A palliative accelerated irradiation regimen (PAIR) for advanced non-small-cell lung cancer (NSCLC)

Use and Reporting of Patient-Reported Outcomes in Trials of Palliative Radiotherapy: A Systematic Review

IMPORTANCE

Approximately 50% of all patients with cancer have an indication for radiotherapy, and approximately 50% of radiotherapy is delivered with palliative intent, with the aim of alleviating symptoms. Symptoms are best assessed by patient-reported outcomes (PROs), yet their reliable interpretation requires adequate reporting in publications.

OBJECTIVE

To investigate the use and reporting of PROs in clinical trials of palliative radiotherapy.

EVIDENCE REVIEW

This preregistered systematic review searched PubMed/Medline, EMBASE, and the Cochrane Center Register of Controlled Trials for clinical trials of palliative radiotherapy published from 1990 to 2020. Key eligibility criteria were palliative setting, palliative radiotherapy as treatment modality, and clinical trial design (per National Institutes of Health definition). Two authors independently assessed eligibility. Trial characteristics were extracted and standard of PRO reporting was assessed in adherence to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. The association of the year of publication with the use of PROs was assessed by logistic regression. Factors associated with higher CONSORT-PRO adherence were analyzed by multiple regression. This study is reported following the PRISMA guidelines.

FINDINGS

Among 7377 records screened, 225 published clinical trials representing 24 281 patients were eligible. Of these, 45 trials (20%) used a PRO as a primary end point and 71 trials (31%) used a PRO as a secondary end point. The most prevalent PRO measures were the Numeric Rating Scale/Visual Analogue Scale (38 trials), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire C30 (32 trials), and trial-specific unvalidated measures (25 trials). A more recent year of publication was significantly associated with a higher chance of PROs as a secondary end point (odds ratio [OR], 1.04 [95% CI, 1.00-1.07]; P = .03) but not as primary end point. Adherence to CONSORT-PRO was poor or moderate for most items. Mean (SD) adherence to the extension adherence score was 46.2% (19.6%) for trials with PROs as primary end point and 31.8% (19.8%) for trials with PROs as a secondary end point. PROs as a primary end point (regression coefficient, 9.755 [95% CI, 2.270-17.240]; P = .01), brachytherapy as radiotherapy modality (regression coefficient, 16.795 [95% CI, 5.840-27.751]; P = .003), and larger sample size (regression coefficient, 0.028 [95% CI, 0.006-0.049]; P = .01) were significantly associated with better PRO reporting per extension adherence score.

CONCLUSIONS AND RELEVANCE

In this systematic review of palliative radiotherapy trials, the use and reporting of PROs had room for improvement for future trials, preferably with PROs as a primary end point.

Clinical survey for registering treatment decision criteria in advanced non-small-cell lung cancer radiotherapy and determination of the dose–response relationship for 1-year survival

Purpose

Recent studies have suggested significant variations in radiotherapy schedules used to treat advanced non-small-cell lung cancer (NSCLC), both between different centers in one country as well as between countries. In this study, different treatment methodologies have been explored using management plans proposed by radiation oncologists regarding general questions and theoretical case histories for patients with advanced NSCLC.

Materials and methods

The survey was conducted by sending a questionnaire to 24 radiotherapy centers in Europe. The questionnaire was composed of two sections. The first section concerned reasons for giving radiotherapy, parameters that influence the choice of total dose and fractionation for radiotherapy and kind of equipment used. The second section concerned the management of five theoretical patients (A–E) regarding the selection of the radiotherapy technique and the aim of treatment (radical or palliative). Furthermore, 19 trials comparing different regimens of palliative radiotherapy in patients with NSCLC were reviewed. There were marked differences in the doses of the investigated radiotherapy schemes, the patient characteristics and the assessed outcome measures.

