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Zheng X, Liu K, Shen N, Gao Y, Zhu C, Li C, Rong C, Li S, Qian B, Li J, Wu X. Predicting overall survival and prophylactic cranial irradiation benefit in small-cell lung cancer with CT-based deep learning: A retrospective multicenter study. Radiother Oncol 2024; 195:110221. [PMID: 38479441 DOI: 10.1016/j.radonc.2024.110221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/26/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND AND PURPOSE To develop a computed tomography (CT)-based deep learning model to predict overall survival (OS) among small-cell lung cancer (SCLC) patients and identify patients who could benefit from prophylactic cranial irradiation (PCI) based on OS signature risk stratification. MATERIALS AND METHODS This study retrospectively included 556 SCLC patients from three medical centers. The training, internal validation, and external validation cohorts comprised 309, 133, and 114 patients, respectively. The OS signature was built using a unified fully connected neural network. A deep learning model was developed based on the OS signature. Clinical and combined models were developed and compared with a deep learning model. Additionally, the benefits of PCI were evaluated after stratification using an OS signature. RESULTS Within the internal and external validation cohorts, the deep learning model (concordance index [C-index] 0.745, 0.733) was far superior to the clinical model (C-index: 0.635, 0.630) in predicting OS, but slightly worse than the combined model (C-index: 0.771, 0.770). Additionally, the deep learning model had excellent calibration, clinical usefulness, and improved accuracy in classifying survival outcomes. Remarkably, patients at high risk had a survival benefit from PCI in both the limited and extensive stages (all P < 0.05), whereas no significant association was observed in patients at low risk. CONCLUSIONS The CT-based deep learning model exhibited promising performance in predicting the OS of SCLC patients. The OS signature may aid in individualized treatment planning to select patients who may benefit from PCI.
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Affiliation(s)
- Xiaomin Zheng
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China; Department of Radiation Oncology, Anhui Provincial Cancer Hospital, Hefei 230031, China
| | - Kaicai Liu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China; Department of Radiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230001, China
| | - Na Shen
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Yankun Gao
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Chao Zhu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Cuiping Li
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Chang Rong
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Shuai Li
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China
| | - Baoxin Qian
- Huiying Medical Technology, Beijing 100192, China
| | - Jianying Li
- CT Advanced Application, GE HealthCare China, Beijing 100186, China
| | - Xingwang Wu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei 230031, China.
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Megyesfalvi Z, Gay CM, Popper H, Pirker R, Ostoros G, Heeke S, Lang C, Hoetzenecker K, Schwendenwein A, Boettiger K, Bunn PA, Renyi-Vamos F, Schelch K, Prosch H, Byers LA, Hirsch FR, Dome B. Clinical insights into small cell lung cancer: Tumor heterogeneity, diagnosis, therapy, and future directions. CA Cancer J Clin 2023; 73:620-652. [PMID: 37329269 DOI: 10.3322/caac.21785] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023] Open
Abstract
Small cell lung cancer (SCLC) is characterized by rapid growth and high metastatic capacity. It has strong epidemiologic and biologic links to tobacco carcinogens. Although the majority of SCLCs exhibit neuroendocrine features, an important subset of tumors lacks these properties. Genomic profiling of SCLC reveals genetic instability, almost universal inactivation of the tumor suppressor genes TP53 and RB1, and a high mutation burden. Because of early metastasis, only a small fraction of patients are amenable to curative-intent lung resection, and these individuals require adjuvant platinum-etoposide chemotherapy. Therefore, the vast majority of patients are currently being treated with chemoradiation with or without immunotherapy. In patients with disease confined to the chest, standard therapy includes thoracic radiotherapy and concurrent platinum-etoposide chemotherapy. Patients with metastatic (extensive-stage) disease are treated with a combination of platinum-etoposide chemotherapy plus immunotherapy with an anti-programmed death-ligand 1 monoclonal antibody. Although SCLC is initially very responsive to platinum-based chemotherapy, these responses are transient because of the development of drug resistance. In recent years, the authors have witnessed an accelerating pace of biologic insights into the disease, leading to the redefinition of the SCLC classification scheme. This emerging knowledge of SCLC molecular subtypes has the potential to define unique therapeutic vulnerabilities. Synthesizing these new discoveries with the current knowledge of SCLC biology and clinical management may lead to unprecedented advances in SCLC patient care. Here, the authors present an overview of multimodal clinical approaches in SCLC, with a special focus on illuminating how recent advancements in SCLC research could accelerate clinical development.
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Affiliation(s)
- Zsolt Megyesfalvi
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Thoracic Surgery, Semmelweis University and National Institute of Oncology, Budapest, Hungary
- National Koranyi Institute of Pulmonology, Budapest, Hungary
| | - Carl M Gay
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Helmut Popper
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Robert Pirker
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gyula Ostoros
- National Koranyi Institute of Pulmonology, Budapest, Hungary
| | - Simon Heeke
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christian Lang
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Division of Pulmonology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Anna Schwendenwein
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Kristiina Boettiger
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Paul A Bunn
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Ferenc Renyi-Vamos
- Department of Thoracic Surgery, Semmelweis University and National Institute of Oncology, Budapest, Hungary
- National Koranyi Institute of Pulmonology, Budapest, Hungary
| | - Karin Schelch
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Center for Cancer Research, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Lauren A Byers
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fred R Hirsch
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Tisch Cancer Institute, Center for Thoracic Oncology, Mount Sinai Health System, New York, NY, USA
| | - Balazs Dome
- Department of Thoracic Surgery, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Thoracic Surgery, Semmelweis University and National Institute of Oncology, Budapest, Hungary
- National Koranyi Institute of Pulmonology, Budapest, Hungary
- Department of Translational Medicine, Lund University, Lund, Sweden
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3
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Alhusaini S, Lanman TA, Ko RB, Therkelsen KE, Eyben RV, Diehn M, Soltys SG, Pollom EL, Chin A, Vitzthum L, Wakelee HA, Padda SK, Ramchandran K, Loo BW, Neal JW, Nagpal S. Real-world risk of brain metastases in stage III non-small cell lung cancer in the era of PET and MRI staging. Front Oncol 2023; 13:1139940. [PMID: 37035171 PMCID: PMC10080021 DOI: 10.3389/fonc.2023.1139940] [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: 01/08/2023] [Accepted: 03/15/2023] [Indexed: 04/11/2023] Open
Abstract
Objective The 2-year incidence of brain metastases (BrMs) in stage III non-small lung cell cancer (NSCLC) has been estimated to be around 30%. However, recent clinical trials have demonstrated considerably lower BrMs rates in this patient population. In this study, we aimed to review the real-world incidence, surveillance, and treatment patterns of BrMs in stage III NSCLC. Materials and methods Using a retrospective single-center study design, we identified patients with stage III NSCLC who received radiation with curative intent over a 10-year period. Outcome variables included BrMs incidence, overall survival (OS), and survival from date of BrMs. Additionally, we assessed patterns of BrMs surveillance in stage III NSCLC and treatment. Results We identified a total of 279 stage III NSCLC patients, of which 160 with adequate records were included in the final analyses [adenocarcinoma (n = 96), squamous cell carcinoma (n = 53), other histology subtype (n = 11)]. The median OS for the entire cohort was 41 months (95% CI, 28-53), while the median time from BrMs to death was 19 months (95% CI, 9-21). Twenty-three patients (14.4%) received planned surveillance brain MRIs at 6, 12, and 24 months after completion of treatment. The remaining 137 patients (85.6%) received brain MRIs at systemic recurrence (restaging) or when neurologically symptomatic. A total of 37 patients (23%) developed BrMs, with a 2-year cumulative BrMs incidence of 17% (95% CI, 11-23). A higher incidence of BrMs was identified in patients with adenocarcinoma relative to those with squamous cell carcinoma (p < 0.01). Similarly, a higher 2-year BrMs incidence was observed in patients who received planned surveillance brain MRI relative to those who did not, although statistical significance was not reached. Stereotactic radiosurgery (SRS) treated 29 of BrMs patients (78.4%) and was preferred over WBRT, which treated only 3 patients (8.1%). Conclusions At our center, BrMs incidence in stage III NSCLC patients was lower than historically reported but notably higher than the incidence described in recent clinical trials. Routine BrMs surveillance potentially allows earlier detection of asymptomatic BrMs. However, asymptomatic BrMs were mostly detected on restaging MRI at the time of recurrence.
