Palliative thoracic radiotherapy in lung cancer: An American Society for Radiation Oncology evidence-based clinical practice guideline

American Radium Society Appropriate Use Criteria for Unresectable Locally Advanced Non-Small Cell Lung Cancer

Importance

The treatment of locally advanced non-small cell lung cancer (LA-NSCLC) has been informed by more than 5 decades of clinical trials and other relevant literature. However, controversies remain regarding the application of various radiation and systemic therapies in commonly encountered clinical scenarios.

Objective

To develop case-referenced consensus and evidence-based guidelines to inform clinical practice in unresectable LA-NSCLC.

Evidence Review

The American Radium Society (ARS) Appropriate Use Criteria (AUC) Thoracic Committee guideline is an evidence-based consensus document assessing various clinical scenarios associated with LA-NSCLC. A systematic review of the literature with evidence ratings was conducted to inform the appropriateness of treatment recommendations by the ARS AUC Thoracic Committee for the management of unresectable LA-NSCLC.

Findings

Treatment appropriateness of a variety of LA-NSCLC scenarios was assessed by a consensus-based modified Delphi approach using a range of 3 points to 9 points to denote consensus agreement. Committee recommendations were vetted by the ARS AUC Executive Committee and a 2-week public comment period before official approval and adoption. Standard of care management of good prognosis LA-NSCLC consists of combined concurrent radical (60-70 Gy) platinum-based chemoradiation followed by consolidation durvalumab immunotherapy (for patients without progression). Planning and delivery of locally advanced lung cancer radiotherapy usually should be performed using intensity-modulated radiotherapy techniques. A variety of palliative and radical fractionation schedules are available to treat patients with poor performance and/or pulmonary status. The salvage therapy for a local recurrence after successful primary management is complex and likely requires both multidisciplinary input and shared decision-making with the patient.

Conclusions and Relevance

Evidence-based guidance on the management of various unresectable LA-NSCLC scenarios is provided by the ARS AUC to optimize multidisciplinary patient care for this challenging patient population.

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

Severity of Financial Toxicity for Patients Receiving Palliative Radiation Therapy

Introduction: Financial toxicity has negative implications for patient well-being and health outcomes. There is a gap in understanding financial toxicity for patients undergoing palliative radiotherapy (RT). Methods: A review of patients treated with palliative RT was conducted from January 2021 to December 2022. The FACIT-COST (COST) was measured (higher scores implying better financial well-being). Financial toxicity was graded according to previously suggested cutoffs: Grade 0 (score ≥26), Grade 1 (14-25), Grade 2 (1-13), and Grade 3 (0). FACIT-TS-G was used for treatment satisfaction, and EORTC QLQ-C30 was assessed for global health status and functional scales. Results: 53 patients were identified. Median COST was 25 (range 0-44), 49% had Grade 0 financial toxicity, 32% Grade 1, 15% Grade 2, and 4% Grade 3. Overall, cancer caused financial hardship among 45%. Higher COST was weakly associated with higher global health status/Quality of Life (QoL), physical functioning, role functioning, and cognitive functioning; moderately associated with higher social functioning; and strongly associated with improved emotional functioning. Higher income or Medicare or private coverage (rather than Medicaid) was associated with less financial toxicity, whereas an underrepresented minority background or a non-English language preference was associated with greater financial toxicity. A multivariate model found that higher area income (HR .80, P = .007) and higher cognitive functioning (HR .96, P = .01) were significantly associated with financial toxicity. Conclusions: Financial toxicity was seen in approximately half of patients receiving palliative RT. The highest risk groups were those with lower income and lower cognitive functioning. This study supports the measurement of financial toxicity by clinicians.

Thirty-day mortality after palliative radiotherapy in advanced cancer patients: Optimizing end-of-life care in Asia

INTRODUCTION

Evidence-based guidelines recommend hypofractionated palliative radiotherapy (PRT); nonetheless, many patients receive prolonged course of PRT. To identify patients with limited benefits from PRT in end-of-life care, we evaluated the pattern of PRT at an Asian institution and factors associated with 30-day mortality after PRT (30dM).

METHODS

We retrospectively reviewed 228 patients who died after PRT in Yonsei Wonju Severance Christian hospital between October 2014 and March 2022. The associations between clinical factors and survival were assessed using the Cox proportional hazards method. Survival was analysed using the existing models to evaluate their performance in our cohort.

RESULTS

The median PRT duration was 13 (IQR, 7-15) days. Only 11.4% of the patients were treated with hypofractionated radiotherapy. One-third of the patients (32.9%) could not complete PRT and 39 (17.1%) died during PRT. The 30dM was 31.6%. The median time from PRT to death was 17 (IQR, 11-23) days for the patients who died within 30 days. The number of involved organs (≤2 vs. >2; P < 0.001), albumin level (<3.3 vs. ≥3.3; P = 0.016), admission during PRT (P < 0.001), admission 3 months before PRT (P = 0.036) and ICU care during PRT (P < 0.001) were prognostic factors. A comparison of survival based on the existing models yielded unsatisfactory results in our cohort.

CONCLUSION

Almost one-third of the patients received PRT in the last 30 days of life. The use of hypofractionation for PRT was low in this Asian population. Further research is necessary to develop a predictive model of early mortality, allowing tailored end-of-life care for Asian patients.

Radiotherapy in the management of synchronous metastatic lung cancer

Metastatic lung cancer classically portends a poor prognosis. The management of metastatic lung cancer has dramatically changed with the emergence of immune checkpoint inhibitors, targeted therapy and due to a better understanding of the oligometastatic process. In metastatic lung cancers, radiation therapy which was only used with palliative intent for decades, represents today a promising way to treat primary and oligometastatic sites with a curative intent. Herein we present through a literature review the role of radiotherapy in the management of synchronous metastatic lung cancers.

Hemoptysis in Cancer Patients

Hemoptysis in cancer patients can occur for various reasons, including infections, tumors, blood vessel abnormalities and inflammatory conditions. The degree of hemoptysis is commonly classified according to the quantity of blood expelled. However, volume-based definitions may not accurately reflect the clinical impact of bleeding. This review explores a more comprehensive approach to evaluating hemoptysis by considering its risk factors, epidemiology and clinical consequences. In particular, this review provides insight into the risk factors, identifies mortality rates associated with hemoptysis in cancer patients and highlights the need for developing a mortality prediction score specific for cancer patients. The use of hemoptysis-related variables may help stratify patients into risk categories; optimize the control of bleeding with critical care; implement the use of tracheobronchial or vascular interventions; and aid in treatment planning. Effective management of hemoptysis in cancer patients must address the underlying cause while also providing supportive care to improve patients' quality of life.

High-dose-rate brachytherapy for airway malignancy a single institution experience

PURPOSE

To evaluate clinical outcomes of endobronchial malignancy treated using high-dose-rate endobronchial brachytherapy (HDREB).

METHODS AND MATERIALS

A retrospective chart review was conducted for all patients treated with HDREB for malignant airway disease between 2010 and 2019 at a single institution. Most patients had a prescription of 14 Gy in two fractions given a week apart. The Wilcoxon signed rank test and paired samples t test were used to compare changes in mMRC dyspnea scale prior to and after brachytherapy at first followup appointment. Toxicity data were collected for dyspnea, hemoptysis, dysphagia, and cough.

RESULTS

A total of 58 patients were identified. Most (84.5%) had primary lung cancer with advanced cancers, stage III or IV (86%). Eight were treated while admitted in the ICU. Previous external beam radiotherapy (EBRT) was received by 52%. An improvement in dyspnea was seen in 72%, with an mMRC dyspnoea scale score improvement of 1.13 points (p < 0.001). Most (22, 88%) had an improvement in hemoptysis and 18 out of 37 (48.6%) had an improvement in cough. Grade four to five events occurred in 8 (13%) at the median time of 2.5 months from brachytherapy. Twenty-two patients (38%) had complete obstruction of the airway treated. Median progression free survival was 6.5 months and median survival was 10 months.

CONCLUSIONS

We report a significant symptomatic benefit among patients receiving brachytherapy with endobronchial malignancy, with rates of treatment related toxicities similar to prior studies. Our study identified new subgroups of patients, ICU patients & those with complete obstruction, who benefited from HDREB.

