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Nymoen HM, Alver TN, Horndalsveen H, Eide HA, Bjaanæs MM, Brustugun OT, Grønberg BH, Haakensen VD, Helland Å. Thoracic radiation in combination with erlotinib-results from a phase 2 randomized trial. Front Oncol 2024; 14:1412716. [PMID: 39148905 PMCID: PMC11324589 DOI: 10.3389/fonc.2024.1412716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/09/2024] [Indexed: 08/17/2024] Open
Abstract
Background Radiotherapy (RT) can be used to reduce symptoms and maintain open airways for patients with non-small cell lung cancer when systemic treatment is not sufficient. For some patients, tumor control is not achieved due to radioresistance. Concurrent inhibition of epidermal growth factor receptors has been proposed as a strategy to overcome radioresistance but may increase toxicity. We performed a randomized trial to assess the efficacy, tolerance, and quality of life of concurrent erlotinib and palliative thoracic RT for patients with advanced non-small cell lung cancer. Methods Patients were randomized 1:1 to RT alone (arm A) or in combination with erlotinib (arm B). A computed tomography (CT) scan at baseline and one at 4-12 weeks after inclusion was used to evaluate treatment response. Adverse events were registered during treatment and the subsequent 30 days. Health-related quality-of-life questionnaires were completed by the patients at baseline, weeks 2, 6, and 20. Results A total of 114 patients were included. Of the 74 patients with CT scans available for evaluation of treatment effect, there were no significant differences in tumor size reduction between the two groups: median 14.5% reduction in the control arm A and 17.0% in the erlotinib arm B (p = 0.68). Overall survival was not significantly different between the two treatment arms: 7.0 and 7.8 months in arm A and arm B, respectively (log-rank p = 0.32). There was no significant increase in adverse events in the experimental arm, other than what is expected from erlotinib treatment alone. Overall, patients reported similar quality of life in both treatment arms. Conclusion Concurrent erlotinib and palliative thoracic RT for patients with advanced non-small cell lung cancer was well tolerated but did not improve the efficacy of the RT. Clinical trial registration ClinicalTrials.gov, identifier NCT02714530.
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Affiliation(s)
- Hanne Marte Nymoen
- Institute for Cancer Research, Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Tine Norman Alver
- Institute for Cancer Research, Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Henrik Horndalsveen
- Institute for Cancer Research, Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | | | | | - Odd Terje Brustugun
- Institute for Cancer Research, Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Oncology, Drammen Hospital, Vestre Viken Health Trust, Drammen, Norway
| | - Bjørn Henning Grønberg
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Oncology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Vilde Drageset Haakensen
- Institute for Cancer Research, Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Åslaug Helland
- Institute for Cancer Research, Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
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Non-Small Cell Lung Cancer Treatment with Molecularly Targeted Therapy and Concurrent Radiotherapy—A Review. Int J Mol Sci 2023; 24:ijms24065858. [PMID: 36982933 PMCID: PMC10052930 DOI: 10.3390/ijms24065858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/22/2023] Open
Abstract
Lung cancer is the leading cause of death worldwide for both men and women. Surgery can be offered as a radical treatment at stages I and II and selected cases of stage III (III A). Whereas at more advanced stages, combined modalities of treatment are applied: radiochemotherapy (IIIB) and molecularly targeted treatment (small molecule tyrosine kinase inhibitors, VEGF receptor inhibitors, monoclonal antibodies, and immunological treatment with monoclonal antibodies). Combination treatment, composed of radiotherapy and molecular therapy, is increasingly employed in locally advanced and metastatic lung cancer management. Recent studies have indicated a synergistic effect of such treatment and modification of immune response. The combination of immunotherapy and radiotherapy may result in the enhancement of the abscopal effect. Anti-angiogenic therapy, in combination with RT, is associated with high toxicity and should be not recommended. In this paper, the authors discuss the role of molecular treatment and the possibility of its concurrent use with radiotherapy in non-small cell lung cancer (NSCLC).