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Affiliation(s)
- Saud Alhusaini
- Division of Neuro-oncology, Department of Neurology and Neurological Sciences, Stanford Cancer Institute, Stanford, CA, United States
| | - Tyler A. Lanman
- Division of Neuro-oncology, Department of Neurology and Neurological Sciences, Stanford Cancer Institute, Stanford, CA, United States
| | - Ryan B. Ko
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Kate E. Therkelsen
- Division of Neuro-oncology, Department of Neurology and Neurological Sciences, Stanford Cancer Institute, Stanford, CA, United States
| | - Rie Von Eyben
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Maximilian Diehn
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Scott G. Soltys
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Erqi L. Pollom
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Alexander Chin
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Lucas Vitzthum
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Heather A. Wakelee
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Sukhmani K. Padda
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Kavitha Ramchandran
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Billy W. Loo
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford, CA, United States
| | - Joel W. Neal
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Seema Nagpal
- Division of Neuro-oncology, Department of Neurology and Neurological Sciences, Stanford Cancer Institute, Stanford, CA, United States
- *Correspondence: Seema Nagpal,
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Chen Y, Wang Y, Ren F, Huang Z, Tan B, Zhao Z, Yu X, Dong P, Yu J, Meng X. Prophylactic cranial irradiation (PCI) versus active surveillance in patients with limited-stage small cell lung cancer: a retrospective, multicentre study. Respir Res 2022; 23:274. [PMID: 36184624 PMCID: PMC9526908 DOI: 10.1186/s12931-022-02196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background The recommendation of PCI for limited-stage small cell lung cancer (LS-SCLC) is primarily based on evidence from the pre-magnetic resonance imaging (MRI) era. However, as MRI accuracy improves and stereotactic radiosurgery advances, the role of PCI for LS-SCLC has become uncertain. This study aims to compare the contemporary survival outcomes of patients with LS-SCLC treated with PCI versus active surveillance. Methods We conducted a retrospective cohort study in which 1068 patients with LS-SCLC who achieved a good response to first-line chemoradiotherapy were consecutively enrolled from 5 tertiary medical centres between June 2009 and June 2019. Of these patients, 440 received PCI, while 628 received surveillance without PCI. Propensity score matching with a 1:1 ratio was performed to balance the baseline characteristics of the two cohorts. The endpoints were overall survival (OS) and the incidence of brain metastasis (BM). Results In total, 648 patients were matched. The baseline characteristics were generally well balanced. At a median follow-up of 64.5 months (range 2–190), patients who underwent PCI had a significantly lower risk for BM than those who underwent surveillance. The 3-year cumulative incidence rate of BM was 28.2% (95% CI 22.5–33.8%) in the PCI cohort and 38.5% (32.6–44.5%) in the surveillance cohort (Gray’s p = 0.002). However, the lower incidence of BM in the PCI cohort did not translate into a significant extension of OS. The median OS was 35.8 months (95% CI 27.6–44.0 months) in the PCI cohort versus 32 months (26.4–37.6 months) in the surveillance cohort (HR 0.90, 95% CI 0.74–1.10, p = 0.29). Multivariable analysis showed that disease stage, chemoradiotherapy sequence, and response to chemoradiotherapy were independent prognostic factors for BM or OS. Conclusions Overall, PCI reduces the risk for BM but does not substantially prolong OS compared with active surveillance. A phase 3, prospective clinical trial (NCT04829708) we initiated is currently underway, which is expected to corroborate our results.
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Affiliation(s)
- Yu Chen
- Shandong University Cancer Center, Jinan, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Yao Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Fei Ren
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China
| | - Zhaoqin Huang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bingxu Tan
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Zhonghua Zhao
- Department of Oncology, Binzhou Medical University Hospital, Binzhou, Shandong, China
| | - Xinshuang Yu
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Lung Cancer Institute, Jinan, Shandong, China
| | - Peng Dong
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Oncology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Lung Cancer Institute, Jinan, Shandong, China
| | - Jinming Yu
- Shandong University Cancer Center, Jinan, Shandong, China.,Shandong Provincial Key Laboratory of Radiation Oncology, Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.,8Research Unit of Radiation Oncology, Chinese Academy of Medical Sciences, Jinan, Shandong, China
| | - Xiangjiao Meng
- Shandong University Cancer Center, Jinan, Shandong, China. .,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, 250117, Shandong, China.
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5
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Wang R, Wang T, Zhou Q. Parotid metastases from primary lung cancer: Case series and systematic review of the features. Front Oncol 2022; 12:963094. [PMID: 36091176 PMCID: PMC9453833 DOI: 10.3389/fonc.2022.963094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Most parotid metastases have been reported to come from the head and neck; however, cases metastasized from the lung are extremely rare. Missed diagnoses and misdiagnoses occurred quite a few times. Thus, accurately identifying the clinical features of parotid metastasis of lung cancer is important. However, current studies about this issue are mostly case reports, and little is known about the detailed and systematic aspects. We reported three cases of parotid metastases from lung cancer and then systematically searched similar cases through “Pub-Med” and “Web of Science”. Finally, twenty-three patients were included in the study. Eighty-three percent of which were males, and 19 patients were over 50 years old. In all cases with smoking history mentioned, 93% were smokers. The predominant pathological type was small cell lung cancer (SCLC, 13 patients, 56%). Seventeen combined with other site metastasis, while more than half of which were brain metastases. The survival time ranged from 3months-17years, and as for SCLCs, it was only 3months-40months. It can be concluded that clinical features, such as sex, age, smoking history, pathological types, and metastasis patterns, could provide valuable evidence for diagnosis. The lung seems to be the most common primary site of parotid metastases except for head and neck tumors. The two circumstances, SCLC coexisting with Warthin’s tumor and parotid small cell carcinoma with lung metastasis, should be differentiated from parotid metastasis of lung cancer with caution For cases presented as SCLC, more aggressive strategies, such as chemotherapy with immunotherapy and maintenance therapy, may be more suitable. Due to the greater tendency of brain metastasis in such diseases, whole-brain radiation therapy, stereotactic radiosurgery or prophylactic cranial irradiation should be applied to corresponding patients in time. Additionally, lung cancer parotid metastases may be a marker of poor prognosis.
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Memantine in the Prevention of Radiation-Induced Brain Damage: A Narrative Review. Cancers (Basel) 2022; 14:cancers14112736. [PMID: 35681716 PMCID: PMC9179311 DOI: 10.3390/cancers14112736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/25/2022] [Accepted: 05/30/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Decline in cognitive function is a major problem for patients undergoing whole-brain radiotherapy (WBRT). Scientific interest has increased due to the high dropout rate of patients in the first months after WBRT and the early onset of cognitive decline. Therefore, the study of antiglutamatergic pharmacological prophylaxis and hippocampal-sparing WBRT techniques has been deepened based on the knowledge of the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline. In order to provide a summary of the evidence in this field, and to foster future research in this setting, this literature review presents current evidence on the prevention of radiation-induced cognitive decline and particularly on the role of memantine. Abstract Preserving cognitive functions is a priority for most patients with brain metastases. Knowing the mechanisms of hyperglutamatergic neurotoxicity and the role of some hippocampal areas in cognitive decline (CD) led to testing both the antiglutamatergic pharmacological prophylaxis and hippocampal-sparing whole-brain radiotherapy (WBRT) techniques. These studies showed a relative reduction in CD four to six months after WBRT. However, the failure to achieve statistical significance in one study that tested memantine alone (RTOG 0614) led to widespread skepticism about this drug in the WBRT setting. Moreover, interest grew in the reasons for the strong patient dropout rates in the first few months after WBRT and for early CD onset. In fact, the latter can only partially be explained by subclinical tumor progression. An emerging interpretation of the (not only) cognitive impairment during and immediately after WBRT is the dysfunction of the limbic and hypothalamic system with its immune and hormonal consequences. This new understanding of WBRT-induced toxicity may represent the basis for further innovative trials. These studies should aim to: (i) evaluate in greater detail the cognitive effects and, more generally, the quality of life impairment during and immediately after WBRT; (ii) study the mechanisms producing these early effects; (iii) test in clinical studies, the modern and advanced WBRT techniques based on both hippocampal-sparing and hypothalamic-pituitary-sparing, currently evaluated only in planning studies; (iv) test new timings of antiglutamatergic drugs administration aimed at preventing not only late toxicity but also acute effects.