Palliative radiotherapy for children: Symptom response and treatment-associated toxicity according to radiation therapy dose and fractionation

BACKGROUND/OBJECTIVES

Radiotherapy is an effective palliative treatment in advanced cancer. Shorter palliative treatment courses are recommended for adults, though pediatric data addressing treatment efficacy and toxicity according to radiation therapy (RT) dose and fractionation are limited.

DESIGN/METHODS

Total 213 patients aged 21 years or younger receiving 422 palliative radiotherapy treatment courses from 2003 to 2016 were included. Symptom response and treatment-associated toxicity were recorded and analyzed in relationship to demographic and treatment variables.

RESULTS

Common diagnoses included sarcoma (32.5%), neuroblastoma (24.9%), leukemia/lymphoma (14.9%), and central nervous system tumors (10.9%). The most common indication for treatment was pain (46.7%). Patients received a median of 10 fractions, 2.5 Gy dose per fraction, and 21 Gy total dose. Number of RT fractions was five or less in 166 (39.3%), six to 10 fractions in 117 (27.2%), and 10 or more fractions in 139 (32.9%) of courses. Complete or partial pain relief was achieved in 85% (151 of 178 evaluable patients), including 77.8% receiving five or less fractions and 89.6% receiving more than five fractions. Highest toxicity was grade 1 in 159 (38.9%), grade 2 in 26 (6.4%), and grade 3 in two (0.5%) treatments. On multivariable analysis, RT delivered 30 or more days from death (OR 12.13, 95% CI: 2.13-69.2, p = .005) and no adjuvant chemotherapy (OR 0.14, 95% CI: 0.03-0.54, p = .005) were significantly associated with pain response, and five or less fractions were significantly associated with lower toxicity (OR 0.24, 95% CI: 0.06-0.97, p = .045).

CONCLUSIONS

Palliative RT courses of five or less fractions result in high rates of pain control and are associated with low toxicity in pediatric patients with cancer.

Radiotherapy for Lung Metastases: Conventional to Stereotactic Body Radiation Therapy

The lung parenchyma and adjacent tissues are one of the most common sites of metastatic disease. Traditionally, the approach to treatment of a patient with lung metastases has been with systemic therapy, with radiotherapy being reserved for palliative management of symptomatic disease. The concept of oligo metastatic disease has paved the way for more radical treatment options, administered either alone or as local consolidative therapy in addition to systemic treatment. The modern-day management of lung metastases is guided by a number of factors, including the number of lung metastases, extra-thoracic disease status, overall performance status, and life expectancy, which all help determine the goals of care. Stereotactic body radiotherapy (SBRT) has emerged as a safe and effective method in locally controlling lung metastases, in the oligo metastatic or oligo-recurrent setting. This article outlines the role of radiotherapy in multimodality management of lung metastases.

Dyspnea in patients with stage IV non-small cell lung cancer: a population-based analysis of disease burden and patterns of care

Background

Patients with metastatic non-small cell lung cancer (NSCLC) experience significant morbidity with dyspnea being a common symptom with a prevalence of 70%. The objective of this study was to determine factors associated with a moderate-to-severe dyspnea score based on the Edmonton Symptom Assessment System (ESAS), as well as resultant patterns of intervention and factors correlated to intervention receipt.

Methods

Using health services administrative data, we conducted a population-based study of all patients diagnosed with metastatic NSCLC treated from January 2007 to September 2018 in the province of Ontario. The primary outcomes of interest are the prevalence of moderate-to-severe dyspnea scores, and the receipt of dyspnea-directed intervention. Differences in baseline characteristic between moderate-to-severe dyspnea and low dyspnea score cohorts were assessed by comparative statistics. Predictors of intervention receipt for patients with moderate-to-severe dyspnea scores were estimated using multivariable modified Poisson regression.

Results

The initial study cohort included 13,159 patients diagnosed with metastatic NSCLC and of these, 9,434 (71.7%) reported a moderate-to-severe dyspnea score. Compared to patients who did not report moderate-to-severe dyspnea scores, those who reported a moderate-to-severe dyspnea score were more likely to complete a greater number of ESAS surveys, be male, have a higher Elixhauser comorbidity index (ECI) score, and receive subsequent systemic therapy after diagnosis. Most patients with a moderate-to-severe dyspnea score received intervention (96%), of which the most common were palliative care management (87%), thoracic radiotherapy (56%) and thoracentesis (37%). Multivariable regression identified older patients to be less likely to undergo pleurodesis. Thoracentesis was less common for patients living in rural and non-major urban areas, lower income areas, and earlier year of diagnosis. Receipt of thoracic radiotherapy was less common for older patients, females, those with ECI ≥4, patients living in major urban areas, and those with later year of diagnosis. Finally, palliative care referrals were less frequent for patients with ECI ≥4, age 60-69, residence outside of major urban areas, earlier year of diagnosis, and lower income areas.

Conclusions

Dyspnea is a prevalent symptom amongst patients with metastatic NSCLC. Subpopulations of patients with moderate-to-severe dyspnea scores were in which inequities may exist in access to care that require further attention and evaluation.

BRACHY: A Randomized Trial to Evaluate Symptom Improvement in Advanced Non-Small Cell Lung Cancer Treated With External Beam Radiation With or Without High-Dose-Rate Intraluminal Brachytherapy

PURPOSE

Uncontrolled studies suggest that the addition of high-dose-rate intraluminal brachytherapy (HDRIB) to external beam radiation therapy (EBRT) may improve palliation for patients with advanced non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the potential clinical benefit of adding HDRIB to EBRT in a multicenter randomized trial.

METHODS AND MATERIALS

Patients with symptomatic stage III or IV NSCLC with endobronchial disease were randomized to EBRT (20 Gy in 5 daily fractions over 1 week or 30 Gy in 10 daily fractions over 2 weeks) or the same EBRT plus HDRIB (14 Gy in 2 fractions separated by 1 week). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks after randomization. Secondary outcomes included improvement in individual symptoms, symptom-progression-free survival, overall survival, and toxicity. The planned sample size was 250 patients based on detection of symptomatic improvement from 40% to 60% with a 2-sided α of .05 and 80% power.

RESULTS

A total of 134 patients were randomized over 4.5 years: 67 to each arm. The study closed early owing to slow accrual. The mean age was 69.8 years, and 67% of patients had metastatic disease. At 6 weeks, 19 patients (28.4%) in the EBRT arm and 20 patients (29.9%) in the EBRT plus HDRIB arm experienced an improvement in lung cancer symptoms (P = .84). When limited to patients who completed the LCSS, percentages were 40.4% versus 47.6%, respectively (P = .49). Between group differences in mean change scores (0.3-0.5 standard deviations) in favor of EBRT plus HDRIB were observed for overall symptoms, but only hemoptysis was significantly improved (P = .03). No significant differences were observed in progression-free or overall survival. Grade 3/4 toxicities were similar between groups.

CONCLUSIONS

Small to moderate improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRIB in addition to EBRT for palliation of lung cancer symptoms.

Simulation-Free Radiation Therapy: An Emerging Form of Treatment Planning to Expedite Plan Generation for Patients Receiving Palliative Radiation Therapy

Purpose

Herein we report the clinical and dosimetric experience for patients with metastases treated with palliative simulation-free radiation therapy (SFRT) at a single institution.

Methods and Materials

SFRT was performed at a single institution. Multiple fractionation regimens were used. Diagnostic imaging was used for treatment planning. Patient characteristics as well as planning and treatment time points were collected. A matched cohort of patients with conventional computed tomography simulation radiation therapy (CTRT) was acquired to evaluate for differences in planning and treatment time. SFRT dosimetry was evaluated to determine the fidelity of SFRT. Descriptive statistics were calculated on all variables and statistical significance was evaluated using the Wilcoxon signed rank test and t test methods.

Results

Thirty sessions of SFRT were performed and matched with 30 sessions of CTRT. Seventy percent of SFRT and 63% of CTRT treatments were single fraction. The median time to plan generation was 0.88 days (0.19-1.47) for SFRT and 1.90 days (0.39-5.23) for CTRT (P = .02). The total treatment time was 41 minutes (28-64) for SFRT and 30 minutes (21-45) for CTRT (P = .02). In the SFRT courses, the maximum and mean deviations in the actual delivered dose from the approved plans for the maximum dose were 4.1% and 0.07%, respectively. All deliveries were within a 5% threshold and deemed clinically acceptable.

