary fibrosis (IPF), and lung cancer poses major diagnostic and therapeutic challenges, yet clinical management remains heterogeneous. The project aims to describe current Italian practices for integrated management of ILD with concomitant lung cancer. Methods: ICARO (Interstiziopatia e Cancro del polmone: AppRoccio al management clinico integratO) is a national cross-sectional clinician survey conducted in Italy on behalf of the Italian Respiratory Society from November 2024 to March 2025. A 12-item multiple-choice questionnaire assessed diagnostic strategies, treatment preferences, and perceived toxicity risks. Invitations were sent to X physicians, among which 38 ansewered (35 specialists and senior 3 registrars (age range: 28-68 years). Results: An ILD multidisciplinary team was available in 26/38 (71.1%) centres. Diagnostic procedures for lung cancer in ILD patients were reported as performed "always/often" by 14/38 (36.8%), with the main concern being ILD progression after procedures (31/38-81.6%). Most respondents continued antifibrotic therapy during systemic cancer treatment (28/38-73.7%). Combined chemotherapy plus immune checkpoint inhibitors was perceived as the highest-risk regimen by 19/38 physicians (50%), and 20/38 (52.6%) were hesitant to offer neoadjuvant immunotherapy in stage II-IIIa NSCLC. Severe toxicity from radiotherapy was reported as frequent by 8/38 (21.1%). Conclusions: Italian clinicians report substantial variability in diagnostic and therapeutic strategies for lung cancer in ILDs, driven mainly by concern for ILD progression and treatment-related pulmonary toxicity. Although limited, this study unveils an urgent need for further prospective studies to better define the safety and efficacy of combined therapeutic approaches and to establish evidence-based guidelines to support clinical decision-making.