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Tsui DCC, Camidge DR, Rusthoven CG. Managing Central Nervous System Spread of Lung Cancer: The State of the Art. J Clin Oncol 2022; 40:642-660. [PMID: 34985937 DOI: 10.1200/jco.21.01715] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.
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Affiliation(s)
- David Chun Cheong Tsui
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado Cancer Center, Anschutz Medical Campus, Aurora, CO
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8
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Lim YJ, Song C, Kim HJ. Survival impact of prophylactic cranial irradiation in small-cell lung cancer in the modern era of magnetic resonance imaging staging. Radiat Oncol 2022; 17:26. [PMID: 35123531 PMCID: PMC8817587 DOI: 10.1186/s13014-022-01994-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/19/2022] [Indexed: 01/12/2023] Open
Abstract
Background In the modern era of magnetic resonance imaging (MRI) staging, the benefit of prophylactic cranial irradiation (PCI) in patients with small-cell lung cancer (SCLC) has been controversial. This study evaluated the prognostic impact of PCI in patients with limited- or extensive-stage SCLC who had no brain metastases at diagnosis according to MRI. Methods Data from newly diagnosed patients in 2014 from the Korean Association for Lung Cancer Registry database were used. Patients with limited- or extensive-stage SCLC who had no brain metastases according to MRI were identified. Univariate and multivariate survival analyses were conducted to assess the prognostic association of PCI. Results Of 107 and 122 patients with limited- and extensive-stage SCLC, 24% and 14% received PCI, respectively. In the limited-stage SCLC group, the 2-year overall survival (OS) rates of patients who received PCI and those who did not were 50% and 29% (P = 0.018), respectively. However, there was no significant difference in OS for patients with extensive-stage SCLC (P = 0.336). After adjusting for other covariates, PCI was found to be associated with improved OS in the limited-stage SCLC group (P = 0.005). Based on the time-course hazard rate function plots in the limited-stage SCLC group, the OS benefit of PCI was maximized within the first year of follow-up. Conclusions In the modern era of MRI staging, PCI might be beneficial for patients with limited-stage SCLC but not for those with extensive-stage SCLC. Further studies with a large sample size are needed to verify the prognostic association of PCI. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-01994-8.
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Rittberg R, Banerji S, Kim JO, Rathod S, Dawe DE. Treatment and Prevention of Brain Metastases in Small Cell Lung Cancer. Am J Clin Oncol 2021; 44:629-638. [PMID: 34628433 DOI: 10.1097/coc.0000000000000867] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Central nervous system (CNS) metastasis will develop in 50% of small cell lung cancer (SCLC) patients throughout disease course. Development of CNS metastasis poses a particular treatment dilemma due to the accompanied cognitive changes, poor permeability of the blood-brain barrier to systemic therapy and relatively advanced state of disease. Survival of patients with untreated SCLC brain metastases is generally <3 months with whole brain radiotherapy used as first-line management in most SCLC patients. To prevent development of CNS metastasis prophylactic cranial irradiation (PCI) is recommended in limited stage disease, after response to chemotherapy and radiation, while PCI may be considered in extensive stage disease after favorable response to upfront treatment. Neurocognitive toxicity with whole brain radiotherapy and PCI is a concern and remains difficult to predict. The mechanism of toxicity is likely multifactorial, but a potential mechanism of injury to the hippocampus has led to hippocampal sparing radiation techniques. Treatment of established non-small cell lung cancer CNS metastases has increasingly focused on using stereotactic radiotherapy (SRS) and it is tempting to extrapolate these results to SCLC. In this review, we explore the evidence surrounding the prediction, prevention, detection, and treatment of CNS metastases in SCLC. We further review whether existing evidence supports extrapolating less toxic treatments to SCLC patients with CNS metastases and discuss trials that may shed more light on this question.
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Affiliation(s)
- Rebekah Rittberg
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
| | - Shantanu Banerji
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
- Research Institute in Oncology and Hematology at CancerCare Manitoba, Winnipeg, MB, Canada
| | | | | | - David E Dawe
- Department of Internal Medicine, University of Manitoba
- Departments of Hematology and Medical Oncology
- Research Institute in Oncology and Hematology at CancerCare Manitoba, Winnipeg, MB, Canada
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Yan M, Toh TS, Lindsay PE, Weiss J, Hueniken K, Yeung C, Sugumar V, Pinto D, Tadic T, Sun A, Bezjak A, Cho J, Raman S, Giuliani M, Moraes FY, Liu G, Hope AJ, Lok BH. Limited-stage small cell lung cancer: Outcomes associated with prophylactic cranial irradiation over a 20-year period at the Princess Margaret Cancer Centre. Clin Transl Radiat Oncol 2021; 30:43-49. [PMID: 34296000 PMCID: PMC8282904 DOI: 10.1016/j.ctro.2021.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 11/25/2022] Open
Abstract
Prophylactic cranial irradiation (PCI) was more commonly used in younger patients. PCI utilization rates did not change throughout our 20-year institutional experience. PCI was associated with improved OS and lower brain metastasis risk, independent of MRI follow-up or era of treatment. For LS-SCLC patients with good thoracic response, PCI remains the standard-of-care.
Background & purpose Prophylactic cranial irradiation (PCI) is recommended for limited-stage small-cell lung cancer (LS-SCLC) patients with good response to concurrent chemoradiation. We report our institution’s 20-year experience with this patient population and associated clinical outcomes. Materials & methods A retrospective cohort of consecutive LS-SCLC patients treated with curative intent chemoradiation at our institution (1997–2018) was reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method, and significant covariates determined by the Cox proportional hazards model. Covariates predictive of PCI were determined using Fisher's exact test and the Mann-Whitney test. Brain failure risk (BFR) was calculated using the cumulative incidence method treating death as a competing event. Treatment cohorts (historic vs. contemporary) were stratified by the median year of diagnosis (2005). Results A total of 369 patients with LS-SCLC were identified, of which 278 patients were notionally PCI eligible. PCI was given to 196 patients (71%). Younger age was associated with PCI utilization (p < 0.001). PCI utilization rates did not change between the historic and contemporary treatment era (p = 0.11), whereas magnetic resonance imaging (MRI) use at baseline and follow-up became more prevalent in the contemporary era (p = <0.001). On multivariable analysis, PCI utilization was associated with improved OS (HR 1.88, 95% CI 1.32–2.69) and decreased BFR (HR 4.66, 95% CI 2.58–8.40). Patients who had MRI follow-up had a higher incidence of BFR (HR 0.35, 95% CI 0.18–0.66) in multivariable analyses. Conclusions For LS-SCLC patients at our institution, PCI is more frequently utilized in younger patients, and the utilization rate did not change significantly over the past 20 years. PCI was independently associated with improved OS and lower BFR. Omission of PCI in LS-SCLC patients should not be routinely practiced in the absence of further prospective data.
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Affiliation(s)
- Michael Yan
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | - Tzen S Toh
- The Medical School, University of Sheffield, Sheffield, United Kingdom.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Patricia E Lindsay
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Katrina Hueniken
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christy Yeung
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
| | - Vijithan Sugumar
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Dixon Pinto
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alexander Sun
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Andrea Bezjak
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - John Cho
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Meredith Giuliani
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Fabio Ynoe Moraes
- Department of Oncology, Cancer Centre of Southeastern Ontario, Queen's University, Kingston, ON, Canada
| | - Geoffrey Liu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Andrew J Hope
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Benjamin H Lok
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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11
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Evidence to Date: Evaluating Pembrolizumab in the Treatment of Extensive-Stage Small-Cell Lung Cancer. Clin Pract 2021; 11:441-454. [PMID: 34287275 PMCID: PMC8293071 DOI: 10.3390/clinpract11030059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/12/2021] [Accepted: 07/02/2021] [Indexed: 01/22/2023] Open
Abstract
Small-cell lung cancer (SCLC) is an aggressive subtype of lung cancer characterized by a rapid initial response and early development of resistance to systemic therapy and radiation. The management of SCLC significantly changed for the first time in decades with the introduction of immune checkpoint inhibitors. Pembrolizumab, a humanized IgG4 isotype antibody, targets the programmed cell death protein 1 (PD-1) pathway to restore anti-tumor immunity. Prospective trials of pembrolizumab in patients with previously treated SCLC showed significant durability of responses. These results led to the U.S. Food and Drug Administration (FDA) granting pembrolizumab accelerated approval as second- or third-line monotherapy for patients with extensive-stage (ES) SCLC. In a recent clinical trial that included patients with previously untreated ES-SCLC, pembrolizumab in combination with platinum/etoposide met its progression-free survival endpoint, but overall survival (OS) did not cross the threshold for superiority. With the therapeutic landscape for SCLC rapidly evolving, we review prior experience and future directions of pembrolizumab in ES-SCLC.