Conclusions

Palliative SFRT is an emerging technique that allowed for a statistically significant lower time to plan generation and was dosimetrically acceptable. This benefit must be weighed against increased total treatment time for patients receiving SFRT compared with CTRT, and appropriate patient selection is critical.

Hypofractionation as a solution to radiotherapy access in latin america: expert perspective

Background

Limited radiation therapy resources have resulted in an interest in developing time and cost-saving innovations to expand access to cancer treatment, in Latin America. Therefore, hypofractionated radiotherapy (HRT) is a possible solution, as this modality delivers radiation over a shorter period of time.

Materials and methods

A selected panel of Latin American (LA) experts in fields related to HRT were provided with a series of relevant questions to address, prior to the multi-day conference. Within this meeting, each narrative was discussed and edited, through numerous rounds of discussion, until agreement was achieved.

Results

The challenges identified in increasing the adoption of HRT in LA include a lack of national and regional clinical practice guidelines and cancer registries; a lack of qualified human resources and personnel education; high up-front costs of equipment; disparate resource distribution and scarce HRT research. An analysis for these overarching challenges was developed and answered with recommendations.

Conclusion

Extending the adoption of HRT in LA can provide a path forward to increase access to radiotherapy and overcome the shortage of equipment. HRT has the potential to improve population health outcomes and patient centered care, while offering comparable local control, toxicity, palliation, and late effects for multiple indications, when compared to conventional RT. Concerted efforts from all involved stakeholders are needed to overcome the barriers in adopting this strategy in LA countries. The recommendations presented in this article can serve as a plan of action for HRT adoption in other countries in a similar situation.

A pilot study of same-day MRI-only simulation and treatment with MR-guided adaptive palliative radiotherapy (MAP-RT)

We conducted a prospective pilot study evaluating the feasibility of same day MRI-only simulation and treatment with MRI-guided adaptive palliative radiotherapy (MAP-RT) for urgent palliative indications (NCT#03824366). All (16/16) patients were able to complete 99% of their first on-table attempted fractions, and no grades 3-5 toxicities occurred.

Non-Small Cell Lung Cancer with Malignant Pleural Effusion May Require Primary Tumor Radiotherapy in Addition to Drug Treatment

PURPOSE

The impact of primary tumour radiotherapy on the prognosis for non-small-cell lung cancer (NSCLC) with controlled malignant pleural effusion (MPE-C) (MPE-C-NSCLC) is unclear. This study aimed to analyze the efficacy and safety of primary tumor radiotherapy in patients with MPE-C-NSCLC.

PATIENTS AND METHODS

A total of 186 patients with MPE-C-NSCLC were enrolled and divided into two groups. The patients in the D group were treated with only drugs. Those in the RD group were treated with drugs plus primary tumour radiotherapy. The Kaplan-Meier method was used for survival analysis, and the Log rank test was used for between-group analysis and univariate prognostic analysis. The Cox proportional hazards model was used to perform multivariate analyses to assess the impacts of factors on survival. Propensity score matching (PSM) was matched based on clinical characteristics, systematic drug treatment and drug response to further adjust for confounding factors.

RESULTS

The overall survival (OS) rates at 1, 2, and 3 years for the RD group and D group were 54.4%, 26.8%, and 13.3% and 31.1%, 11.5%, and 4.4%, respectively; the corresponding MSTs were 14 months and 8 months, respectively (χ 2=15.915, p<0.001). There was a significant difference in survival by PSM (p=0.027).Before PSM, multivariate analysis showed that metastasis status (organ≤3 and metastasis≤5), primary tumour radiotherapy, chemotherapy cycles≥4, and drug best response (CR+PR) were independent predictors of prolonged OS. After PSM, primary tumour radiotherapy and drug best response (CR+PR) were independent predictors of prolonged OS were still independent predictors of prolonged OS. There were no grade 4-5 radiation toxicities.

CONCLUSION

For MPE-C-NSCLC, the response of systemic drug treatment plays a crucial role in survival outcomes, and we also should pay attention to primary tumour radiotherapy in addition to systematic drug treatment.

The Use of Palliative Radiotherapy in the Treatment of Lung Cancer

There have been significant advances in the systemic treatment of stage IV lung cancer, which is now recommended first line in patients with adequate fitness. This includes some patients with brain metastases due to the increased understanding of the central nervous system penetration of targeted therapies. The trials evidence base for palliative radiotherapy pre-dated this routine use of systemic therapy in our practice, which means that the sequence and role of palliative radiotherapy are not currently well defined in the first-line treatment setting. However, due to its efficacy in symptom control, radiotherapy remains a core component in the palliative management of lung cancer, particularly in the second-line setting and those unsuited to primary systemic treatment. This overview focuses on the evidence behind palliative radiotherapy to the thorax and brain for non-small cell and small cell lung cancer and the potential for future studies, including the TOURIST Trial Platform, to guide the future direction of these treatments.

Multisite Radiotherapy Combined With Tislelizumab for Metastatic Castration-Resistant Prostate Cancer With Second-Line and Above Therapy Failure: Study Protocol for an Open-Label, Single-Arm, Phase Ib/II Study

Background

Tislelizumab combined with radiotherapy as a salvage treatment for patients with end-stage metastatic castration-resistant prostate cancer (mCRPC) is not reported. This study aimed to describe a protocol to evaluate the safety and efficacy of multisite radiotherapy combined with tislelizumab as a salvage therapy for mCRPC in patients who had at least one second-line treatment failure.

Methods

The study included patients with mCRPC who had at least one lesion suitable for radiotherapy and failed androgen deprivation therapy (ADT), followed by at least one novel second-line endocrine therapy. All patients received tislelizumab monotherapy induction therapy for two cycles, then combined with multisite radiotherapy for one cycle, followed by tislelizumab maintenance therapy, until either disease progressed or the patient developed unacceptable toxicity. Radiation methods and lesions were individually selected according to the specified protocol. Primary endpoints included safety and objective response rate. Secondary endpoints included prostate-specific antigen (PSA) response rate, disease control rate, overall survival, radiographic progression-free survival (rPFS), and biochemical progression-free survival (bPFS). Furthermore, the exploratory endpoints included the identification of the predictive biomarkers and exploration of the correlation between biomarkers and the tumor response to the combined regimen.

Discussion

This study included three treatment stages to evaluate the efficacy of immunotherapy and the combination of immunotherapy and radiotherapy for patients with mCRPC who have had at least second-line treatment failure. Additionally, radiation-related and immune-related early and late toxicities were determined, respectively. Furthermore, the study also aimed to identify the predictive biomarkers associated with immunotherapy for treating mCRPC.

Trial Registration

https://www.chictr.org.cn/showproj.aspx?proj=126359, identifier ChiCTR2100046212.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Palliative Radiation for Advanced Central Lung Tumors With Intentional Avoidance of the Esophagus (PROACTIVE): A Phase 3 Randomized Clinical Trial

Question

Can modern radiation techniques reduce the risk of radiation-associated esophageal adverse effects in patients with advanced lung cancer?

Findings

In this phase 3 randomized clinical trial of esophageal-sparing intensity-modulated radiotherapy (ES-IMRT) or standard palliative radiotherapy for 90 patients with stage III/IV incurable non–small cell lung cancer, ES-IMRT significantly reduced symptomatic esophagitis (24% [n = 11] vs 2% [n = 1]), but did not significantly improve esophageal-related quality of life.

Meaning

In this trial, the use of ES-IMRT did not definitively improve esophageal quality of life but reduced symptomatic esophagitis in patients with advanced lung cancer who were receiving palliative thoracic radiotherapy; this technique holds merit for translation into clinical practice.

Importance

Palliative thoracic radiotherapy (RT) can alleviate local symptoms associated with advanced non–small cell lung cancer (NSCLC), but esophagitis is a common treatment-related adverse event. Whether esophageal-sparing intensity-modulated RT (ES-IMRT) achieves a clinically relevant reduction in esophageal symptoms remains unclear.

Objective

To examine whether ES-IMRT achieves a clinically relevant reduction in esophageal symptoms compared with standard RT.