Results

70% of the responders answered that the most important factors for deciding what dose and fractionation scheme to use were: metastases, performance status (PS) of the patient, lung function and size of the primary tumour. The most common reasons for giving the treatment were symptom relief, prolongation of life and, in some cases, possibly cure. More than 95% of the responders stated that they would give radiotherapy in each of these cases. The total doses proposed where 20 Gy in five fractions or 30 Gy in ten fractions in 2 weeks for the cases A and D. If the previous two schemes were converted to a fractionation scheme delivering 2 Gy per fraction, the equivalent doses would be 23 and 33 Gy, respectively. For the cases B, C and E, the proposed fractionation schemes were 2 Gy daily to 60–68 Gy in 6 weeks or 2 Gy daily to 68 Gy in 7 weeks. For the case E, 20% of the responders suggested Stereotactic Body Radiotherapy (SBRT) giving 21 Gy three times a week with a day apart to 63 Gy. The total dose and number of fractions of radiotherapy are related to the perceived aims and expectations of treatment. Those aiming at extending life would give significantly higher total doses in a larger number of fractions, whereas those aiming at relieving symptoms would give significantly lower total doses. There is evidence for an increase in survival, in patients who are given higher radiotherapy doses, especially in those patients with better PS.

Conclusions

This survey demonstrates a range of treatment strategies for advanced and inoperable NSCLC within Europe. There are a number of factors that influence the perceived aims of treatment and treatment planning. These factors should be taken into account when evaluating the effectiveness of different irradiation techniques, especially in the determination of radiobiological parameters and dose–response relations. The majority of patients should be treated with short courses of palliative radiotherapy, of one or two fractions. The use of high-dose palliative regimens using many fractions or SBRT should be considered for selected patients with good PS.

Prognostic factors in non-small cell lung cancer: a decade of progress

STUDY OBJECTIVES

To provide a systematic overview of the literature investigating patient and tumor factors that are predictive of survival for patients with non-small cell lung cancer (NSCLC), and to analyze patterns in the design of these studies in order to highlight problematic aspects of their design and to advocate for appropriate directions of future studies.

DESIGN

A systematic search of the MEDLINE database and a synthesis of the identified literature.

MEASUREMENTS AND RESULTS

The database search (January 1990 to July 2001) was carried out combining the MeSH terms prognosis and carcinoma, nonsmall cell lung. Eight hundred eighty-seven articles met the search criteria. These studies identified 169 prognostic factors relating either to the tumor or the host. One hundred seventy-six studies reported multivariate analyses. Concerning 153 studies reporting a multivariate analysis of prognostic factors in patients with early-stage NSCLC, the median number of patients enrolled per study was 120 (range, 31 to 1,281 patients). The median number of factors reported to be significant in univariate analyses was 4 (range, 2 to 14 factors). The median number of factors reported to be significant in multivariate analyses per study was 2 (range, 0 to 6 factors). The median number of studies examining each prognostic factor was 1 (range, 1 to 105 studies). Only 6% of studies addressed clinical outcomes other than patient survival.

CONCLUSIONS

While the breadth of prognostic factors studied in the literature is extensive, the scope of factors evaluated in individual studies is inappropriately narrow. Individual studies are typically statistically underpowered and are remarkably heterogeneous with regard to their conclusions. Larger studies with clinically relevant modeling are required to address the usefulness of newly available prognostic factors in defining the management of patients with NSCLC.

A palliative accelerated irradiation regimen for advanced non-small-cell lung cancer vs. conventionally fractionated 60 GY: results of a randomized equivalence study

PURPOSE

Radiation oncologists are often faced with patients with advanced non-small-cell lung cancer (NSCLC), who are not suitable candidates for state-of-the-art radical treatment, but who also are not judged to have a very short life expectancy. Some physicians treat these patients palliatively, whereas others advocate more intensive treatment. To find out if there is a substantial difference in outcome between these approaches, we performed a randomized prospective study.

METHODS AND MATERIALS

Between 1994 and 1998, 152 eligible patients with advanced NSCLC Stage III (n = 121) or minimal Stage IV (n = 31) were randomized to receive conventionally fractionated (cf; A: 60 Gy, 6 weeks, n = 79) or short-term treatment (PAIR; B: 32 Gy, 2 Gy b.i.d.; n = 73) of tumor and mediastinum.

RESULTS

One-year survival rate for all patients was 37% with no significant difference between the two treatment arms (A: 36%; B: 38%; p = 0.76). As far as can be judged from limited data available, palliation was adequate and similar for the two treatment arms. Apart from expected differences in the time course of esophagitis, acute side effects were moderate and equally distributed. No severe late effects were observed.

CONCLUSIONS

In the present randomized trial, survival and available data on palliation were not different after cf to 60 Gy compared to the palliative PAIR regimen. Therefore, for patients who are not suitable for radical treatment approaches, the prescription of a palliative short-term irradiation appears preferable compared to cf over several weeks.

