Timing of concurrent radiotherapy and chemotherapy in limited-disease small-cell lung cancer: "Meta-analysis of meta-analyses"

Clinical outcomes and toxicities of locally advanced esophageal squamous cell carcinoma patients treated with early thoracic radiation therapy after induction chemotherapy

OBJECTIVE

The purpose of this study was to compare the clinical outcomes and toxicities between induction chemotherapy (IC) + chemo-radiotherapy (CRT) and CRT alone in patients with locally advanced esophageal squamous cell carcinoma (ESCC), to explore the appropriate thoracic radiotherapy (TRT) timing after IC and to identify prognostic factors.

METHODS

450 ESCC patients were included from September 2011 to December 2020, 238 of whom received IC/CRT. Propensity score matching was performed to balance potential confounders between the two groups. Multivariate Cox regression analysis was used to identify the independent prognostic factors.

RESULTS

Patients who received IC/CRT experienced improved overall survival (OS) (38.5 vs. 28.8 months) and progression-free survival (PFS) (41.0 vs. 22.0 months) before matching, with similar results after matching. In the IC/CRT group, early TRT had more favorable survival than late TRT both matching before and after. In subgroup analysis, early TRT combination concurrent chemotherapy had better OS and PFS than late TRT combination concurrent chemotherapy. In addition, early TRT had better survival benefits regardless of the N stage. Notably, the IC/CRT group and early TRT group had manageable toxicities reaction compared with CRT alone group and the late TRT group. The nomogram was developed to predict the OS and PFS based on multivariate analysis results. The C-index was 0.743 and 0.722, respectively.

CONCLUSION

IC/CRT and early TRT could yield satisfactory clinical outcomes and controllable toxicities in locally advanced ESCC. The IC plus early concurrent CRT might be a promising treatment strategy for improving further survival in ESCC.

Real-World Treatment Patterns of Lung Cancer in a Resource-Restricted Country: the Experience of Georgia

Lung cancer (LC) is the most common malignancy responsible for 1.8 million of deaths worldwide. Lung and bronchus cancer represents 13% (n = 1217) of all new cancer cases in Georgia. In 2018, in Georgian males lung cancer age-standardized incidence rate was 35.7/per 100 000, less compared to regional countries as Turkey (70.6), Russia (48.2), Ukraine (41.7), and Armenia (58.5), but higher than in neighbor Azerbaijan (25.5). Incidence is higher compared to central and eastern Europe (27.3) and near similar to North America (34.5). Georgia is an Eastern European, middleincome country with 3.7 million residents and one of the highest numbers of active smokers in the European Region. The Georgian health care system is divided into a public and a private sector, with coverage of nearly 100% of the population. There is a national healthcare system as well as private insurance and all patients, irrespective of insurance (private or governmental) can choose the hospital for treatment by themselves all over the country. The Basic Package of the Universal Health Care Program includes the treatment of oncologic patients, specifically surgery, chemotherapy, hormone therapy and radiotherapy and investigations and medications related to these procedures. The program covers all types of laboratory and instrumental investigations related to planned treatment. Georgia lacks an LC screening program for smokers and partially because of this, the majority of patients with lung cancer present at an advanced stage. The National Centre for the Disease Control (NCDC) showed that almost 90% of LC patients in the country present with advanced stages (III-IV) with 60% of patients having stage IV disease at diagnosis . Lung cancer is generally diagnosed at an advanced stage. For non-small cell lung cancer (NSCLC), the proportion with metastatic disease (TNM stage IV) ranged from 46.8% to 61.2% in developed countries. In recent years, there have been several publications addressing specifics of LC worldwide, but none concerning Georgia. In light of the rapidly changing landscape in the diagnosis, staging, and treatment of LC, we thought to define the state of practice in Georgia by convening specialists who treat LC across 13 institutions in our country with the goal to describe differences in access and approaches to LC.

