Combined modality treatment for locally advanced non-small cell lung cancer: preoperative chemoradiation does not result in a poorer quality of life

The Effect of Thoracic Radiotherapy on the Quality of Life in Lung Cancer Patients

Introduction

This study aimed to investigate changes in respiratory symptoms and quality of life (QoL) in patients with locally advanced and metastatic lung cancer receiving thoracic radiotherapy (RT). We investigated the correlation between the level of symptom relief and tumor response.

Methods

Thirty-two patients were included in this study. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QoL) Questionnaire (QLQ)-C30 and EORTC QLQ-LC13 were used to investigate QoL changes. Assessments were performed on the first day of RT, on the last day of RT, routinely monthly follow-ups, and three months after RT.

Results

The median age of the patients was 62; 88% of the patients were male. For the symptom scale, fatigue and dyspnea provided significant improvement at the end of RT (p=0.000, p=0.047). No significant improvement was observed at the end of RT in pain and insomnia. While coughing showed substantial improvement at the end of RT (p=0.004), the maximum improvement was achieved during the third-month follow-up (p<0.001). No significant improvement was observed at the end of RT in hemoptysis, but a considerable improvement was observed during the third-month follow-up (p=0.008).

Conclusion

This study confirms that RT offered palliation of respiratory symptoms and improved QoL in a substantial proportion of patients with lung cancer.

Impact of Lung Cancer Treatment on Cognitive Functioning

The impact of oncologic treatment for (non)-small-cell lung cancer (NSCLC and SCLC, respectively) on cognition is relevant when deciding which treatment is the most preferable option, especially when curation is not possible. A systematic search of Medline and EMBASE for studies on the effect of treatment on cognition in patients with lung cancer was performed. A total of 39 longitudinal articles were included. Study populations were heterogeneous with regards to stage and treatment type. In the 7 studies concerning SCLC, the median age of patients was between 59 and 68 years. Eighty-six percent of these studies had a loss to follow-up > 10%. Six studies used objective tests to assess cognition. Objective measurements showed a negative effect on attention, memory, and fluency after treatment. Thirty-three studies concerning NSCLC were included. The mean age of patients was between 53 and 77 years. Seventy percent of these studies included patients with stage III and IV NSCLC. Over one-half of the studies had a high rate of loss to follow-up. Eighty-eight percent used objective scales to assess cognitive functioning. Subjective decline of cognitive functioning up to 11.1% was experienced, with recovery at 4 to 6 months. Objective measurement of attention showed improvement over the course of chemotherapy. In SCLC, there is a significant negative effect on attention, memory, and fluency. In NSCLC, the longer term impact of treatment on both subjective and objective cognitive functioning appears limited. Thus, there is no evidence directing treatment choice for NSCLC based on longer term cognitive deficits. Further research is needed to precisely assess the impact of lung cancer treatment on cognition.

Pre- and postoperative care for stage I-III NSCLC: Which quality of care indicators are evidence-based?

Identification of evidenced-based Quality of Care (QoC) indicators for lung cancer care is essential to quality improvement. The aim of this review was to identify evidence-based quality indicators for the pre- and postoperative care of stage I-III Non Small Cell Lung Cancer (NSCLC) provided by the lung physician. To obtain these indicators, a search in PubMed, Embase and the Cochrane library database was performed. English literature published between 1980 and 2012 was included and search terms regarding 'lung neoplasms', 'quality of care', 'pathology', 'diagnostic methods', 'preoperative and postoperative treatment' were used. The potential indicators were categorized as structure, process or outcome measures and the indicators supported by literature with high evidence level were selected. Five QoC indicators were identified. The use of the positron emission tomography-computed tomography (PET-CT) results in more accurate mediastinal staging compared to the CT scan. Endoscopic Ultrasound-Fine Needle Aspiration and Endobronchial Ultrasound-Fine Needle Aspiration are sensitive diagnostic tools for mediastinal staging and reduce futile thoracotomies. Pathological conformation of lung cancer can best be obtained by a combination of cytological and histological diagnostics used during bronchoscopy. For patients with clinical stage III NSCLC, preoperative multimodality treatment (i.e. preoperative chemoradiation) results in superior survival and increased mediastinal downstaging compared to single modality treatment (i.e. preoperative chemotherapy or radiotherapy). After surgery, the addition of chemotherapy results in a significant survival benefit for patients with pathological stage II and III NSCLC. These five QoC indicators can be used for benchmarking and ultimately quality improvement of lung cancer care.

Use of the lung cancer-specific Quality of Life Questionnaire EORTC QLQ-LC13 in clinical trials: A systematic review of the literature 20 years after its development

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer 13 (QLQ-LC13) covers 13 typical symptoms of lung cancer patients and was the first module developed in conjunction with the EORTC core quality-of-life (QL) questionnaire. This review investigates how the module has been used and reported in cancer clinical trials in the 20 years since its publication. Thirty-six databases were searched with a prespecified algorithm. This search plus an additional hand search generated 770 hits, 240 of which were clinical studies. Two raters extracted data using a coding scheme. Analyses focused on the randomized controlled trials (RCTs). Of the 240 clinical studies that were identified using the LC13, 109 (45%) were RCTs. More than half of the RCTs were phase 3 trials (n = 58). Twenty RCTs considered QL as the primary endpoint, and 68 considered it as a secondary endpoint. QL results were addressed in the results section of the article (n = 89) or in the abstract (n = 92); and, in half of the articles, QL results were presented in the form of tables (n = 53) or figures (n = 43). Furthermore, QL results had an impact on the evaluation of the therapy that could be clearly demonstrated in the 47 RCTs that yielded QL differences between treatment and control groups. The EORTC QLQ-LC13 fulfilled its mission to be used as a standard instrument in lung cancer clinical trials. An update of the LC13 is underway to keep up with new therapeutic trends and to ensure optimized and relevant QL assessment in future trials.