Design, Setting, and Participants

Palliative Radiation for Advanced Central Lung Tumors With Intentional Avoidance of the Esophagus (PROACTIVE) is a multicenter phase 3 randomized clinical trial that enrolled patients between June 24, 2016, and March 6, 2019. Data analysis was conducted from January 23, 2020, to October 22, 2021. Patients had up to 1 year of follow-up. Ninety patients at 6 tertiary academic cancer centers who had stage III/IV NSCLC and were eligible for palliative thoracic RT (20 Gy in 5 fractions or 30 Gy in 10 fractions) were included.

Interventions

Patients were randomized (1:1) to standard RT (control arm) or ES-IMRT. Target coverage was compromised to ensure the maximum esophagus dose was no more than 80% of the RT prescription dose.

Main Outcomes and Measures

The primary outcome was esophageal quality of life (QOL) 2 weeks post-RT, measured by the esophageal cancer subscale (ECS) of the Functional Assessment of Cancer Therapy: Esophagus questionnaire. Higher esophageal cancer subscale scores correspond with improved QOL, with a 2- to 3-point change considered clinically meaningful. Secondary outcomes included overall survival, toxic events, and other QOL metrics. Intention-to-treat analysis was used.

Results

Between June 24, 2016, and March 6, 2019, 90 patients were randomized to standard RT or ES-IMRT (median age at randomization, 72.0 years [IQR, 65.6-80.3]; 50 [56%] were female). Thirty-six patients (40%) received 20 Gy and 54 (60%) received 30 Gy. For the primary end point, the mean (SD) 2-week ECS score was 50.5 (10.2) in the control arm (95% CI, 47.2-53.8) and 54.3 (7.6) in the ES-IMRT arm (95% CI, 51.9-56.7) (P = .06). Symptomatic RT-associated esophagitis occurred in 24% (n = 11) of patients in the control arm vs 2% (n = 1) in the ES-IMRT arm (P = .002). In a post hoc subgroup analysis based on the stratification factor, reduction in esophagitis was most evident in patients receiving 30 Gy (30% [n = 8] vs 0%; P = .004). Overall survival was similar with standard RT (median, 8.6; 95% CI, 5.7-15.6 months) and ES-IMRT (median, 8.7; 95% CI, 5.1-10.2 months) (P = .62).

Conclusions and Relevance

In this phase 3 randomized clinical trial, ES-IMRT did not significantly improve esophageal QOL but significantly reduced the incidence of symptomatic esophagitis. Because post hoc analysis found that reduced esophagitis was most evident in patients receiving 30 Gy of RT, these findings suggest that ES-IMRT may be most beneficial when the prescription dose is higher (30 Gy).

Trial Registration

ClinicalTrials.gov Identifier: NCT02752126

Palliative radiotherapy indications during the COVID-19 pandemic and in future complex logistic settings: the NORMALITY model

Introduction

The COVID-19 pandemic has challenged healthcare systems worldwide over the last few months, and it continues to do so. Although some restrictions are being removed, it is not certain when the pandemic is going to be definitively over. Pandemics can be seen as a highly complex logistic scenario. From this perspective, some of the indications provided for palliative radiotherapy (PRT) during the COVID-19 pandemic could be maintained in the future in settings that limit the possibility of patients achieving symptom relief by radiotherapy.

This paper has two aims: (1) to provide a summary of the indications for PRT during the COVID-19 pandemic; since some indications can differ slightly, and to avoid any possible contradictions, an expert panel composed of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) and the Palliative Care and Supportive Therapies Working Group (AIRO-palliative) voted by consensus on the summary; (2) to introduce a clinical care model for PRT [endorsed by AIRO and by a spontaneous Italian collaborative network for PRT named “La Rete del Sollievo” (“The Net of Relief”)]. The proposed model, denoted “No cOmpRoMise on quality of life by pALliative radiotherapy” (NORMALITY), is based on an AIRO-palliative consensus-based list of clinical indications for PRT and on practical suggestions regarding the management of patients potentially suitable for PRT but dealing with highly complex logistics scenarios (similar to the ongoing logistics limits due to COVID-19).

Material and Methods

First, a summary of the available literature guidelines for PRT published during the COVID-19 pandemic was prepared. A systematic literature search based on the PRISMA approach was performed to retrieve the available literature reporting guideline indications fully or partially focused on PRT. Tables reporting each addressed clinical presentation and respective literature indications were prepared and distributed into two main groups: palliative emergencies and palliative non-emergencies. These summaries were voted in by consensus by selected members of the AIRO and AIRO-palliative panels. Second, based on the summary for palliative indications during the COVID-19 pandemic, a clinical care model to facilitate recruitment and delivery of PRT to patients in complex logistic scenarios was proposed. The summary tables were critically integrated and shuffled according to clinical presentations and then voted on in a second consensus round. Along with the adapted guideline indications, some methods of performing the first triage of patients and facilitating a teleconsultation preliminary to the first in-person visit were developed.

Results

After the revision of 161 documents, 13 papers were selected for analysis. From the papers, 19 clinical presentation items were collected; in total, 61 question items were extracted and voted on (i.e., for each presentation, more than one indication was provided from the literature). Two tables summarizing the PRT indications during the COVID-19 pandemic available from the literature (PRT COVID-19 summary tables) were developed: palliative emergencies and palliative non-emergencies. The consensus of the vote by the AIRO panel for the PRT COVID-19 summary was reached. The PRT COVID-19 summary tables for palliative emergencies and palliative non-emergencies were adapted for clinical presentations possibly associated with patients in complex clinical scenarios other than the COVID-19 pandemic. The two new indication tables (i.e., “Normality model of PRT indications”) for both palliative emergencies and palliative non-emergencies were voted on in a second consensus round. The consensus rate was reached and strong. Written forms facilitating two levels of teleconsultation (triage and remote visits) were also developed, both in English and in Italian, to evaluate the patients for possible indications for PRT before scheduling clinical visits.

Conclusion

We provide a comprehensive summary of the literature guideline indications for PRT during COVID-19 pandemic. We also propose a clinical care model including clinical indications and written forms facilitating two levels of teleconsultation (triage and remote visits) to evaluate the patients for indications of PRT before scheduling clinical visits. The normality model could facilitate the provision of PRT to patients in future complex logistic scenarios.

Patient-Provider Communication, Decision-Making, and Psychosocial Burdens in Palliative Radiotherapy: A Qualitative Study on Patients' Perspectives

CONTEXT

Patient-provider communication impacts how patients with cancer make decisions about treatment.

OBJECTIVES

To examine patient perceptions of discussions, decision-making, and psychosocial burdens related to receiving palliative radiotherapy (RT), in order to inform best practices for communication about palliative RT.

METHODS

We conducted an exploratory qualitative study using oral questionnaires and semi-structured interviews. Seventeen patients receiving their first course of palliative RT for lung or bone metastases at a comprehensive cancer center were interviewed. Patient interviews were transcribed verbatim and thematically analyzed using NVivo software.

RESULTS

Themes that impacted patients' decisions to initiate RT included a desire to minimize pain, optimism about what RT could provide for the future, perception of having "no other choice," disappointment about cancer progression, and unfamiliarity with RT. Most patients preferred shared decision-making regarding RT initiation and reported patient empowerment, effective communication, and team collaboration as contributing to shared decision-making. Most patients preferred their physicians to make decisions about RT treatment intensity and described trust in their physicians, institutional reputation, and RT expertise as motivators for this preference. Patients who possessed a proactive decisional mindset about initiating RT as opposed to having "no other choice" were less likely to report experiencing psychosocial burdens.

CONCLUSION

Most patients prefer shared decision-making regarding RT initiation but prefer their radiation oncologists to make decisions regarding treatment intensity. Communication that empowers patients in their desired level of engagement for RT decision-making may help patients make informed decisions, contribute toward a proactive decisional mindset, and reduce their perception of psychosocial burdens.

Palliative treatment with high-dose-rate endobronchial interventional radiotherapy (Brachytherapy) for lung cancer patients

PURPOSE

to report on the use of high-dose-rate (HDR) endobronchial interventional radiotherapy (brachytherapy, EBIRT) for palliation of symptoms in patients with lung cancer.

PATIENTS AND METHODS

retrospective review of lung cancer patients treated with HDR-EBIRT at our institution (1995-2017). Treatment results and treatment related toxicity were recorded. Clinical response was subjectively evaluated within 3 months after treatment. Overall survival (OS) was analyzed.