[Radiotherapy for stage III, inoperable, asymptomatic small cell lung cancer. Final results of a prospective randomized study (240 patients)]

PURPOSE

To report the results of a prospective randomized study concerning the role of radiotherapy in the treatment of stage III, unresectable, asymptomatic non-small cell lung cancer.

MATERIAL AND METHODS

Between 1992 and 1996, 240 patients with stage III, unresectable, asymptomatic non-small cell lung cancer were enrolled in this study, and sequentially randomized to one of the three treatment arms: conventional irradiation, hypofractionated irradiation and control group. In the conventional irradiation arm (79 patients), a dose of 50 Gy in 25 fractions in five weeks was delivered to the primary tumor and the mediastinum. In the hypofractionated irradiation arm (81 patients), there were two courses of irradiation separated by an interval of four weeks. In each series, patients received 20 Gy in five fractions in five days, in the same treatment volume as the conventional irradiation group. In the control group arm, 80 patients initially did not receive radiotherapy and were only observed. Delayed palliative hypofractionated irradiation (20-25 Gy in four to five fractions in four to five days) was given to the primary tumor when major symptoms developed.

RESULTS

The two-year actuarial survival rates for patients in the conventional irradiation, hypofractionated irradiation and control group arms were 18%, 6% and 0%, with a median survival time of 12 months, nine months and six months respectively. The differences between survival rates were statistically significant at the 0.05 level.

CONCLUSION

Although irradiation provides good palliation, the results are disappointing. The comparison of conventional and hypofractionated irradiation shows an advantage for conventional schedules.

[Lung cancer--hopelessness in inoperability? A 10-year follow-up]

BACKGROUND

According to reports of Durrant et al. [19] and Berry et al. [5] it was concluded that non-operable non-small cell lung tumors cannot be cured. In this consequence initiation of radiotherapy was fixed at the beginning of symptoms. However, long-time survivors in our follow-up lead us to analyse not only quality of life and secondary therapeutic effects but also this special group with the results of the whole collective treated in the same period of interest.

PATIENTS AND METHODS

Between 1.1. 1981 and 31. 12. 1983 a number of 169 patients had been recommended for locoregional radiotherapy treatment of lung cancer; 145 patients received at least 50 Gy, 134 out of them 60 Gy or more. Men/female ratio was 137:8, median age was 65 (36 to 88) years. Classified according to the TN-stage there were 59 patients in T1-4 N0 and 86 patients in T1-4 N1-3 M0. Histologically: 98 squamous cell carcinomas, 23 adenocarcinomas, 9 large cell carcinomas and 15 specimens mixed from the named subgroup or rare histologies. Treatment concept including repetition of bronchoscopic evaluation after 60 Gy was prospectively discussed and fixed with our pneumologist. Radiation dose was given with a shrinking-field technique to mediastinum and primary. In case of macroscopically or microscopically persistence of tumor we continued radiation dose up to 80 Gy. Radiotherapy was not followed by chemotherapy. A telecobalt unit has been used for treatment due to the lack of high-voltage linear accelerators. In absence of a computer assisted planning system-a problem in most of the radiotherapeutic centers in this time-dose calculation was done by central beam planning of ICRU-point in the middle of the tumor respectively the center of target volume on the base of a cross section. Usually there was used a 3-field plan ap/pa opposite and an oblique field with an angle of 30 degrees from the ipsilateral back or ventral side, depending on the position of the tumor. Spinal cord was shielded to avoid a dose-more than 36 to 42 Gy. The longer distance and higher weightiness of the oblique fields had as consequence lung fibrosis in the irradiated lung area and a considerable higher maximal dose situated in the soft tissue and skin often followed by strong indurations in this area 1 to 3 years after radiation therapy without further limitations of quality of life.

RESULTS

From 145 patients with non-small cell lung cancer 64.1% (93/145) survived 6 months, 42.8% (62/145) 1 year, 19.3% (28/145) 2 years and 7.6% (11/145) 5 and 4.8 (7/145) more than 10 years. According to TN-stages T1-4 N0 collective had a survival rate of 67.8% (40/59) after half a year, 50.8% (30/59) after 1 year, 23.7% (14/59) after 2 and 11.9% (7/59) after 5 years. Treatment results by patients with positive lymph nodes T1-4 N1-3 after the same intervals are: 61.6% (53/86), 37.2% (32/86), 16.2% (14/86) respectively 4.7% (4/86). In the period 5 to 10 years after irradiation 4 patients died, 1 with local relapse, 2 with contralateral lung cancer-ipsilateral region was endoscopically and histologically free of tumor- and 1 patient in consequence of heart insufficiency of several years. Seven patients are still alive after 13 to 16 years. There is no sign of tumor in this group or any effects limitating their quality of life. Twenty-four patients received less than 50 Gy. All patients but 2 did not survive 6 months. One patient survived half a year and 1 patient 2 years.