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Fabian A, Domschikowski J, Letsch A, Schmalz C, Freitag-Wolf S, Dunst J, Krug D. Use and Reporting of Patient-Reported Outcomes in Trials of Palliative Radiotherapy: A Systematic Review. JAMA Netw Open 2022; 5:e2231930. [PMID: 36136335 PMCID: PMC9500555 DOI: 10.1001/jamanetworkopen.2022.31930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Justus Domschikowski
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anne Letsch
- Department of Haematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Juergen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
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Guimond E, Tsai CJ, Hosni A, O'Kane G, Yang J, Barry A. Safety and Tolerability of Metastasis Directed Radiotherapy in the Era of Evolving Systemic, Immune and Targeted Therapies. Adv Radiat Oncol 2022; 7:101022. [PMID: 36177487 PMCID: PMC9513086 DOI: 10.1016/j.adro.2022.101022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/02/2022] [Indexed: 11/17/2022] Open
Abstract
AbstractPurpose Systemic, immune, and target therapies are growing in use in the management of metastatic cancers. The aim of this review was to describe up-to-date published data on the safety and tolerability of metastasis-directed hypofractionated radiation therapy (RT) when combined with newer systemic, immune, and targeted therapies and to provide suggested strategies to mitigate potential toxicities in the clinical setting. Methods and Materials A comprehensive search was performed for the time period between 1946 and August 2021 using predetermined keywords describing the use of noncentral nervous system palliative RT with commonly used targeted systemic therapies on PubMed and Medline databases. A total of 1022 articles were screened, and 130 met prespecified criteria to be included in this review. Results BRAF and MEK inhibitors are reported to be toxic when given concurrently with RT; suspension 3 days and 1 to 2 days, respectively, prior and post-RT is suggested. Cetuximab, erlotinib/gefitinib, and osimertinib were generally safe to use concomitantly with conventional radiation. But in a palliative/hypofractionated RT setting, suspending cetuximab during radiation week, erlotinib/gefitinib 1 to 2 days, and osimertinib ≥2 days pre- and post-RT is suggested. Vascular endothelial growth factor inhibitors such as bevacizumab reported substantial toxicities, and the suggestion is to suspend 4 weeks before and after radiation. Less data exist on sorafenib and sunitinib; 5 to 10 days suspension before and after RT should be considered. As a precaution, until further data are available, for cyclin-dependent kinase 4-6 inhibitors, consideration of suspending treatment 1 to 2 days before and after RT should be given. Ipilimumab should be suspended 2 days before and after RT, and insufficient data exist for other immunotherapy agents. Trastuzumab and pertuzumab are generally safe to use in combination with RT, but insufficient data exist for other HER2 target therapy. Conclusions Suggested approaches are described, using up-to-date literature, to aid clinicians in navigating the integration of newer targeted agents with hypofractionated palliative and/or ablative metastatic RT. Further prospective studies are required.
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Affiliation(s)
- Elizabeth Guimond
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
- Corresponding author: Elizabeth Guimond, MD, FRCPC
| | - Chiaojung Jillian Tsai
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
| | - Grainne O'Kane
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
| | - Jonathan Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Toronto, Ontario
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Chemoradiotherapy with extended nodal irradiation and/or erlotinib in locally advanced oesophageal squamous cell cancer: long-term update of a randomised phase 3 trial. Br J Cancer 2020; 123:1616-1624. [PMID: 32958820 PMCID: PMC7686329 DOI: 10.1038/s41416-020-01054-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/23/2020] [Accepted: 08/26/2020] [Indexed: 11/08/2022] Open
Abstract
Background To report the long-term outcomes of a phase III trial designed to test two hypotheses: (1) elective nodal irradiation (ENI) is superior to conventional field irradiation (CFI), and (2) chemoradiotherapy plus erlotinib is superior to chemoradiotherapy in locally advanced oesophageal squamous cell cancer (ESCC). Methods Patients with locally advanced ESCC were randomly assigned (1:1:1:1 ratio) to one of the four groups: A: radiotherapy adoption of ENI with two cycles of concurrent TP chemotherapy (paclitaxel and cisplatin) plus erlotinib; B: radiotherapy adoption of ENI with two cycles of concurrent TP; C: radiotherapy adoption of CFI with two cycles of concurrent TP plus erlotinib and D: radiotherapy adoption of CFI with two cycles of concurrent TP. A total of 60 Gy of radiation doses was delivered over 30 fractions. We explored the impact of epidermal growth factor receptor (EGFR) expression on the efficacy of erlotinib plus chemoradiotherapy. Results A total of 352 patients (88 assigned to each treatment group) were enrolled. The 5-year survival rates were 44.9%, 34.8%, 33.8% and 19.6% in groups A, B, C and D, respectively (P = 0.013). ENI significantly improved OS compared with standard CFI (median, 38.5 vs 22.6 months; HR, 0.74; P = 0.018). The addition of erlotinib significantly improved OS (median, 39.4 vs 27.4 months; HR, 0.75; P = 0.025). Patients with overexpressing EGFR treated with erlotinib had a better OS and PFS than those without erlotinib. Conclusions Concurrent chemoradiotherapy with ENI and/or erlotinib improved long-term survival in locally advanced ESCC. Clinical trial registration Trial registration: NCT00686114.