RESULTS

347 patients were identified. The median age was 69 years and the median follow-up time was 13.4 months. Most patients received external beam radiation therapy during the primary treatment. Within 3 months, 87.7% of the patients had complete or major response of their presenting symptoms. OS was 55.2% at 1 year, 18.3% at 2 years. Patients who had complete or major response had a longer median survival than other patients (13 versus 7 months, p = 0.03). Chronic bronchitis was found in 26.8%, while 7.8% of the patients died due to uncontrollable hemoptysis.

CONCLUSION

HDR-EBIRT is a safe and effective treatment option for the palliative treatment of lung cancer patients. HDR-EBIRT is most suitable as a re-irradiation technique. Further clinical studies are needed to validate its role.

Efficacy and Survival after Palliative Radiotherapy for Malignant Pulmonary Obstruction

Introduction: The purpose of this study was to determine the efficacy of palliative radiotherapy (PRT) for patients with pulmonary obstruction from advanced malignancy and identify factors associated with lung re-expansion and survival. Materials and Methods: We reviewed all patients treated with PRT for malignant pulmonary obstruction (n = 108) at our institution between 2010 and 2018. Radiographic evidence of lung re-expansion was determined through review of follow-up CT or chest X-ray. Cumulative incidence of re-expansion and overall survival (OS) were estimated using competing risk methodology. Clinical characteristics were evaluated for association with re-expansion, OS, and early mortality. Treatment time to remaining life ratio (TT:RL) was evaluated as a novel metric for palliative treatment. Results: Eighty-one percent of patients had collapse of an entire lung lobe, 46% had Eastern Cooperative Oncology Group (ECOG) performance status 3-4, and 64% were inpatient at consultation. Eighty-four patients had follow-up imaging available, and 25 (23%) of all patients had lung re-expansion at median time of 35 days. Rates of death without re-expansion were 38% and 65% at 30 and 90 days, respectively. Median OS was 56 days. Death within 30 days of PRT occurred in 38%. Inpatients and larger tumors trended toward lower rates of re-expansion. Notable factors associated with OS were re-expansion, nonlung histology, tumor size, and performance status. Median TT:RL was 0.11 and significantly higher for subgroups: ECOG 3-4 (0.19), inpatients (0.16), patients with larger tumors (0.14), those unfit for systemic therapy (0.17), and with 10-fraction PRT (0.14). Conclusion: One-fourth of patients experienced re-expansion after PRT for malignant pulmonary obstruction. Survival is poor and a significant proportion of remaining life may be spent on treatment. Careful consideration of these clinical factors is recommended when considering PRT fractionation.

Palliative Radiotherapy for Advanced Cancers: Indications and Outcomes

Palliative radiotherapy (PRT) is well-tolerated, effective treatment for pain, bleeding, obstruction, and other symptoms/complications of advanced cancer. It is an important component of multidisciplinary management. It should be considered even for patients with poor prognosis, because it can offer rapid symptomatic relief. Furthermore, expanding indications for treatment of noncurable disease have shown that PRT can extend survival for select patients. For those with good prognosis, advanced PRT techniques may improve the therapeutic ratio, maximizing tumor control while limiting toxicity. PRT referral should be considered for any patient with symptomatic or asymptomatic sites of disease where local control is desired.

Can Polymetastatic Disease Be ARRESTed Using SABR? A Dosimetric Feasibility Study to Inform Development of a Phase 1 Trial

Purpose

Phase 2 randomized trials suggest that stereotactic ablative radiation therapy improves progression-free and overall survival in patients with oligometastatic cancer, with phase 3 trials currently testing stereotactic ablative radiation therapy in up to 10 metastases. Whether stereotactic radiation therapy could provide similar benefits in polymetastatic disease (>10 metastases) is unknown. We sought to evaluate the dosimetric feasibility of using stereotactic radiation therapy in polymetastatic disease in preparation for a phase 1 trial.

Methods and Materials

Five craniospinal computed tomography simulations were used to simulate 24 metastatic targets (n = 2 patients), 30 targets (n = 2 patients), and 50 targets (n = 1 patient) that were not present on the initial scan. Creation of radiation therapy plans was attempted for doses up to 30 Gy in 5 fractions, with de-escalation to 24 Gy/4, 18 Gy/3, 12 Gy/2, or 6 Gy/1 if not feasible based on standardized dose constraints. Plans were created using Raystation for delivery on linear accelerators using volumetric modulated arc therapy and validated using Mobius 3D.

Results

A stereotactic radiation therapy treatment plan was generated for each simulated patient. Dose constraints were met to a dose of 30 Gy in 5 fractions for the patients with 24 and 30 lesions. For the patient with 50 targets, dose de-escalation to 12 Gy in 2 fractions was required to meet lung constraints. Estimated beam-on time varied between 18 and 29 minutes per fraction of 6 Gy. Median D95 planning target volume dosimetry ranged from 96.6% to 97.7% of the prescription dose. The conformity index (R100) range was 0.89 to 0.95, and R50 range was 6.84 to 8.72.

Conclusions

Stereotactic radiation therapy treatment plans meeting standardized dose constraints could be created in the setting of 24 to 50 metastatic lesions using volumetric modulated arc therapy. This safety of this approach is being evaluated in a phase 1 trial (NCT04530513).

Radiation pneumonitis after palliative radiotherapy in cancer patients with interstitial lung disease

PURPOSE

The risk of radiation pneumonitis (RP) after palliative radiotherapy (RT) in cancer patients with interstitial lung disease (ILD) remains unclear. This study aimed to investigate the incidence, severity, and predictive factors of RP among patients with ILD who received palliative RT.

METHODS AND MATERIALS

The medical records of cancer patients with ILD who received palliative RT involving a lung field between January 2008 and December 2019 were retrospectively reviewed. Screening for ILD was performed by using the ICD-10 diagnosis code, and the ILD was evaluated on the basis of pretreatment computed tomography (CT). RP was scored using Common Terminology Criteria for Adverse Events, version 5.0. Associations between both clinical and dosimetric factors and RP were assessed by univariate and multivariate analyses.

RESULTS

Sixty-two patients were included in the analysis. The median prescribed physical dose of RT was 25 Gy (range, 6-40 Gy). The RP was graded 1, 2, 3, 4, and 5 in 6 (10%), 3 (5%), 1 (2%), 2 (3%), and 6 (10%) patients, respectively. The median time to onset of grade 3 or more RP (≥Gr3 RP) was 39 days (range, 10-155). The results of the multivariate analysis indicated that ILD pattern was a significant predictive factor for ≥Gr3 RP (odds ratio, 12.0; 95% confidence interval, 1.02-1664; P < 0.05).

CONCLUSIONS

RT involving a lung field, even when prescribed with palliative intent, should be administered carefully to ILD patients. Evaluation of the ILD pattern on pretreatment CT images may be of help in determining whether to perform RT.

Palliative radiation therapy for children with cancer

Radiation therapy (RT) is often used as a palliative treatment for children with recurrent malignant disease to ameliorate or prevent symptoms. However, no guidelines exist regarding the clinical indications or dose fractionation for palliative RT. The goal of this report is to provide guidelines for the use of palliative RT in children with cancer. In this guideline, appropriate indications for palliative RT, recommended dose-fractionation schedules, relevant toxicities, and avenues for future research are explored. RT is an effective palliative treatment for bone, brain, liver, lung, abdominopelvic and head-and-neck metastases, spinal cord compression, superior vena cava syndrome, and bleeding. Single-fraction regimens (8 Gy in one fraction) for children with short life expectancy are recommended for simple, uncomplicated bone metastases and can be considered for some patients with lung or liver metastases. A short, hypofractionated regimen (20 Gy in five fractions) may be used for other indications to minimize overall burden of therapy. There are little data supporting use of more prolonged fractionation regimens, though they may be considered for patients with very good performance status. Future research should focus on response and outcomes data collection, and to rigorously evaluate the role of stereotactic body RT in well-designed, prospective studies.

Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care

BACKGROUND

Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals.

MATERIALS AND METHODS

All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed.

RESULTS

In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045).

CONCLUSIONS

Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.