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12
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Kim H, Keller A, Beriwal S, Smith KJ, Vargo JA. Cost-Effectiveness of Prophylactic Cranial Irradiation Versus MRI Surveillance for Extensive-Stage Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2021; 111:1186-1194. [PMID: 33984410 DOI: 10.1016/j.ijrobp.2021.04.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 01/30/2023]
Abstract
PURPOSE Owing to conflicting prospective data, controversy exists regarding prophylactic cranial irradiation (PCI) in extensive-stage small cell lung cancer (ES-SCLC). We evaluated the cost-effectiveness of PCI versus magnetic resonance imaging (MRI) surveillance for patients with ES-SCLC based on currently available evidence and in the context of the proposed Centers for Medicare & Medicaid Services alternative payment model. METHODS AND MATERIALS A Markov state transition model was constructed to perform a cost-effectiveness analysis comparing MRI surveillance alone with PCI for ES-SCLC. Clinical parameters were obtained from clinical trial data, and cost data were based on 2019 Medicare reimbursement. Strategies were compared using the incremental cost-effectiveness ratio (ICER) with effectiveness in quality-adjusted life years (QALYs) and evaluated with a willingness-to-pay threshold of $100,000 per QALY gained. One-way and probabilistic sensitivity analyses were performed to consider model uncertainty. RESULTS In the base-case scenario, PCI was not cost-effective in this model, with an ICER of $168,456 per QALY gained compared with MRI surveillance alone, assuming that overall survival was 10 months for MRI surveillance alone and 12.5 months for PCI. One-way sensitivity analysis showed that results were most sensitive to the variation of overall survival and cognitive decline rates between the 2 groups. In a scenario analysis in which all patients received hippocampal-avoidance PCI, the model results became nearly cost-effective with PCI. CONCLUSIONS PCI was not found to be cost-effective within this model compared with MRI surveillance alone, owing to the neurocognition decline effect of PCI based on available evidence. Hippocampal-avoidance PCI may be a potential cost-effective strategy for ES-SCLC, with confirmation expected after an ongoing prospective clinical trial (The Southwest Oncolology Group MRI Brain Surveillance Alone Versus MRI Surveillance And Prophylactic Cranial Irradiation [MAVERICK]), which includes assessments of cognitive function.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Andrew Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Kenneth J Smith
- Clinical and Translational Science and Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania.
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13
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Kepka L, Socha J, Sas-Korczynska B. Radiotherapy for brain metastases from small-cell lung cancer in distinct clinical indications and scenarios. J Thorac Dis 2021; 13:3269-3278. [PMID: 34164219 PMCID: PMC8182529 DOI: 10.21037/jtd.2019.10.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 10/14/2019] [Indexed: 12/25/2022]
Abstract
Management of brain metastases (BM) from small-cell lung cancer (SCLC) is complex and not supported by a strong evidence from prospective clinical trials. Owing to the different clinical and pathological characteristics of SCLC, patients with this histology were not included in the prospective studies on the value of whole-brain radiotherapy (WBRT) and local surgical or ablative radiation treatment like stereotactic radiosurgery (SRS). Chemotherapy also represents a major part of the armamentarium against BM from SCLC due to the well-recognized chemoresponsiveness of this cancer and the frequent presentation of BM with extracranial progression. WBRT in combination with chemotherapy has long been a standard approach in this setting. However, data on the neurocognitive toxicity and the lack of documented impact on overall survival of WBRT in the management of BM from other solid tumors, as well as the increasing availability of the stereotactic radiotherapy technologies, has led to the increasing use of SRS with omission of WBRT also in SCLC. In the current review the use of different modalities of radiotherapy and ways of combining radiotherapy with chemotherapy for BM from SCLC will be presented for distinct clinical situations: presentation of BM synchronous with primary, metachronous presentation of BM-without previous prophylactic cranial irradiation (PCI) vs. after PCI, and asymptomatic BM found at the staging before PCI.
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Affiliation(s)
- Lucyna Kepka
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Joanna Socha
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
| | - Beata Sas-Korczynska
- Department of Radiotherapy, Military Institute of Medicine, Warsaw, Poland
- Institute of Medical Sciences, Medical College of Rzeszow University, Rzeszow, Poland
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14
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Ghanta S, Keller A, Rodríguez-López JL, Patel A, Beriwal S. Utility of Prophylactic Cranial Irradiation for Limited Stage Small Cell Lung Cancer in the Modern Era with Magnetic Resonance Imaging Surveillance. Clin Oncol (R Coll Radiol) 2021; 33:e323-e330. [PMID: 33888381 DOI: 10.1016/j.clon.2021.03.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/03/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023]
Abstract
AIMS To retrospectively analyse the impact of prophylactic cranial irradiation (PCI) on survival and intracranial progression in patients with limited stage small cell lung cancer (LS-SCLC) in the modern era of widespread magnetic resonance imaging brain screening. MATERIALS AND METHODS Patients with LS-SCLC treated within our network between 2009 and 2020 who responded to initial therapy were stratified by receipt of PCI and stage of disease. A propensity score match analysis was carried out for stage II-III patients. Overall and neurological survival were defined as time to death and presumed death due to uncontrolled intracranial disease, respectively. Brain metastasis-free survival and symptomatic brain metastasis-free survival were defined as freedom from intracranial progression and symptomatic intracranial progression, respectively. The effect of PCI on these outcomes was assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS In total, 243 (69.6%) of 349 patients received PCI. On multivariate analysis in the propensity matched stage II-III cohort, PCI was a significant predictor of improved neurological survival (hazard ratio 0.23, 95% confidence interval 0.08-0.65; P = 0.01), brain metastasis-free survival (hazard ratio 0.25, 95% confidence interval 0.12-0.51; P < 0.01) and symptomatic brain metastasis-free survival (hazard ratio 0.21, 95% confidence interval 0.08-0.55; P < 0.01), but not improved overall survival. Two-year neurological survival estimates within the propensity matched cohort were 96.8% (95% confidence interval 87.6-99.2%) with PCI and 77.2% (95% confidence interval 63.0-86.4%) without PCI and 1- and 2-year estimates of incidence of brain metastases were 3.9% (95% confidence interval 1.3-11.7%) and 11.7% (95% confidence interval 5.6-23.5%) in the PCI group and 31.6% (95% confidence interval 22.1-43.9%) and 40.4% (95% confidence interval 29.2-54.0%) in the no PCI group, respectively. CONCLUSIONS In the modern era of magnetic resonance imaging screening, PCI was associated with reduced incidence of intracranial progression in patients with stage II-III LS-SCLC who respond to initial therapy. This, importantly, translated to a decreased risk of neurological death within our propensity matched cohort, without significant improvement in overall survival.
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Affiliation(s)
- S Ghanta
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - A Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - J L Rodríguez-López
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - A Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA
| | - S Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.
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15
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Couñago F, de la Pinta C, Gonzalo S, Fernández C, Almendros P, Calvo P, Taboada B, Gómez-Caamaño A, Guerra JLL, Chust M, González Ferreira JA, Álvarez González A, Casas F. GOECP/SEOR radiotherapy guidelines for small-cell lung cancer. World J Clin Oncol 2021; 12:115-143. [PMID: 33767969 PMCID: PMC7968106 DOI: 10.5306/wjco.v12.i3.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancers. The main treatment is chemotherapy (Ch). However, the addition of radiotherapy significantly improves overall survival (OS) in patients with non-metastatic SCLC and in those with metastatic SCLC who respond to Ch. Prophylactic cranial irradiation reduces the risk of brain metastases and improves OS in both metastatic and non-metastatic patients. The 5-year OS rate in patients with limited-stage disease (non-metastatic) is slightly higher than 30%, but less than 5% in patients with extensive-stage disease (metastatic). The present clinical guidelines were developed by Spanish radiation oncologists on behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Society of Radiation Oncology to provide a current review of the diagnosis, planning, and treatment of SCLC. These guidelines emphasise treatment fields, radiation techniques, fractionation, concomitant treatment, and the optimal timing of Ch and radiotherapy. Finally, we discuss the main indications for reirradiation in local recurrence.