Effects of thoracic radiotherapy timing and duration on progression-free survival in limited-stage small cell lung cancer

Concurrent chemoradiotherapy (CRT) has been recommended and applied widely as the standard treatment for limited‐stage small cell lung cancer (LS‐SCLC). However, controversies remain regarding the optimal timing and treatment duration of thoracic radiotherapy (TRT), and their effects on patient survival. To evaluate prognostic values of TRT timing and duration on progression‐free survival (PFS) in LS‐SCLC and their dependence on TRT fractionation and clinicopathological characteristics, we retrospectively analyzed 197 LS‐SCLC patients receiving CRT from 2000 to 2016 at Sun Yat‐sen University Cancer Center. Based on the optimal cut‐off values of TRT timing and duration generated by Cutoff Finder, patients were divided into early TRT/late TRT group and short TRT/long TRT group respectively. Univariate and multivariate Cox analysis were performed to assess correlations of TRT timing, duration, fractionation, and clinicopathological characteristics with PFS. Univariate analysis revealed that early‐initiated TRT (P = 2.54 × 10⁻⁴) and short TRT (P = .001) significantly correlated with longer PFS. Their PFS benefits persisted in patients receiving hyperfractionated TRT and etoposide‐cisplatin (EP) chemotherapy, but were less prominent in those receiving once‐daily TRT and non‐EP chemotherapy. Multivariate analysis further identified early initiated TRT (P = .004) and short TRT (P = .017) as independent prognostic factors for longer PFS in LS‐SCLC. Our study confirmed that early‐initiated TRT and short TRT had positive prognostic roles in LS‐SCLC, especially in patients receiving hyperfractionated TRT and etoposide‐cisplatin chemotherapy. TRT fractionation was not an independent prognostic factor in LS‐SCLC.

IMRT for head and neck cancer: reducing xerostomia and dysphagia

Dysphagia and xerostomia are the main sequellae of chemoradiotherapy for head and neck cancer, and the main factors in reducing long-term patient quality of life. IMRT uses advanced technology to focus the high radiation doses on the targets and avoid irradiation of non-involved tissues. The decisions about sparing organs and tissues whose damage causes xerostomia and dysphagia depends on the evidence for dose-response relationships for the organs causing these sequellae. This paper discusses the evidence for the contribution of radiotherapy to xerostomia via damage of the major salivary glands (parotid and submandibular) and minor salivary glands within the oral cavity, and the contribution of radiotherapy-related effect on important swallowing structures causing dysphagia. Recommendations for dose limits to these organs, based on measurements of xerostomia and dysphagia following radiotherapy, are provided here.

Radiochemotherapy in special populations with limited-disease small-cell lung cancer and locally advanced non-small-cell lung cancer

SUMMARY The evidence to date confirms that concurrent radiochemotherapy (RT–ChT) is the treatment of choice in small-cell lung cancer and locally advanced non-small-cell lung cancer. But these patients require a good performance status and an interdisciplinary group of clinicians, which is hard to find at some facilities around the world. Socioeconomic differences worldwide, inadequate tolerance to RT–ChT, tobacco comorbidities, the high percentage of elderly patients and their low level of recruitment in clinical trials could explain, in part, the reason why lung cancer still remains the leading cause of cancer-related death around the world. This review focuses on RT–ChT in a special population of eldery, comorbid patients and populations with limited resources from developing countries with locally advanced non-small-cell lung cancer and limited-disease small-cell lung cancer.

Impact of intracranial extension on survival in stage IV nasopharyngeal carcinoma: identification of a subset of patients with better prognosis

OBJECTIVE

T-stage is an imperfect prognostic indicator for patients with nasopharyngeal carcinoma. We evaluated the effect of extent of intracranial involvement on survival after conventional radiotherapy in patients with Stage T4 nasopharyngeal carcinoma.

METHODS

We conducted a retrospective analysis of the results of computed tomography, magnetic resonance imaging and treatment outcomes in 84 consecutive patients with Stage T4 nasopharyngeal carcinoma during the period September 1993 to December 2002 in Taiwan. The patients were subcategorized into those who had limited intracranial involvement (primary nasopharyngeal tumors with involvement of the unilateral cavernous sinus or the parasellar region only) or extensive involvement (extension of the tumors to the bilateral cavernous sinus or the parasellar region, into the orbit and the ethmoid sinus anteriorly, or to the prepontine region and the posterior cranial fossa).

RESULTS

Extensive intracranial involvement was found in 51.2% of the patients. Among these patients, the 5-year rate of overall survival after conventional radiotherapy was only 3.4%. In contrast, the 5-year survival among patients with limited intracranial involvement was 42.9%. This difference was significant (P < 0.001). In the multivariate analysis, extensive intracranial involvement, advanced age and a nodal status of N3 correlated with poor overall survival (all P < 0.05).

CONCLUSIONS

Among patients with T4 nasopharyngeal carcinoma, better treatment outcomes were associated with limited intracranial involvement. We conclude that a subdivision of Stage T4 nasopharyngeal carcinoma disease based on the extent of intracranial involvement would provide better prognostic information.