Ablative radiation therapy to restrain everything safely treatable (ARREST): study protocol for a phase I trial treating polymetastatic cancer with stereotactic radiotherapy

BACKGROUND

Patients with polymetastatic cancer are most often treated with systemic therapy to improve overall survival and/or delay progression, with palliative radiotherapy reserved for sites of symptomatic disease. Stereotactic ablative radiotherapy (SABR) has shown promise in the treatment of oligometastatic disease, but the utility of SABR in treating all sites of polymetastatic disease has yet to be evaluated. This study aims to evaluate the maximally tolerated dose (MTD) of SABR in patients with polymetastatic disease.

METHODS

Up to 48 patients with polymetastatic cancer (> 10 sites) will be enrolled on this phase I, modified 3 + 3 design trial. Eligible patients will have exhausted (or refused) standard systemic therapy options. SABR will be delivered as an escalating number of weekly fractions of 6 Gy, starting at 6 Gy × 2 weekly fractions (dose level 1). The highest dose level (dose level 4) will be 6 Gy × 5 weekly fractions. Feasibility and safety of SABR will be evaluated 6 weeks following treatment using a composite endpoint of successfully completing treatment as well as toxicity outcomes.

DISCUSSION

This study will be the first to explore delivering SABR in patients with polymetastatic disease. SABR will be planned using the guiding principles of: strict adherence to dose constraints, minimization of treatment burden, and minimization of toxicity. As this represents a novel use of radiotherapy, our phase I study will allow for careful selection of the MTD for exploration in future studies.

TRIAL REGISTRATION

This trial was prospectively registered in ClinicalTrials.gov as NCT04530513 on August 28, 2020.

Thoracic radiotherapy in small cell lung cancer-a narrative review

Small-cell lung cancer (SCLC) represents 10–15% of all lung cancers and has a poor prognosis. Thoracic radiotherapy plays a central role in current SCLC management. Concurrent chemoradiotherapy (CTRT) is the standard of care for localised disease (stage I−III, limited-stage, LS). Definitive thoracic radiotherapy may be offered in metastatic patients (stage IV, extensive stage, ES-SCLC) after chemotherapy. For LS-SCLC, the gold standard is early accelerated hyperfractionated twice-daily CTRT (4 cycles of cisplatin etoposide, starting with the first or second chemotherapy cycle). Modern radiation techniques should be used with involved-field radiotherapy based on baseline CT and PET/CT scans. In ES-SCLC, thoracic radiotherapy should be discussed in cases of initial bulky mediastinal disease/residual thoracic disease not progressing after induction chemotherapy. This strategy was however not assessed in recent trials establishing chemo-immunotherapy as the standard first line treatment in ES-SCLC. Future developments include technical radiotherapy advances and the incorporation of new drugs. Thoracic irradiation is delivered more precisely given technical developments (IMRT, image-guided radiotherapy, stereotactic radiotherapy), reducing the risks of severe adverse events. Stereotactic ablative radiotherapy may be discussed in rare early stage (T1 to 2, N0) inoperable patients. A number of current clinical trials are investigating immunoradiotherapy. In this review, we highlight the current role of thoracic radiotherapy and describe ongoing research in the integration of biological surrogate markers, advanced radiotherapy technologies and novel drugs in SCLC patients.

Palliative Radiotherapy Within the Veterans Health Administration: Barriers to Referral and Timeliness of Treatment

PURPOSE

Most Veterans Health Administration hospitals do not have radiation oncology (RO) departments on-site. The purpose of this study is to determine the impact of on-site RO on referral patterns and timeliness of palliative radiation therapy (PRT).

MATERIALS AND METHODS

A survey was sent to medical directors at 149 Veterans Health Administration centers. Questions evaluated frequency of referral for PRT, timeliness of RO consults and treatment, and barriers to referral for PRT. Chi-square analysis was used to evaluate differences between centers that have on-site RO and centers that refer to outside facilities.

RESULTS

Of 108 respondents, 33 (31%) have on-site RO. Chi-square analysis revealed that RO consult within 1 week is more likely at centers with on-site RO (68% v 31%; P = .01). Centers with on-site RO more frequently deliver PRT for spinal cord compression within 24 hours (94% v 70%; P = .01). Those without on-site RO were more likely to want increased radiation oncologist involvement (64% v 26%; P < .001). Barriers to referral for PRT included patient ability to travel (81%), patient noncompliance (31%), delays in consult and/or treatment (31%), difficulty contacting a radiation oncologist (14%), and concern regarding excessive number of treatments (13%). Respondents with on-site RO less frequently reported delays in consult and/or treatment (6% v 41%; P < .0001) and difficulty contacting a radiation oncologist (0% v 20%; P = .0056) as barriers.

CONCLUSION

Respondents with on-site RO reported improved communication with radiation oncologists and more timely consultation and treatment initiation. Methods to improve timeliness of PRT for veterans at centers without on-site RO should be considered.

A narrative review of evolving roles of radiotherapy in advanced non-small cell lung cancer: from palliative care to active player

Radiotherapy, along with other loco-regional interventions, is conventionally utilized as a palliative approach to alleviate symptoms and mitigate oncological emergencies in advanced non-small cell lung cancer (NSCLC). Thanks to the ongoing improvement of medical treatments in the last decade, such as targeted therapy and immunotherapy, the survival of patients with advanced NSCLC has been considerably prolonged, making it feasible and clinically beneficial for radiotherapy to play a more active role in highly selected subpopulations. In this review, we will focus on the evolving roles of radiotherapy in advanced NSCLC. First of all, among patients who are initially unable to tolerate aggressive treatment due to severe symptoms caused by metastases and/or tumor emergencies, timely radiotherapy could significantly improve their performance status (PS) and general condition, thus giving them a chance for intensive treatment and prolonged survival. The efficacy, potential candidates, and optimal dose-fractionation regimens of radiotherapy in this clinical scenario will be discussed. Additionally, radiotherapy can play a curative role as a concurrent therapy, consolidation therapy, and salvage therapy for patients with oligo-metastatic, oligo-residual, and oligo-progressive disease, respectively. Accumulating evidence from recent clinical trials, basic research, and translational investigations regarding the potentially curative roles of radiotherapy in NSCLC patients with oligo-metastatic disease will be summarized. Moreover, with the advent of various small molecular tyrosine kinase inhibitors (TKIs), the treatment efficacy and overall survival of oncogene-addicted NSCLC with brain metastases have been significantly improved, and the clinical value and optimal timing of cranial radiotherapy have become topics of much debate. Finally, synergistic antitumor interactions between radiotherapy and immunotherapy have been repeatedly demonstrated. Thus, the immune sensitizing role of radiotherapy in advanced NSCLC is also highlighted in this review.

Synergy between early-incorporation immunotherapy and extracranial radiotherapy in metastatic non-small cell lung cancer

Background

Combining radiotherapy (RT) and immunotherapy (IT) may enhance outcomes for metastatic non-small cell lung cancer (mNSCLC). However, data on the immunomodulatory effects of extracranial RT remains limited. This retrospective database analysis examined real-world practice patterns, predictors of survival, and comparative effectiveness of extracranial radioimmunotherapy (RT + IT) versus early-incorporation immunotherapy (eIT) in patients with mNSCLC.

Methods

Patients diagnosed with mNSCLC between 2004-2016 treated with eIT or RT + IT were identified in the National Cancer Database. Practice patterns were assessed using Cochrane-Armitrage trend test. Cox proportional hazards and Kaplan-Meier method were used to analyze overall survival (OS). Propensity score matching was performed to account for baseline imbalances. Biologically effective doses (BED) were stratified based on the median (39 Gy₁₀). Stereotactic body radiotherapy (SBRT) was defined as above median BED in ≤5 fractions.

Results

eIT utilization increased from 0.3% in 2010 to 13.2% in 2016 (P<0.0001). Rates of RT + eIT increased from 38.8% in 2010 to 49.1% in 2016 among those who received eIT (P<0.0001). Compared to eIT alone, RT + eIT demonstrated worse median OS (11.2 vs. 13.2 months) while SBRT + eIT demonstrated improved median OS (25 vs. 13.2 months) (P<0.0001). There were no significant differences in OS based on sequencing of eIT relative to RT (log-rank P=0.4415) or irradiated site (log-rank P=0.1606). On multivariate analysis, factors associated with improved OS included chemotherapy (HR 0.86, P=0.0058), treatment at academic facilities (HR 0.83, P<0.0001), and SBRT (HR 0.60, P=0.0009); after propensity-score multivariate analysis, SBRT alone showed improved OS (HR 0.28, P<0.0001).