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Affiliation(s)
- Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Hospital La Luz, Universidad Europea de Madrid, Madrid 28223, Madrid, Spain
| | - Carolina de la Pinta
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, GenesisCare Madrid, Madrid 28043, Spain
| | - Piedad Almendros
- Department of Radiation Oncology, Hospital General Universitario, Valencia 46014, Spain
| | - Patricia Calvo
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Begoña Taboada
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Antonio Gómez-Caamaño
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - José Luis López Guerra
- Department of Radiation Oncology, Hospital Universitario Virgen del Rocío, Sevilla 41013, Spain
| | - Marisa Chust
- Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología, Valencia 46009, Spain
| | | | | | - Francesc Casas
- Department of Radiation Oncology, Thoracic Unit, Hospital Clinic, Barcelona 08036, Spain
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16
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Deng L, Zhang Y, Zhang W, Feng L, Zhang K, Wang W, Zhou Z, Wang L, Hui Z. Prospective Exploratory Study of the Clinical Significance of Circulating Tumor Cells in Patients With Small Cell Lung Cancer Exposed to Prophylactic Cranial Irradiation. Front Oncol 2021; 10:575394. [PMID: 33628727 PMCID: PMC7897656 DOI: 10.3389/fonc.2020.575394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/21/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Circulating tumor cells (CTCs) can predict the efficacy of anti-cancer treatments and indicate prognosis. Here we investigate the significance of CTCs in relation to the prediction of treatment efficacy and prognosis in patients with small cell lung cancer (SCLC) who have received prophylactic cranial irradiation (PCI). METHODS CTCs were detected in 20 patients with SCLC before and after PCI using the oHSV1-hTERT-GFP method. The primary endpoints were progression-free survival (PFS) and overall survival (OS). RESULTS Eleven patients had limited-stage SCLC, and nine had extensive-stage SCLC. All patients completed chemo-radiotherapy and received PCI. The median baseline CTC count before PCI was 12. After PCI, the median CTC count was 4. The median follow-up time for all enrolled patients was 39.2 months. The median PFS and OS were significantly reduced in patients with ≥4 CTCs after PCI compared to those with <4 CTCs (PFS, 28.1 months vs. not reached, p = 0.001; OS, not reached vs. not reached, p = 0.029). Seven of the 10 patients with ≥4 CTCs after PCI failed after treatment, whereas the10 patients with <4 CTCs after PCI remained alive without tumors. The median PFS and OS were significantly improved in patients who exhibited a rate of CTC decline of ≥58% after PCI compared with patients who exhibited a decline rate of <58% (PFS, 26.4 months vs. not reached, p = 0.006; OS, not reached vs. not reached, p = 0.029). CONCLUSION In SCLC patients who receive PCI, the CTC count and rate of CTC decline after PCI significantly correlate with prognosis.
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Affiliation(s)
- Lei Deng
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen Zhang
- Department of Immunology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Feng
- State Key Laboratory of Molecular Oncology, Department of Etiology and Carcinogenesis, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kaitai Zhang
- State Key Laboratory of Molecular Oncology, Department of Etiology and Carcinogenesis, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenqing Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zongmei Zhou
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Luhua Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Zhouguang Hui
- Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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17
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Abstract
Small-cell lung cancer (SCLC) represents about 15% of all lung cancers and is marked by an exceptionally high proliferative rate, strong predilection for early metastasis and poor prognosis. SCLC is strongly associated with exposure to tobacco carcinogens. Most patients have metastatic disease at diagnosis, with only one-third having earlier-stage disease that is amenable to potentially curative multimodality therapy. Genomic profiling of SCLC reveals extensive chromosomal rearrangements and a high mutation burden, almost always including functional inactivation of the tumour suppressor genes TP53 and RB1. Analyses of both human SCLC and murine models have defined subtypes of disease based on the relative expression of dominant transcriptional regulators and have also revealed substantial intratumoural heterogeneity. Aspects of this heterogeneity have been implicated in tumour evolution, metastasis and acquired therapeutic resistance. Although clinical progress in SCLC treatment has been notoriously slow, a better understanding of the biology of disease has uncovered novel vulnerabilities that might be amenable to targeted therapeutic approaches. The recent introduction of immune checkpoint blockade into the treatment of patients with SCLC is offering new hope, with a small subset of patients deriving prolonged benefit. Strategies to direct targeted therapies to those patients who are most likely to respond and to extend the durable benefit of effective antitumour immunity to a greater fraction of patients are urgently needed and are now being actively explored.
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Affiliation(s)
- Charles M Rudin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Elisabeth Brambilla
- Institute for Advanced Biosciences, Université Grenoble Alpes, Grenoble, France
| | - Corinne Faivre-Finn
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Julien Sage
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Genetics, Stanford University, Stanford, CA, USA
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18
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Pereira I, Slotman B, Rusthoven CG, Katz MS, Simcock R, Saeed H. Stereotactic radiosurgery (SRS) - A new normal for small cell lung cancer? Clin Transl Radiat Oncol 2020; 25:10-15. [PMID: 33294642 PMCID: PMC7695539 DOI: 10.1016/j.ctro.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/25/2022] Open
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19
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Taylor JM, Rusthoven CG, Moghanaki D. Prophylactic cranial irradiation or MRI surveillance for extensive stage small cell lung cancer. J Thorac Dis 2020; 12:6225-6233. [PMID: 33209461 PMCID: PMC7656401 DOI: 10.21037/jtd.2020.03.80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The treatment paradigm for extensive stage small cell lung cancer (ES-SCLC) is evolving. Prophylactic cranial irradiation (PCI) has long been considered a component of standard treatment in patients with extensive stage disease who respond to chemotherapy. However, in the modern era of magnetic resonance imaging, the role of PCI has become an area of controversy following conflicting level I evidence. Due to conflicting data and toxicity concerns, the routine use of PCI has declined. Recent improvements in systemic disease control with the use of immunotherapy and reductions in the toxicity attributable to PCI with hippocampal avoidance and memantine have reignited the discussion. As such, we present here a narrative review of PCI with a focus on historical milestones, randomized data, risk mitigation and future directions.
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Affiliation(s)
- James M Taylor
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado-Denver, Aurora, CO, USA
| | - Drew Moghanaki
- Department of Radiation Oncology, Atlanta VA Health Care System, Emory University School of Medicine, Atlanta, GA, USA
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20
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Kochbati L, Vanderpuye V, Moujahed R, Rejeb MB, Naimi Z, Olasinde T. Cancer care and COVID-19: tailoring recommendations for the African radiation oncology context. Ecancermedicalscience 2020; 14:1144. [PMID: 33343703 PMCID: PMC7738267 DOI: 10.3332/ecancer.2020.1144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Indexed: 12/24/2022] Open
Abstract
Africa is the second most populous continent after Asia comprising 54 countries. Given the healthcare system deficiencies in Africa, the impact of the COVID-19 pandemic was expected to be disastrous. The first case of COVID-19 on the continent was reported in Egypt on 14 February 2020. By 13 May, cases had been reported in all 54 countries. Several practice guidelines specific to radiation oncology departments have been published, including prioritisation criteria for postponing radiotherapy, continuation of treatment, hypofractionation or even omitting radiotherapy. The oncology community in Africa has suddenly needed to protect both patients and caregivers and to ensure continuity of essential clinical services despite several challenges. Considering equipment unavailability, lack of human resources and poor infrastructure, tailoring COVID-19 pandemic management to the African context seems mandatory and a unified approach to guideline development in this context is encouraged. In this article, we discuss contextual issues coming into play, highlighting steps to be taken by radiotherapy centres in Africa to mitigate fallouts from the current pandemic to ensure the safety of our patients and staff as well as the impact on future care.