Health-related quality of life questionnaires in lung cancer trials: a systematic literature review

BACKGROUND

Lung cancer is one of the leading causes of cancer deaths. Treatment goals are the relief of symptoms and the increase of overall survival. With the rising number of treatment alternatives, the need for comparable assessments of health-related quality of life (HRQoL) parameters grows. The aim of this paper was to identify and describe measurement instruments applied in lung cancer patients under drug therapy.

METHODS

We conducted a systematic literature review at the beginning of 2011 using the electronic database Pubmed.

RESULTS

A total of 43 studies were included in the review. About 17 different measurement instruments were identified, including 5 generic, 5 cancer-specific, 4 lung cancer-specific and 3 symptom-specific questionnaires. In 29 studies at least 2 instruments were used. In most cases these were cancer and lung cancer-specific ones. The most frequently used instruments are the EORTC QLQ-C30 and its lung cancer modules LC13 or LC17. Only 5 studies combined (lung) cancer-specific questionnaires with generic instruments.

CONCLUSIONS

The EORTC-C30 and EORTC-LC13 are the most frequently used health-related quality of life measurement instruments in pharmacological lung cancer trials.

Radical treatment of non-small cell lung cancer during the last 5 years

The management of non-small cell lung cancer (NSCLC) has continued to improve over the last 5 years due to advances in surgery, radiological staging, combined modality therapies and advances in radiation technology. We have an updated staging classification (7th Edition American Joint Committee on Cancer staging) and now in 2011, a new histology classification introducing the concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma. This classification has profound surgical implications as the role of limited resection is reconsidered for early stage lesions. Surgery is curative in early stage disease. The role of surgery in locally advanced NSCLC remains controversial. The principal aim is a complete resection as this will determine long-term prognosis. Intraoperative staging of lung cancer is extremely important to determine the extent of resection according to the tumour and nodal status. Systematic nodal dissection is generally advocated to obtain accurate intraoperative staging and to help decide on adjuvant therapy. Radiotherapy currently plays a major role in the management of lung cancer as most patients are not surgical candidates due to disease stage, fitness and co-morbidities. In the last 5 years we have seen continuing optimisation of chemo-radiotherapy combinations and technological advances including the development of image guided radiotherapy (IGRT), stereotactic ablative body radiotherapy (SABR) and intensity modulated radiotherapy (IMRT). Quality of life evaluation is becoming increasingly important and should be considered when deciding on a specific treatment, especially in a multimodality setting.

Multimodality treatment of stage III non-small cell lung cancer: analysis of a phase II trial using preoperative cisplatin and gemcitabine with concurrent radiotherapy

INTRODUCTION

We report the results of a phase II trial exploring the efficacy and the feasibility of combination of gemcitabine and cisplatin concurrent with radiotherapy followed by surgery in patients with stage III non-small cell lung cancer.

METHODS

Patients with histocytologically confirmed non-small cell lung cancer were treated with cisplatin 80 mg/sqm/wk of 1 and 4 or 20 mg/sqm/d of weeks 1 and 4 and weekly gemcitabine at 300 to 350 mg/m2 plus involved field radiotherapy. A 3D-conformal radiotherapy was delivered up to 50.4 Gy, with daily fractionation of 1.8 Gy. After clinical, radiologic, and pneumological reassessment, patients who reentered criteria for resectability were operated.

RESULTS

The stage at diagnosis was IIIA-N2 in 29 patients and IIIB-T4N0-2 for vascular direct infiltration for the remaining 21. Fifteen patients (30%) experienced acute grade 3 to 4 hematological toxicity, whereas acute grade 3 esophageal toxicity was recorded in three patients (6%). One patient developed a grade 4 pulmonary toxicity (2%). Clinical response was 40 (80%) partial response, one (2%) stable disease, and nine (18%) progressive disease. Thirty-six patients (72%) underwent surgery. Final pathology showed a downstaging to stage 0 to I in 25 cases (50%). Median overall survival for all patients was 21.8 months, with a 3-year survival of 40.2%.

CONCLUSIONS

The results of this phase II trial confirm the feasibility and the efficacy of concurrent chemoradiotherapy followed by surgery.

[Postoperative risk after induction treatment on surgery in non-small cell lung cancer]

Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.

Occurrence, severity, and longitudinal course of twelve common symptoms in 1129 consecutive patients during radiotherapy for cancer

Little is known about the frequency, severity, and course of symptoms experienced by patients receiving radiotherapy (RT). For this descriptive study, 1129 patients with a variety of cancer diagnoses completed a 12-item Symptom Inventory (SI) at the start of RT; 419 of these patients also completed the SI weekly for an additional 4 weeks (five data points). Eighty-four percent of the 1129 patients were already experiencing symptoms when treatment began. All symptoms significantly increased in frequency over a typical 5 week RT course (all Ps<0.001). Skin problems showed the largest increase. The most common symptoms (fatigue, drowsiness, and sleep problems) were also the most severe. Female patients and patients younger than the median age (59 years) reported significantly more symptoms than males and those 59 years or older. Symptom frequency and severity varied significantly by cancer diagnosis. Improved understanding about the time course and dose response of radiation-induced toxicity will permit more accurate presentation of side effect risk at the time patient consent is obtained.