Conclusions

Utilization of RT + eIT in mNSCLC is increasing. SBRT + eIT was associated with improved OS on propensity-score matched analysis. There were no significant differences in OS based on RT + eIT sequencing or site irradiated. Whether these observations reflect patient selection or possible immunomodulatory benefits of RT is unclear and warrants further study.

Brachytherapy for lung cancer

Brachytherapy (BT) is a minimally invasive anticancer radiotherapeutic modality where the tumor is directly irradiated via a radioactive source that is precisely implanted in or adjacent to the tumor. BT for lung cancer may be conducted in the form of endobronchial BT and radioactive seed implantation (RSI-BT), mainly for nonsmall cell lung cancer (NSCLC). For patients with early-stage lung cancer who are not suitable for surgery or external beam radiotherapy (EBRT), BT may be used as an alternative treatment, and curative results could be achieved in certain patients with cancer confined to the trachea lumen. For patients with locally advanced/metastatic lung cancer, BT could be selectively applied alone or as a boost to EBRT, which could improve the local tumor control and patient's survival. In addition, BT is also useful as a salvage treatment in select patients with locally recurrent/residual lung cancer that failed other treatments (e.g., surgery, chemotherapy, and EBRT). However, clinical outcomes are mainly obtained from retrospective studies. Prospective studies are limited and needed. In recent years, the introduction of modern image guidance, novel radioactive seeds, BT treatment planning systems (BT-TPS), after-loading technique, and three-dimensional printing template (3D-PT) assistance, among others, have potentially improved the clinical outcomes of BT. However, a comprehensive review of BT with newly published literature was lacking. This review is to discuss BT for NSCLC based on recent literature published in PubMed.

Implications of COVID-19 pandemic on lung cancer management: A multidisciplinary perspective

Treatment of patients with lung cancer during the current COVID-19 pandemic is challenging. Lung cancer is a heterogenous disease with a wide variety of therapeutic options. Oncologists have to determine the risks and benefits of modifying the treatment plans of patients especially in situation where the disease biology and treatment are complex. Health care visits carry a risk of transmission of SARS-CoV-2 and the similarities of COVID-19 symptoms and lung cancer manifestations represent a dominant problem. Efforts to modify treatment of lung cancer during the current pandemic have been adapted by many healthcare institutes to reduce exposure of lung cancer patients to SARS-CoV-2. We summarized the implications of COVID-19 pandemic on the management of lung cancer from the perspective of different specialties of thoracic oncology multidisciplinary team.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.

GOECP/SEOR clinical recommendations for lung cancer radiotherapy during the COVID-19 pandemic

The coronavirus disease 2019 crisis has had a major and highly complex impact on the clinical practice of radiation oncology worldwide. Spain is one of the countries hardest hit by the virus, with devastating consequences. There is an urgent need to share experiences and offer guidance on decision-making with regard to the indications and standards for radiation therapy in the treatment of lung cancer. In the present article, the Oncological Group for the Study of Lung Cancer of the Spanish Society of Radiation Oncology reviews the literature and establishes a series of consensus-based recommendations for the treatment of patients with lung cancer in different clinical scenarios during the present pandemic.

Bracing for impact with new 4R's in the COVID-19 pandemic - A provincial thoracic radiation oncology consensus

As COVID-19 pandemic continues to explode, cancer centers worldwide are trying to adapt and are struggling with this constantly changing scenario. Intending to ensure patient safety and deliver quality care, we sought consensus on the preferred thoracic radiation regimen in a Canadian province with 4 new R's of COVID era.

Re-irradiation in the thorax - An analysis of efficacy and safety based on accumulated EQD2 doses

INTRODUCTION

Thoracic re-irradiation remains a challenge regarding the balance of local efficacy and acceptable toxicities. In this retrospective analysis we analyzed dosimetrical and clinical data of patients treated with thoracic re-irradiation based on accumulated EQD2Gy doses.

METHODS AND MATERIAL

We retrospectively analyzed the data of 42 consecutive single-institutional patients treated with repeated courses of thoracic radiotherapy from 12/2011 to 01/2017. Accumulated EQD2 dose distributions were calculated and dose parameters for organs at risk and target volumes were analysed.

RESULTS

The median prescription dose was 42.2 Gy (10-70.6 Gy) for all RT courses. The median Dmean of both lungs was 10.1 Gy₃ (range: 1.9 Gy₃-17.9 Gy₃) with a maximum D0.1 cc of 253.86 Gy₃. The median D0.1 cc of the esophagus was 62.2 Gy₃ with a maximum of 103.78 Gy₃. The maximum D0.1 cc for the bronchial tree was 187.33 Gy₃ (median 74.35 Gy₃) and for the Aorta 216.1 Gy₃ (median 70.9 Gy₃). Median OS after first re-irradiation was 19 months (range 1-45 months). 12-month local control after a course of re-irradiation was 52.6%. 80% of patients suffered from a G1-G2 toxicity, most frequently coughing. One patient suffered from a G5 complication probably unrelated to re-irradiation.

CONCLUSION

Even though several organs at risk received maximum accumulated doses of >100 Gy₃, thoracic reirradiation resulted in an acceptable toxicity profile. Local tumor control and overall survival remained encouraging even after multiple courses of thoracic radiotherapy.

Thoracic Radiation Therapy During Coronavirus Disease 2019: Provisional Guidelines from a Comprehensive Cancer Center within a Pandemic Epicenter

Coronavirus disease 2019 is an unprecedented pandemic with significant and evolving impact on the practice of radiation oncology. Radiation oncology departments must anticipate and account for coronavirus disease 2019 exposure risk for both patients and staff. The potential for severe radiation therapy resource constraints, particularly due to staff illness, must also be considered. Here we present provisional guidelines for thoracic radiation therapy adopted at our facility, a high-volume cancer center located in a United States pandemic epicenter. Generally, these guidelines reflect the principle that where evidence-supported hypofractionated schedules with comparable efficacy and toxicity exist, the shortest such schedules should be employed. In addition, we discuss potential adaptations in the prioritization and timing of radiation therapy for thoracic malignancies under these circumstances.

Palliative Lung Radiotherapy: Higher Dose Leads to Improved Survival?

Aims

Choosing the optimal palliative lung radiotherapy regimen is challenging. Guidance from The Royal College of Radiologists recommends treatment stratification based on performance status, but evidence suggests that higher radiotherapy doses may be associated with survival benefits. The aim of this study was to investigate the effects of fractionation regimen and additional factors on the survival of palliative lung cancer radiotherapy patients.

Materials and methods

A retrospective univariable (n = 925) and multivariable (n = 422) survival analysis of the prognostic significance of baseline patient characteristics and treatment prescription was carried out on patients with non-small cell and small cell lung cancer treated with palliative lung radiotherapy. The covariates investigated included: gender, age, performance status, histology, comorbidities, stage, tumour location, tumour side, smoking status, pack year history, primary radiotherapy technique and fractionation scheme. The overall mortality rate at 30 and 90 days of treatment was calculated.

Results

Univariable analysis revealed that performance status (P < 0.001), fractionation scheme (P < 0.001), comorbidities (P = 0.02), small cell histology (P = 0.02), ‘lifelong never’ smoking status (P = 0.01) and gender (P = 0.06) were associated with survival. Upon multivariable analysis, only better performance status (P = 0.01) and increased dose/fractionation regimens of up to 30 Gy/10 fractions (P < 0.001) were associated with increased survival. Eighty-five (9.2%) and 316 patients (34%) died within 30 and 90 days of treatment, respectively.

Conclusion

In this retrospective single-centre analysis of palliative lung radiotherapy, increased total dose (up to and including 30 Gy/10 fractions) was associated with better survival regardless of performance status.

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Larger doses of palliative lung radiotherapy are associated with increased survival.

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Performance status is independently linked to survival.

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Palliative lung radiotherapy dose is independently linked to survival.