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Arscott WT, Emmett J, Ghiam AF, Jones JA. Palliative Radiotherapy: Inpatients, Outpatients, and the Changing Role of Supportive Care in Radiation Oncology. Hematol Oncol Clin North Am 2019; 34:253-277. [PMID: 31739947 DOI: 10.1016/j.hoc.2019.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Palliative radiotherapy is an effective treatment in alleviating many symptoms of advanced cancer. Short courses of radiotherapy provide rapid symptom relief and minimize impact on patients. Patients referred for palliative radiotherapy have many concerns beyond radiotherapy; often, these concerns are not fully addressed in traditional radiotherapy clinics. Discussions of prognosis, patient goals, and concerns are areas for improved collaboration. Innovative, dedicated palliative radiotherapy programs have developed over the past 20 years to provide holistic care to patients referred for palliative radiotherapy and have improved patient-focused outcomes. Advanced radiotherapy techniques may provide opportunities to further improve palliative radiotherapy outcomes.
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Affiliation(s)
| | - Jaclyn Emmett
- Inpatient Oncology, Department of Hematology/Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Alireza Fotouhi Ghiam
- Department of Radiation Oncology, British Columbia Cancer Agency (BCCA), University of British Columbia, 2410 Lee Avenue, Victoria, British Columbia V8R 6V5, Canada
| | - Joshua A Jones
- Palliative Radiotherapy Service, Department of Radiation Oncology, University of Pennsylvania Health System, Philadelphia, PA, USA.
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7
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Liu R, Wei S, Zhang Q, Zhang X, Luo H, Tian J, Li Y, Ge L, Wang X. Epidermal growth factor receptor tyrosine kinase inhibitors combined with thoracic radiotherapy or chemoradiotherapy for advanced or metastatic non-small cell lung cancer: A systematic review and meta-analysis of single-arm trials. Medicine (Baltimore) 2019; 98:e16427. [PMID: 31335695 PMCID: PMC6708798 DOI: 10.1097/md.0000000000016427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 05/24/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Preclinical in vitro experiments demonstrated that epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) might have synergistic effect in combination with radiotherapy on Non-small cell lung cancer (NSCLC), but the clinical trials showed inconsistence results in NSCLC patients with EGFR status unknow or mutations. This study aimed to determine if added TKIs to Thoracic radiotherapy (TRT) improve primary disease response rate (RR) and survival outcomes in advanced or metastatic NSCLC. METHODS We searched MEDLINE, EMBASE, and Cochrane Library from January 2000 to December 2017 for eligible studies where patients received concurrent EGFR TKIs and TRT or CRT. Concerned outcomes were primary tumor RR, overall survival (OS), and adverse events (AEs). The meta-analysis was performed using Stata software (version 12.0). Random effects models were used to pool outcomes across studies. Sensitivity analysis was performed to determine if the results would be different. RESULTS We found 16 prospective clinical trials with mature results for meta-analyses. Twelve studies including 446 patients reported the RR and survival outcomes of TRT combined TKIs. The CR, PR, SD, and PD, respectively, were 0.06 (95% CI 0.03-0.09, I = 0%), 0.44 (95% CI 0.38-0.49, I = 64.9%), 0.29 (95% CI 0.24-0.34, I = 78.4%), and 0.15 (95% CI 0.11-0.19, I = 84.2%). One- and 2-year OS, respectively, were 0.52 (95% CI 0.44-0.60, I = 38.8%) and 0.26 (95% CI 0.18-0.33, I = 0%). Four studies including 182 patients reported the RR and survival outcomes of CRT combined TKIs. The pooled CR, PR, SD, and PD, respectively, were 0.12 (95% CI 0.02-0.22, I = 69.1%), 0.41 (95% CI 0.27-0.55, I71.6%), 0.31 (95% CI 0.16-0.46, I = 79%), and 0.14 (95% CI -0.01-0.30, I = 87.8%). Only 1 study reported the survival event rate, 1- and 2-year OS, respectively, were 0.83 (95% CI 0.71-0.94) and 0.67 (95% CI 0.54-0.81). There were not severe adverse events (SAEs) reported either TRT combined TKIs or CRT combined TKIs. CONCLUSION There is evidence, albeit of low quality, that added the TKIs to TRT or CRT may improve RR and survival outcomes in patients with EGFR mutant status unknown advanced or metastatic NSCLC relative to other studies of TKIs alone, TRT alone or CRT.