CONCLUSIONS

The reported treatment results in a period with modest technological possibilities, a telecobalt unit, should encourage to a curative intention, when dissemination cannot be proved. If lung cancer is limited to the primary region with or without lymph node metastases the possibility of tumor elimination is small but feasible. If inoperable lung cancer is not curable, this mostly is not due to inability of locoregional radiotherapy, but rather can be seen as a lack of reliable and permanent elimination or prevention of

Radiotherapy for palliation of symptoms in incurable cancer

Approximately one half of prescribed radiotherapy is given for palliation of symptoms due to incurable cancer. Distressing symptoms including pain, bleeding, and obstruction can often be relieved with minimal toxic effects. Painful osseous metastasis is common in oncologic practice. Ninety percent of patients with symptomatic bone metastases obtain some pain relief with a lowdose, brief course of palliative radiotherapy. One half of the responding patients may experience complete pain relief. A single dose of 800 cGy in the setting of painful bone metastasis may provide pain control comparable to more protracted treatment at a higher dose of radiation. Patients with lytic disease in weight-bearing bones, particularly in the presence of cortical destruction, should be considered for prophylactic surgical stabilization of their condition. Routinely a brief, fractionated course of radiotherapy is given postoperatively. Pain due to multiple bone metastases uncontrolled by analgesics can be managed with single doses of halfbody irradiation. Doses of 600 cGy delivered to the upper half-body (above the umbilicus) and 800 cGy to the lower half-body (from the umbilicus to the middle of the femur) will provide some pain relief in 73% of patients. Half-body techniques have been investigated as prophylactic treatment, as a complement to local-field irradiation, and as fractionated rather than singledose therapy. Although intravenous administration of strontium 89 has been associated with myelosuppression, this treatment has been shown (a) to relieve pain due to bone metastasis and (b) to delay development of new painful sites. Recent data from phase III trials demonstrated that bisphosphonates have a role in reducing skeletal morbidity due to bone metastasis. Bone pain was reduced, and the incidence of pathologic fracture and the need for future radiotherapy was decreased. Radiotherapy relieves clinical symptoms in 70% to 90% of patients with brain metastases. Brief treatment schedules (e.g., 2000 cGy in five fractions over 1 week) are as effective as more prolonged therapy. Patients with solitary brain metastasis and no extracranial disease or controlled extracranial disease should be considered for surgical resection, because phase III data indicate enhanced survival with such an approach. Whole-brain radiotherapy is routinely administered postoperatively. A phase III study is examining the impact of accelerated fractionated doses of radiotherapy (two treatments per day) on survival of patients with brain metastases. Stereotaxic radiosurgical treatment is becoming increasingly available and permits delivery of radiation to metastatic intracranial tumor with minimal exposure of normal surrounding brain This treatment is most commonly used at the time of a solitary recurrence of disease in patients who previously received whole-brain radiotherapy. A role for this modality in newly diagnosed brain metastases remains to be defined. Chest symptoms are common in patients with locally advanced lung cancer and are effectively palliated with one 1000 cGy or two 850 cGy one fraction doses of radiation to the thoracic inlet and mediastinum. Chest pain and hemoptysis are more effectively palliated than cough and dyspnea. In patients with stage III cancer there is no compelling evidence that radiotherapy confers a survival advantage, and it may be reasonable to administer thoracic radiotherapy only when the patient has significant symptoms and the goal is to achieve control of these symptoms. Approximately 75% of the cases of superior vena cava syndrome are due to lung cancer, and small-cell lung cancer is the most common histologic type. A histologic diagnosis should be obtained before treatment is started, because detection of lymphoma or small-cell carcinoma would necessitate systemic therapy. Eighty percent of the patients with vena cava syndrome due to malignant disease achieve symptom relief with a brief, fractionated, palliative course of rad