Radiotherapeutic Care of Patients With Stage IV Lung Cancer with Thoracic Symptoms in the Veterans Health Administration

BACKGROUND

Radiotherapy plays an important role in the palliation of lung cancer, which is the second most common cancer diagnosed in the Veterans Health Administration (VHA). The American Society for Radiation Oncology (ASTRO) developed evidenced-based treatment guidelines for the management of patients with metastatic lung cancer.

METHODS

In May 2016, an electronic survey of 88 VHA radiation oncologists (ROs) was conducted to assess metastatic lung cancer management. Demographic information was obtained and 2 clinical scenarios were presented to glean opinions on dose/fractionation schemes preferred, preferences for/against concurrent chemotherapy, and use of endobronchial brachytherapy (EBB) and/or yttrium aluminum garnet (YAG) laser technology. Survey results were assessed for concordance with published ASTRO guidelines.

RESULTS

The survey response rate was 61%, with 93% of the 40 VHA radiation departments represented. Among respondents, 96% were board certified, and 90% held academic appointments. 88% were familiar with ASTRO guidelines. Preferred fractionation schemes were 20 Gy in 5 fractions (69%) and 30 Gy in 10 fractions (22%). The vast majority (98%) did not recommend concurrent chemotherapy for palliation. In the setting of bronchial obstruction with lung collapse, about half (49%) recommended EBB or YAG lung reexpansion before external beam radiotherapy. A minority of respondents use stereotactic body radiotherapy or EBB for palliation.

CONCLUSION

Most respondents demonstrated up-to-date knowledge of current evidence-based treatment guidelines. We found no distinction in clinical decisions based on demographic profiles.

PD-L1 induction in tumor tissue after hypofractionated thoracic radiotherapy for non-small cell lung cancer

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Radiotherapy induced high PD-L1 expression in initially PD-L1 negative metastatic nsclc patient.

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High PD-L1 expression was also evident in gut metastasis that developed after radiotherapy.

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Due to high PD-L1 expression, immunotherapy has been effective even after 4 lines of chemotherapy.

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Radiotherapy might have a potential to increase the efficacy of checkpoint inhibitors.

We report on a 67-year old male with advanced stage lung adenocarcinoma (initially PD-L1 negative, EGFR and ALK negative) diagnosed in 2014. The patient received 4 lines of palliative chemotherapy from 2014 to 2017, however the disease progressed. In 2015, he also received palliative hypofractionated radiotherapy to a mediastinal mass, which was causing discomfort and pain. Since there was some data, that radiotherapy could induce PD-L1 expression, a new biopsy was taken in 2017 from the irradiated mediastinal mass. Subsequent pathologic report revealed that PD-L1 status was turned to be highly positive, with tumor proportion score of 100%. Similar high expression of PD-L1 was detected in a new metastasis in the duodenum, which was excised due to a duodenal perforation in 2017. From October 2017 to October 2019, the patient had 2-years of treatment (32 courses) with pembrolizumab and has had a positive effect (partial response) on all the lesions and following stabilization of the disease. Currently, this patient is under follow up and he is in a good condition without any complaints. Last CT-scan in March 2020 showed persisting partial response.

Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review

BACKGROUND

Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed.

METHODS

Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients.

RESULTS

Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary.

CONCLUSION

Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

Analysis of dose distribution between contemporary and standard planning in high-dose-rate endobronchial brachytherapy based on three-dimensional imaging

Purpose

The treatment planning (TP) in high-dose-rate (HDR) endobronchial brachytherapy (EB) can be based on various forms of imaging. In the case of lung cancer, one-dimensional or two-dimensional imaging is standard. The dose coverage of the target (planning target volume – PTV) and organs at risk (OAR) is unknown, because the doses are calculated on the basis of the dose points. In modern brachytherapy, TP can be based on three-dimensional (3D) images. A plan created in this way contains information about the dose distribution in the PTV and OAR. Treatment plans based on standard planning (SP) and contemporary planning (CP) may differ in dose distribution in the patient’s body. Those differences between SP and CP may have an effect on the dose distribution in PTV, OAR and follow-up.

Material and methods

The study involved a group of 31 patients prospectively treated with advanced, inoperable, non-small cell lung cancer. As many as 76 treatment fractions were analyzed. Firstly, the coverage of the PTV parameter in 2D and 3D for V₈₅, V₁₀₀ and V₁₁₅ was analyzed. Secondly, the dosage that OAR would take in was evaluated. In the cases of the heart, spinal cord and esophagus, the examined dosage equaled D_0.1cm³, D_1cm³ and D_2cm³ for each of the structures. Also, heart D₂₀ was examined as well as D₅ for the healthy lung.

Results

The median dose to the target volume was on average 43.33% higher for V₈₅ with the contemporary planning method when compared to standard planning, with statistical significance. This came with the cost of an OAR mean dose increase of 1 Gy in D_0.1cm³ for the heart.

Conclusions

Contemporary TP in EB allows one to adjust the dose distribution for individual clinical situations and allows one to improve clinical target volume (CTV) coverage, increase doses to the OAR and increase overall survival. The use of new methods of treatment plans in EB has significantly increased the follow-up to 21 months in a treated group of patients.

Clinical Specialist Radiation Therapist in Palliative Radiation Therapy: Report of an Orientation, Training, and Support Program

INTRODUCTION

A clinical specialist radiation therapist (CSRT) position in palliative radiation therapy (RT) was created at our institution. Herein, we report the details of the CSRT's orientation, training, and support program.

METHODS

We performed an audit and needs assessment of palliative RT services at our centre. This identified opportunities for improvement that could be facilitated by the CSRT. We defined the CSRT job description including priority responsibilities: (1) optimizing palliative RT services for outpatients and developing a rapid access palliative RT program, (2) optimizing palliative RT services for inpatients at our institution, (3) improving links to community physicians and hospitals caring for patients with advanced cancers. We formed a core resource team to provide ongoing support and to design and implement the orientation and training program. The program involved training in clerical and administrative systems as well as treatment planning and physics training relevant to palliative RT. Clinical placements at several hospitals were arranged in both inpatient and outpatient settings. The CSRT worked with radiation and medical oncologists, palliative care specialists, nurse practitioners, hospitalists, and social workers.

RESULTS

Through clinical placements and self-directed learning, the CSRT gained knowledge and competencies in patient care coordination, history taking and physical examination, clinical oncology practice including the evidence-based use of palliative RT and symptom control measures, treatment planning, communication, patient advocacy, and advance care planning. We provided practice resources including office space and a planning station, educational opportunities including workshops in palliative and psychosocial care, and research opportunities including methodologic and research ethics training.

DISCUSSION

To our knowledge, this is the first detailed report of its kind for an advanced practice radiation therapy role. We hope our report will inform the design and implementation of programs elsewhere to help prepare individuals for similar roles in palliative RT.

CONCLUSION

The CSRT in palliative RT at our institution underwent a comprehensive orientation and training program. Institutions with similar CSRT positions are encouraged to report the details of their own programs.

Radiotherapy in the control of bleeding from primary and secondary lung tumours

This literature review clarifies the role of radiotherapy in the management of low-volume haemoptysis. Embase and Medline were interrogated, and PRISMA guidelines were then used to select relevant articles. Seventy-eight articles were considered relevant and manually reviewed. The evidence suggests that external beam radiotherapy is more effective than endobronchial brachytherapy at controlling low-volume haemoptysis. There is no evidence to recommend a combination of the two techniques. Different doses and fractionations appear equally effective, with a potential survival advantage of higher dose regimens for fitter patients. Palliative radiotherapy is effective at controlling low-volume haemoptysis. External beam radiotherapy is the first-line treatment, with endobronchial brachytherapy recommended following external beam radiotherapy failure. Choice of dose and fractionation should take into account the patient's performance status.

Current landscape of palliative radiotherapy for non-small-cell lung cancer

Radiotherapy (RT) is a cornerstone in the management of advanced stage III and stage IV non-small-cell lung cancer (NSCLC) patients. Despite international guidelines, clinical practice remains heterogeneous. Additionally, the advent of stereotactic ablative RT (SABR) and new systemic treatments such as immunotherapy have shaken up dogmas in the approach of these patients. This review will focus on palliative thoracic RT for NSCLC but will also discuss the role of stereotactic radiotherapy, endobronchial brachytherapy (EBB), the interest of concomitant treatments (chemotherapy and immunotherapy), and the role of RT in lung cancer emergencies with palliative intent.