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Affiliation(s)
- Ruifeng Liu
- The First Clinical Medical College of Lanzhou University
- Radiotherapy Oncology Department, Gansu Provincial Cancer Hospital
| | - Shihong Wei
- Radiotherapy Oncology Department, Gansu Provincial Cancer Hospital
| | - Qiuning Zhang
- The First Clinical Medical College of Lanzhou University
- Radiotherapy Oncology Department, Gansu Provincial Cancer Hospital
| | - Xueliang Zhang
- Radiotherapy Oncology Department, Gansu Provincial Cancer Hospital
| | - Hongtao Luo
- The First Clinical Medical College of Lanzhou University
- Radiotherapy Oncology Department, Gansu Provincial Cancer Hospital
| | - Jinhui Tian
- Center of Evidence Based Medicine, Lanzhou University, Lanzhou
| | - Yi Li
- The First Clinical Medical College of Lanzhou University
- Hebei provincial chest Hospital, Shijiazhuang, PR China
| | - Long Ge
- The First Clinical Medical College of Lanzhou University
- Center of Evidence Based Medicine, Lanzhou University, Lanzhou
| | - Xiaohu Wang
- The First Clinical Medical College of Lanzhou University
- Radiotherapy Oncology Department, Gansu Provincial Cancer Hospital
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Cui J, Wang MC, Zhang YM, Ren MZ, Wang SX, Nan KJ, Song LP. Combination of S-1 and gefitinib increases the sensitivity to radiotherapy in lung cancer cells. Cancer Chemother Pharmacol 2018; 81:717-726. [PMID: 29480364 DOI: 10.1007/s00280-018-3539-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/04/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the potential radiosensitization of S-1 and gefitinib in human non-small cell lung cancer (NSCLC) in vitro and in vivo. METHODS The impact of radiation, 5-fluorouracil (5-Fu), and gefitinib on the proliferation and apoptosis of human NSCLC A549, H1299, H1975, and HCC827 cells was examined by MTT and flow cytometry. The effect of radiation, 5-Fu, and gefitinib on the clonogenicity of H1975 and HCC827 cells was determined by colony formation assay. The effect of radiation, 5-fluorouracil (5-Fu), and gefitinib on the EGFR, AKT, and ERK1/2 activation in H1975 cells was determined by Western blot. The therapeutic efficacy of radiation, S-1, and gefitinib in the growth of implanted H1975 tumors and the AKT activation in the tumors were examined in vivo and immunohistochemistry, respectively. RESULTS Combination of radiation, 5-Fu, and gefitinib significantly inhibited the proliferation of H1975 cells and triggered their apoptosis, but not other NSCLC cells tested. The combination therapy significantly mitigated the clonogenicity and attenuated the activation of EGFR and AKT signaling in H1975 cells. Furthermore, combination of S-1, gefitinib, and radiation significantly inhibited the growth of implanted H1975 tumors in mice and remarkably reduced the AKT phosphorylation in the tumors. CONCLUSIONS Our data indicated that combination of S-1 and gefitinib significantly increased radiosensitivity of H1975 cells. The triple combination therapies may benefit patients with the EGFR T790M mutant NSCLC.
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Affiliation(s)
- Jie Cui
- Department of Oncology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China.,The General Practice College of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Min-Cong Wang
- Department of Radiotherapy, the Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, People's Republic of China
| | - Ya-Min Zhang
- Department of Oncology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China.,The General Practice College of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Ming-Zhi Ren
- Department of Oncology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China.,The General Practice College of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Shi-Xiong Wang
- Department of Oncology, the First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China.,The General Practice College of Xi'an Medical University, Xi'an, Shaanxi, People's Republic of China
| | - Ke-Jun Nan
- Department of Oncology, the First Affiliated Hospital, Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, Shaanxi, People's Republic of China.
| | - Li-Ping Song
- Department of Radiotherapy, the First Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, 710061, Shaanxi, People's Republic of China.
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