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Affiliation(s)
- Lotfi Kochbati
- Radiotherapy department, Abderrahman Mami Hospital 2090, El Manar University. Tunis, Tunisia
| | - Verna Vanderpuye
- National Center for Radiotherapy and Nuclear Medicine, Korle-Bu Teaching Hospital, Accra, PO Box KB369, Ghana
| | - Rim Moujahed
- Radiotherapy department, Abderrahman Mami Hospital 2090, El Manar University. Tunis, Tunisia
| | - Mouna Ben Rejeb
- Radiotherapy department, Abderrahman Mami Hospital 2090, El Manar University. Tunis, Tunisia
| | - Zeineb Naimi
- Radiotherapy department, Abderrahman Mami Hospital 2090, El Manar University. Tunis, Tunisia
| | - Tajudeen Olasinde
- Ahmadu Bello University / Ahmadu Bello University Teaching Hospital, Shika-Zaria, Nigeria
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21
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Robin TP, Rusthoven CG. Radiosurgery for small-cell lung cancer brain metastases: a review. J Thorac Dis 2020; 12:6234-6239. [PMID: 33209462 PMCID: PMC7656430 DOI: 10.21037/jtd.2020.03.90] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/16/2020] [Indexed: 01/22/2023]
Abstract
First-line stereotactic radiosurgery (SRS) is now considered the preferred treatment over whole brain radiation therapy (WBRT) for limited brain metastases arising from most tumor histologies. This standard was reached following the consistent results of multiple phase III studies which demonstrated that, despite improved CNS control, the addition of WBRT to SRS does not improve overall survival (OS) and is associated with a reduction in cognitive function. Thus, it may be reasonable to consider the benchmark necessary to favor a paradigm of SRS alone over strategies incorporating WBRT as the demonstration of comparable OS in the context of decreased treatment-related side effects. However, patients with small-cell lung cancer (SCLC) brain metastases were excluded from the landmark trials that established SRS alone for limited brain metastases, largely due to concerns for short-interval CNS progression in SCLC as well the historic role of prophylactic cranial irradiation (PCI) in SCLC in the absence of known brain metastases. As a result, WBRT has remained the standard for SCLC for limited and even solitary brain lesions. With shifting SCLC care patterns including increased MRI surveillance, decreased PCI delivery, and emerging systemic agents, interest in first-line SRS for SCLC is likely to continue to increase over time. Herein we will review the emerging data for first-line SRS in the management of SCLC brain metastases and the potential for its increasing role in the setting of a greater utilization of MRI surveillance and improving systemic therapies.
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Affiliation(s)
- Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
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Hinduja RH, George K, Barthwal M, Pareek V. Radiation oncology in times of COVID-2019: A review article for those in the eye of the storm - An Indian perspective. Semin Oncol 2020; 47:315-327. [PMID: 32819712 PMCID: PMC7357513 DOI: 10.1053/j.seminoncol.2020.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023]
Abstract
The global COVID-2019 pandemic has presented to the field of radiation oncology a management dilemma in providing evidence-based treatments to all cancer patients. There is a need for appropriate measures to be taken to reduce infectious spread between the medical healthcare providers and the patient population. Such times warrant resource prioritization and to continue treatment with best available evidence, thereby reducing the risk of COVID-2019 transmission in times where the workforce is reduced. There has been literature presented in different aspects related to providing safety measures, running of a radiation department and for the management of various cancer subsites. In this article, we present a comprehensive review for sustaining a radiation oncology department in times of the COVID-2019 pandemic.
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Affiliation(s)
- Ritika Harjani Hinduja
- Associate Consultant, Department of Radiation Oncology, P.D Hinduja Hospital, Mumbai, India.
| | - Karishma George
- Junior Consultant, Department of Radiation Oncology, Vivekanand Cancer Hospital and Optimus Oncology Centre, Latur, India.
| | - Mansi Barthwal
- Senior Resident, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India.
| | - Vibhay Pareek
- Senior Resident, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India.
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Rusthoven CG, Camidge DR, Robin TP, Brown PD. Radiosurgery for Small-Cell Brain Metastases: Challenging the Last Bastion of Preferential Whole-Brain Radiotherapy Delivery. J Clin Oncol 2020; 38:3587-3591. [PMID: 32776807 DOI: 10.1200/jco.20.01823] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - D Ross Camidge
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MD
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Consolidation radiotherapy for patients with extended disease small cell lung cancer in a single tertiary institution: impact of dose and perspectives in the era of immunotherapy. Radiol Oncol 2020; 54:353-363. [PMID: 32726294 PMCID: PMC7409599 DOI: 10.2478/raon-2020-0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background Consolidation radiotherapy (cRT) in extended disease small cell lung cancer (ED-SCLC) showed improved 2-year overall survival in patients who responded to chemotherapy (ChT) in CREST trial, however results of two meta - analysis were contradictive. Recently, immunotherapy was introduced to the treatment of ED-SCLC, making the role of cRT even more unclear. The aim of our study was to access if consolidation thoracic irradiation improves survival of ED-SCLC patients treated in a routine clinical practice and to study the impact of cRT dose on survival. We also discuss the future role of cRT in the era of immunotherapy. Patients and methods We retrospectively reviewed 704 consecutive medical records of patients with small cell lung cancer treated at the Institute of Oncology Ljubljana from January 2010 to December 2014 with median follow up of 65 months. We analyzed median overall survival (mOS) of patients with ED-SCLC treated with ChT only and those treated with ChT and cRT. We also compared mOS of patients treated with different consolidation doses and performed univariate and multivariate analysis of prognostic factors. Results Out of 412 patients with ED-SCLC, ChT with cRT was delivered to 74 patients and ChT only to 113 patients. Patients with cRT had significantly longer mOS compared to patients with ChT only, 11.1 months (CI 10.1-12.0) vs. 7.6 months (CI 6.9-8.5, p < 0.001) and longer 1-year OS (44% vs. 23%, p = 0.0025), while the difference in 2-year OS was not significantly different (10% vs. 5%, p = 0.19). The cRT dose was not uniform. Higher dose with 45 Gy (in 18 fractions) resulted in better mOS compared to lower doses 30-36 Gy (in 10-12 fractions), 17.2 months vs. 10.3 months (p = 0.03) and statistically significant difference was also seen for 1-year OS (68% vs. 30%, p = 0.01) but non significant for 2-year OS (18% vs. 5%, p = 0.11). Conclusions Consolidation RT improved mOS and 1-year OS in ED-SCLC as compared to ChT alone. Higher dose of cRT resulted in better mOS and 1-year OS compared to lower dose. Consolidation RT, higher number of ChT cycles and prophylactic cranial irradiation (PCI) were independent prognostic factors for better survival in our analysis. For patients who received cRT, only higher doses and PCI had impact on survival regardless of number of ChT cycles received. Role of cRT in the era of immunotherapy is unknown and should be exploited in further trials.
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Tjong MC, Mak DY, Shahi J, Li GJ, Chen H, Louie AV. Current Management and Progress in Radiotherapy for Small Cell Lung Cancer. Front Oncol 2020; 10:1146. [PMID: 32760673 PMCID: PMC7372592 DOI: 10.3389/fonc.2020.01146] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Radiotherapy (RT) and chemotherapy continue to be widely utilized in small cell lung cancer (SCLC) management. In most limited stage (LS)-SCLC cases, the standard initial therapy remains concurrent chemoradiotherapy (CRT), typically with an etoposide and platinum-based regimen. Hyperfractionated twice daily (BID) RT remains the standard of care, though conventional daily (QD) RT is now a viable alternative supported by randomized evidence. In LS-SCLC patients who experienced good response to CRT, prophylactic cranial irradiation (PCI) remains the standard of care. Brain imaging, ideally with MRI, should be performed prior to PCI to screen for clinically apparent brain metastases that may require a higher dose of cranial irradiation. Platinum doublet chemotherapy alone is the historic standard initial therapy in extensive stage (ES)-SCLC. Addition of immunotherapy such as atezolizumab and durvalumab to chemotherapy is now recommended after their benefits were demonstrated in recent trials. In patients with response to chemotherapy, consolidation thoracic RT and PCI could be considered, though with caveats. Emergence of hippocampal avoidance cranial irradiation and SRS in SCLC patients may supplant whole cranial irradiation as future standards of care. Incorporation of novel systemic therapies such as immunotherapies has changed the treatment paradigm and overall outlook of patients with SCLC. This narrative review summarizes the current state, ongoing trials, and future directions of radiotherapy in management of SCLC.