Radiochemotherapy in the elderly with lung cancer

Lung cancer is the leading cause of cancer mortality with the median age of incidence being 69 years in males and 67 years in females. Radiochemotherapy (RT-CHT) is indicated in locally advanced non-small-cell lung cancer and limited-stage small-cell lung cancer; however, a significant under-representation of the elderly has been observed in patient recruitment in cancer treatment trials. In the last decades of the 20th Century, studies showed that elderly patients achieved the best quality-adjusted survival with radiotherapy alone, but recent trials have found that fit elderly patients benefit from concurrent RT-CHT, although with more short-term toxicity. Age alone should not exclude fit patients and deprive them of the standard treatment. Using tools, such as comprehensive geriatric assessment, a patient's tolerance to therapy can be assessed and monitoring can be performed. This review will focus on RT-CHT treatment in elderly patients with nonoperable stage III non-small-cell lung cancer and limited-stage small-cell lung cancer exclusively.

Influence of interfraction interval on local tumor control in patients with limited-disease small-cell lung cancer treated with radiochemotherapy

PURPOSE

To investigate the influence of interfraction interval (IFI) on local recurrence-free survival (LRFS) in patients with limited-disease small-cell lung cancer (LD SCLC) treated with accelerated hyperfractionated radiotherapy (Acc Hfx RT) and concurrent cisplatin and etoposide (PE).

METHODS AND MATERIALS

A total of 103 patients were treated with either "early" (Cycle 1) or "late" (Cycle 4) concurrent Acc Hfx RT/PE. Two daily fractions were nonrandomly given using an IFI of either 4.5-5.0 h ("shorter") (n = 52) or 5.5-6.0 h ("longer") (n = 51).

RESULTS

The median LRFS and 5-year LRFS rate for all 103 patients were 52 months and 48%, respectively. Besides gender, Karnofsky performance status, and treatment group, IFI also influenced LRFS, whereas age and weight loss did not. When a multivariate model was used, IFI was marginally insignificant (p = 0.0770) as a predictor of LRFS. In terms of individual treatment groups, IFI was not significant in "early" Acc Hfx RT/PE but showed a strong trend in a "late" Acc Hfx RT/PE regimen. Although a shorter IFI led to a higher incidence of high-grade (>or=3) esophagitis, leukopenia, and infection, a correlation analysis of toxicities with all potential prognostic factors showed that a shorter IFI was not an independent predictor of any acute high-grade toxicity.

CONCLUSION

"Shorter" IFI had a marginally insignificant influence on LRFS. A strong trend favoring it was observed in patients treated with "late" concurrent Acc Hfx RT/PE. This may be of interest because it could contribute to further understanding of potential biologic parameters influencing treatment outcome.

Resources and management strategies for the use of radiotherapy in the treatment of lung cancer in Central and Eastern European countries: Results of an International Atomic Energy Agency (IAEA) survey

PURPOSE

To assess resources and management strategies for the use of radiotherapy (RT) in the treatment of lung cancer in developing Central and Eastern European countries.

MATERIALS/METHODS

Questionnaires on patterns of care of NSCLC and SCLC were sent to radiation oncologists of Central and Eastern Europe. Comparisons were made between two groups of countries-ex-USSR states and other Eastern and Central European countries.

RESULTS

Twenty-four out of twenty-eight surveyed countries responded. There were significant differences in access to modern treatment facilities (3D planning systems, number of linear accelerators), percentage of patients with lung cancer receiving radiotherapy, schedules of palliative RT, use of postoperative RT for early stages between both analysed groups of countries. 3D systems were in use in 25% of centres for an entire treatment, in 28% for a part of the treatment, and in 47% curative RT was 2D planned. Sequential chemo-RT was the most common approach to radical management of NSCLC, followed by RT alone and concomitant chemo-RT; median percentages of patients receiving respective treatments per centre were 57%, 30%, and 10%. For SCLC, the concurrent approach was declared by 56%, and the sequential approach by 42% of responders.

CONCLUSIONS

Patterns of care of lung cancer in the analysed countries differed in some part from existing, evidence-based data on lung cancer. In particular, this difference was observed between ex-USSR countries and the rest of European developing countries in the equipment available and specific diagnostic and treatment parameters in radiotherapy of lung cancer, the latter group's practices more resembling those of developed European countries.