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Affiliation(s)
- Michael C Tjong
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - David Y Mak
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeevin Shahi
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - George J Li
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Simcock R, Thomas TV, Estes C, Filippi AR, Katz MA, Pereira IJ, Saeed H. COVID-19: Global radiation oncology's targeted response for pandemic preparedness. Clin Transl Radiat Oncol 2020; 22:55-68. [PMID: 32274425 PMCID: PMC7102593 DOI: 10.1016/j.ctro.2020.03.009] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
As the global COVID-19 pandemic escalates there is a need within radiation oncology to work to support our patients in the best way possible. Measures are required to reduce infection spread between patients and within the workforce. Departments need contingency planning to create capacity and continue essential treatments despite a reduced workforce. The #radonc community held an urgent online journal club on Twitter in March 2020 to discuss these issues and create some consensus on crucial next steps. There were 121 global contributors. This document summarises these discussions around themes of infection prevention, rationalisation of workload and working practice in the presence of infection.
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Affiliation(s)
| | | | | | - Andrea R Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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Palmer JD, Trifiletti DM, Gondi V, Chan M, Minniti G, Rusthoven CG, Schild SE, Mishra MV, Bovi J, Williams N, Lustberg M, Brown PD, Rao G, Roberge D. Multidisciplinary patient-centered management of brain metastases and future directions. Neurooncol Adv 2020; 2:vdaa034. [PMID: 32793882 PMCID: PMC7415255 DOI: 10.1093/noajnl/vdaa034] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The incidence of brain metastasis is increasing as improvements in systemic therapy lead to increased survival. This provides new and challenging clinical decisions for patients who are trying to balance the risk of recurrence or progression with treatment-related side effects, and it requires appropriate management strategies from multidisciplinary teams. Improvements in prognostic assessment and systemic therapy with increasing activity in the brain allow for individualized care to better guide the use of local therapies and/or systemic therapy. Here, we review the current landscape of brain-directed therapy for the treatment of brain metastasis in the context of recent improved systemic treatment options. We also discuss emerging treatment strategies including targeted therapies for patients with actionable mutations, immunotherapy, modern whole-brain radiation therapy, radiosurgery, surgery, and clinical trials.
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Affiliation(s)
- Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurosurgery, The James Cancer Hospital and Solove Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Trifiletti
- Departments of Radiation Oncology and Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Vinai Gondi
- Department of Radiation Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Radiation Oncology Consultants LLC, Chicago, Illinois, USA
- Northwestern Medicine Chicago Proton Center Warrenville, Chicago, Illinois, USA
| | - Michael Chan
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Giuseppe Minniti
- Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, Phoenix, Arizona, USA
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Bovi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nicole Williams
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maryam Lustberg
- Department of Medical Oncology, The James Cancer Hospital and Solove Research Institute at The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ganesh Rao
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Roberge
- Department of Radiation Oncology, Centre Hospitalier de l’ Université de Montreal, Montreal, Quebec, Canada
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Nesbit EG, Leal TA, Kruser TJ. What is the role of radiotherapy for extensive-stage small cell lung cancer in the immunotherapy era? Transl Lung Cancer Res 2019; 8:S153-S162. [PMID: 31673520 DOI: 10.21037/tlcr.2019.05.01] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Small cell lung cancer has been a difficult disease to treat with poor survival and few significant improvements in outcomes in the last three decades. Most recently the addition of atezolizumab to chemotherapy in the first-line treatment of extensive-stage small cell lung cancer (ES-SCLC) resulted in improved overall survival and progression-free survival compared to chemotherapy alone. Recent randomized studies examining both consolidative thoracic radiotherapy and prophylactic cranial irradiation (PCI) in ES-SCLC have impacted the utilization of these interventions. The approval of immune checkpoint inhibitors (ICIs) to platinum/etoposide chemotherapy for the treatment of ES-SCLC in the front-line setting may also further impact the role of radiotherapy in this disease. In this article, we review the current evidence supporting thoracic radiotherapy in ES-SCLC and discuss the promising therapeutic implications of thoracic radiation in light of the inclusion of ICIs. We also address how the increasing routine use of surveillance brain magnetic resonance imaging (MRI) and ICIs may diminish the use of PCI in ES-SCLC.
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Affiliation(s)
- Eric G Nesbit
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ticiana A Leal
- Division of Hematology & Oncology, University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | - Tim J Kruser
- Department of Radiation Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Limited-Stage Small Cell Lung Cancer: Is Prophylactic Cranial Irradiation Necessary? Pract Radiat Oncol 2019; 9:e599-e607. [PMID: 31271904 DOI: 10.1016/j.prro.2019.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Prophylactic cranial irradiation (PCI) reduces the incidence of brain metastases in patients with limited stage small cell lung cancer (LS-SCLC). However, PCI is associated with neurotoxicity. Previous studies have not consistently used pretreatment magnetic resonance imaging. Modern imaging improvements continue to enhance early metastasis detection, potentially decreasing the utility of PCI. We sought to determine whether PCI was associated with improved outcomes in LS-SCLC patients with modern imaging. METHODS AND MATERIALS We identified LS-SCLC patients with no intracranial disease who were treated between 2007 and 2018. Kaplan-Meier estimates of overall survival (OS) and progression-free survival (PFS) were calculated and multivariate Cox proportional hazards models were generated. The cumulative incidence of brain metastases was estimated using competing risks methodology. RESULTS Ninety-two patients were identified without intracranial disease at initial staging, 39 of whom received PCI. Median follow-up was 56.7 months. The median OS for the cohort was 35.5 months (95% CI, 25.8-49.3), and median PFS was 19.1 months (95% CI, 12.3-30.5). Median OS with PCI versus observation was 37.9 months (95% CI, 31.8-not reached) versus 30.5 months (95% CI, 14.6-56.1; P = .07), whereas median PFS was 26.3 months (95% CI 19.1-not reached) versus 12.3 months (95% CI, 8.5-30.5; P = .02), respectively. Overall, at 2 years, the cumulative incidence of brain metastases was 10% with PCI and 29% without; this increased to 32% and 29% by 4 years (P = .66). In those patients who had negative magnetic resonance imaging of the brain after completing initial treatment, the 1-year cumulative incidence of brain metastasis was not significantly different at 8% versus 11% (P = .46) respectively. Both PCI and treatment response were independent predictors for PFS on multivariate analysis. Stratified by disease response, patients with a complete response did not benefit from PCI (P = .50), whereas those with partial response or stable disease experienced improved PFS (P = .01). CONCLUSIONS Overall, PCI was associated with improved PFS and reduced early incidence of brain metastases. Patients achieving a complete response to initial therapy did not experience a PFS benefit with PCI. This may indicate that subsets of LS-SCLC patients can potentially be spared from PCI in the era of modern imaging.
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Small Cell Lung Cancer: PCI Uncertainty and Emerging Radiosurgery Interest. Int J Radiat Oncol Biol Phys 2019; 103:1034-1035. [PMID: 30900556 DOI: 10.1016/j.ijrobp.2018.12.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 11/27/2018] [Accepted: 12/15/2018] [Indexed: 11/21/2022]
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Moghavem N, Wakelee HA, Nagpal S. Case closed: another prophylactic cranial irradiation trial for stage 3 non-small cell lung cancer fails to improve overall survival. ANNALS OF TRANSLATIONAL MEDICINE 2019; 6:S118. [PMID: 30740439 DOI: 10.21037/atm.2018.12.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nuriel Moghavem
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Heather A Wakelee
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Seema Nagpal
- Department of Neurology, Stanford University School of Medicine, Palo Alto, CA, USA
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Rusthoven CG. Prophylactic Cranial Irradiation in Non-Small-Cell Lung Cancer: The Costs Outweigh the Benefits. J Clin Oncol 2018; 36:JCO1800732. [PMID: 30346898 DOI: 10.1200/jco.18.00732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Chad G Rusthoven
- Chad G. Rusthoven, University of Colorado School of Medicine, Aurora, CO
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Robin TP, Rusthoven CG. Strategies to Preserve Cognition in Patients With Brain Metastases: A Review. Front Oncol 2018; 8:415. [PMID: 30356657 PMCID: PMC6189295 DOI: 10.3389/fonc.2018.00415] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/07/2018] [Indexed: 12/25/2022] Open
Abstract
Brain metastases are common to the natural history of many advanced malignancies. Historically, whole brain radiation therapy (WBRT) has played a key role in the management of brain metastases, especially for patients with multiple lesions. However, prospective trials have demonstrated consistent neurocognitive toxicities after WBRT, and various pharmacologic and anatomic strategies designed to mitigate these toxicities have been studied in recent years. Memantine, an NMDA receptor antagonist, taken during and after WBRT improved cognitive preservation in a randomized trial over placebo. Deliberate reductions in radiation dose to the hippocampus, via hippocampal-avoidance (HA)-WBRT, resulted in improved cognition over historic controls in a phase II trial, and follow-up randomized trials are now ongoing to evaluate cognitive outcomes with HA vs. conventional brain radiation techniques. Nevertheless, some of the most promising strategies currently available to reduce the cognitive effects of brain radiation may be found in efforts to avoid or delay WBRT administration altogether. Stereotactic radiosurgery (SRS), involving focused, high-dose radiation to central nervous system (CNS) lesions with maximal sparing of normal brain parenchyma, has become the standard for limited brain metastases (classically 1–3 or 4 lesions) in the wake of multiple randomized trials demonstrating equivalent survival and improved cognition with SRS alone compared to SRS plus WBRT. Today, there is growing evidence to support SRS alone for multiple (≥4) brain metastases, with comparable survival to SRS alone in patients with fewer lesions. In patients with small-cell lung cancer, the routine use of prophylactic cranial irradiation (PCI) for extensive-stage disease has been also been challenged following the results of a randomized trial supporting an alternative strategy of MRI brain surveillance and early salvage radiation for the development of brain metastases. Moreover, new systemic agents are demonstrating increasing CNS penetration and activity, with the potential to offer greater control of widespread and microscopic brain disease that was previously only achievable with WBRT. In this review, we endeavor to put these clinical data on cognition and brain metastases into historical context and to survey the evolving landscape of strategies to improve future outcomes.
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Affiliation(s)
- Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, United States
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Prophylactic Cranial Irradiation for Limited-Stage Small-Cell Lung Cancer Patients: Secondary Findings From the Prospective Randomized Phase 3 CONVERT Trial. J Thorac Oncol 2018; 14:294-297. [PMID: 30292850 DOI: 10.1016/j.jtho.2018.09.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The impact of the dose and fractionation of thoracic radiotherapy on the risk of developing brain metastasis (BM) has not been evaluated prospectively in limited stage SCLC patients receiving prophylactic cerebral irradiation (PCI). METHODS Data from patients treated with PCI from the CONVERT trial were analyzed. RESULTS Four hundred forty-nine of 547 patients (82%) received PCI after completion of chemoradiotherapy. Baseline brain imaging consisted of computed tomographic scans in 356 of 449 patients (79%) and magnetic resonance imaging in 83 of 449 (18%) patients. PCI was delivered to 220 of 273 participants (81%) in the twice-daily (BD) group and 229 of 270 in the once-daily (OD) group (85%; p = 0.49). Total median PCI dose was 25 Gy in both the BD and OD groups (p = 0.74). In patients who received PCI, 75 (17%) developed BM (35 [8%] in OD and 40 [9%] in BD) and 173 (39%) other extracranial progression. In the univariate analysis, gross tumor volume (GTV) was associated with an increased risk of BM (p = 0.007) or other radiological progression events (p = 0.006), whereas in a multivariate analysis both thoracic GTV (tGTV) and ECOG performance score were associated with either progression type. The median overall survival (OS) of patients treated with PCI was 29 months. In the univariate analysis of OS, PCI timing from end of chemotherapy, weight loss of more than 10%, and tGTV were prognostic factors associated with OS. In the multivariate analysis, only tGTV was associated with OS. Delay between end of chemotherapy and PCI was not associated with OS. CONCLUSIONS Patients receiving OD or BD thoracic radiotherapy have the same risk of developing BM. Larger tumors are associated with a higher risk of BM.
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Risk factors for brain metastasis in patients with small cell lung cancer without prophylactic cranial irradiation. Strahlenther Onkol 2018; 194:1152-1162. [DOI: 10.1007/s00066-018-1362-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 08/20/2018] [Indexed: 11/25/2022]
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36
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Maeng CH, Song JU, Shim SR, Lee J. The Role of Prophylactic Cranial Irradiation in Patients With Extensive Stage Small Cell Lung Cancer: A Systematic Review and Meta-Analysis. J Thorac Oncol 2018. [PMID: 29526825 DOI: 10.1016/j.jtho.2018.02.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The role of prophylactic cranial irradiation (PCI) is controversial in patients with extensive stage small cell lung cancer. The aim of this study was to determine the impact of PCI in these patients. METHODS We performed a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane Central Register. The primary outcome was overall survival (OS). RESULTS We identified five studies comprising 984 patients, of whom 448 received PCI and 536 did not receive PCI. In pooled estimates, PCI did not statistically improve OS compared with controls (hazard ratio [HR] = 0.82; 95% confidence interval [CI]: 0.60-1.11; I2 = 77%; p = 0.19). However, the PCI group had a significant advantage in 1-year survival compared to the no-PCI group (37.1% versus 27.1%; risk ratio = 0.87; 95% CI: 0.80-0.95; I2 = 47%; p = 0.002), and the pooled estimates indicated that progression-free survival and the risk of brain metastasis were associated with significant benefit in the PCI group (HR = 0.83; 95% CI: 0.70-0.98; I2 = 22%; p = 0.03; and HR = 0.34; 95% CI: 0.23-0.50; I2 = 0%; p < 0.001, respectively). CONCLUSIONS Our findings suggest that PCI in patients with extensive stage small cell lung cancer may lead to a significant benefit in 1-year survival, progression-free survival, and the risk of brain metastasis, despite the lack of a significant advantage in OS.
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Affiliation(s)
- Chi Hoon Maeng
- Division of Medical Oncology-Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Jae-Uk Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Ryul Shim
- Institute for Clinical Molecular Biology Research, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Jonghoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, South Korea.
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Robin TP, Sannes TS, Spring Kong FM, Mornex F, Hirsch FR, Rusthoven CG, Gaspar LE. Physician Bias in Prophylactic Cranial Irradiation Decision Making-An Opportunity for a Patient Decision Aid. Clin Lung Cancer 2018; 19:476-483. [PMID: 29544717 DOI: 10.1016/j.cllc.2018.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/25/2018] [Accepted: 02/11/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Guidelines have recommended prophylactic cranial irradiation (PCI) for patients with limited-stage small-cell lung cancer with at least a partial response after thoracic chemoradiation. However, the survival advantage has been small and was observed in an era before magnetic resonance imaging and surveillance. Neurotoxicity also remains a concern, especially in older adults. Thus, patients have a complex value-laden decision to make. We sought to better understand the role physicians play in patient decision making and introduce a patient decision aid (PDA) to potentially facilitate these discussions. MATERIALS AND METHODS An e-mail survey was sent to International Association for the Study of Lung Cancer members querying their personal perspectives and professional recommendations regarding PCI for limited-stage small-cell lung cancer. RESULTS We received 295 responses. Most were from the United States (35%) and Europe (35%) and were radiation (45%) or medical (43%) oncologists. Of those responding, 88% and 50% reported they would recommend PCI to a 50- and 70-year-old patient, respectively. Also, 79% reported that they would wish to receive PCI if faced with this decision. The physicians who would have chosen PCI if faced with the decision were 27.6 and 12.9 times more likely to recommend PCI to a 50- and 70-year-old patient, respectively, than were physicians who would not undergo PCI themselves. Most of the respondents had positive responses to the proposed PDA. CONCLUSION Physician bias appears to play a role in PCI counseling, and most physicians reported that the provided PDA was better than their present method for discussing PCI and would help patients make such value-laden choices.
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Affiliation(s)
- Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Timothy S Sannes
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Francoise Mornex
- Department of Radiation Oncology, University Claude Bernard, Lyon, France
| | - Fred R Hirsch
- Department of Medical Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - Laurie E Gaspar
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO.
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Liu M. Professor David Ball: prophylactic cranial irradiation (PCI) benefits patients with SCLC. Transl Lung Cancer Res 2018; 7:S81-S82. [PMID: 29531916 PMCID: PMC5835641 DOI: 10.21037/tlcr.2018.01.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/10/2018] [Indexed: 11/06/2022]
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