Multimodal therapy for solid tumors

Radiotherapy or chemotherapy followed by radiotherapy with or without amifostine in locally advanced lung cancer

Radiotherapy (RT) or radiochemotherapy is the treatment of choice for patients with medically or technically inoperable non-small cell lung cancer (NSCLC) localized to the primary site and regional lymph nodes. Radiation-induced damage has been recognized as a major complication in thoracic RT. The use of concurrent chemoradiation has been associated with an increase in acute and late toxicity. Amifostine (Ethyol) is an effective cytoprotective agent and also may have a role in protecting healthy lung tissue during radiation treatment. The purpose of these 2 clinical trials was to investigate whether daily pretreatment with amifostine could reduce the incidence of esophagitis, and acute and late lung toxicity without affecting the antitumor efficacy of the treatment. The first was a phase III randomized trial of 146 patients with locally advanced lung cancer. All patients received conventional RT to a total of 55 to 60 Gy, and they were assigned randomly to pretreatment with 340 mg/m(2) of amifostine (A). Acute and late toxicities were graded according to the Radiation Therapy Oncology Group (RTOG) grading system from grades 0 to 4. Ninety-seven patients were evaluated 2 months post-RT for the incidence of pneumonitis; 43% (23 of 53) of patients in the RT arm and 9% (9 of 44) in the A plus RT arm experienced grade > or = 2 pneumonitis (P <.001). Forty-nine percent (26 of 53) of patients in the RT arm and 16% (7/44) in the A plus RT arm showed changes that were representative of grade > or = 2 lung damage in the computed tomography (CT) scan. Fibrosis was present in 53% (19 of 36) of patients receiving RT versus 28% (9 of 32) in the A plus RT arm at 6 months (P < 0.05). The incidence of esophagitis grade > or = 2 during week 4 was 42% (31 of 73) in the RT arm versus 4% (3 of 73) in the A plus RT arm (P <.001). Among 97 patients evaluable for response 2 months after RT, complete or partial responses were present in 76% (40 of 53) of patients in the RT arm and 75% (33 of 44) in the A plus RT arm (P = 1.0). The second trial was a phase II randomized study of 45 patients with NSCLC. All patients had received platinum-based induction chemotherapy before being referred for conventional radiation treatment with or without A; a total dose of 55 to 60 Gy was administered at the primary site. Acute and late toxicities were evaluated and graded according the RTOG criteria from grades 0 to 4. Forty-five patients were evaluable for response 2 months after RT. Complete or partial responses were achieved in 78% (18 of 23) of patients in the RT arm and 82% (18 of 22) in the A plus RT arm (P =.278). By week 5, 74% (17 of 23) of patients in the RT group versus 36% (8 of 22) in the A plus RT group experienced grade > or = 2 esophagitis. (During the follow-up period, pulmonary toxicity was evaluated by CT scan.) Three months after RT, 65% (15/23) of patients in the RT group and 32% (7 of 22) in the A plus RT group presented with grade > or = 2 pneumonitis (P =.038). Amifostine reduces the incidence of acute and late radiation-induced toxicities.

Role of chemotherapy in stages I to III non-small cell lung cancer

The management of resectable non-small cell lung cancer (NSCLC) has been the focus of extensive investigation over the last decade. Nonetheless, existing management strategies are suboptimal for all stage groupings. The only exception is complete resection for stage IA NSCLC, in which a cure is achieved in 70 to 85% of patients. A number of studies demonstrate that adjuvant chemotherapy may be associated with some biological effect. Nonetheless, chemotherapy remains experimental and cannot be definitively recommended outside the context of a randomized trial. Radiation therapy appears to be associated with a reduction in local recurrence in stage II NSCLC. With regard to potentially resectable stage IIIA NSCLC, the results of randomized trials support the conclusion that induction chemotherapy followed by resection (with or without postoperative radiation) may enhance survival compared to that achieved with resection alone. Among patients with stage IIIA and IIIB NSCLC who are treated without resection, numerous phase III studies demonstrate that induction chemotherapy with definitive radiation improves outcome when compared to thoracic radiation therapy alone. While there may be an advantage for concurrent chemoradiation compared to sequential therapy, definitive results are not yet available to support this conclusion. While the magnitude of benefit associated with induction chemotherapy or chemoradiation in regionally advanced NSCLC is debatable, the results of multimodality studies provide a basis for optimism that real therapeutic progress is being achieved. Further study of therapeutic strategies that incorporate aggressive systemic treatment and local-regional therapy in stage IIIA and IIIB NSCLC is warranted. Moreover, completion of randomized studies focusing on the role of adjuvant chemotherapy in stage IB and stage II NSCLC should be given priority.

Chemotherapy for advanced non-small cell lung cancer

Lung cancer is the most lethal cancer in both men and women. Given that chemotherapy for advanced disease is marginally beneficial and noncurative, its use must be governed judiciously, with each decision being evaluated individually for each patient. Chemotherapy for lung cancer has progressed over the past decade, and with the advent of new agents, its future looks promising.

Randomized trials of radiotherapy alone versus combined chemotherapy and radiotherapy in stages IIIa and IIIb nonsmall cell lung cancer. A meta-analysis

BACKGROUND

For patients with Stage III nonsmall cell lung cancer (NSCLC), radiation is the standard treatment, but survival remains poor. The authors performed a meta-analysis study using clinical trials that evaluated combined radiotherapy plus chemotherapy versus radiotherapy alone in patients with Stages IIIa and IIIb NSCLC:

METHODS

For the meta-analysis study and the point estimates, essential data were extracted directly from published reports.

RESULTS

Survival probabilities at 1, 2, 3, and 5 years, as estimated from published survival curves, were considered as the endpoints of interest. For survival at 3 and 5 years, the point estimates and the confidence intervals were used. Quality scoring of the studies also was performed. Fourteen trials were selected, comprising 1887 patients in the meta-analysis. For the cisplatin-based group, the estimated pooled odds ratio of death at 1 and 2 years was 0.76 (0.6-0.9 CI) and 0.70 (0.5-0.9 CI), with a reduction in mortality of 24% and 30%, respectively. For the noncisplatin-based group, the estimated pooled odds ratio at 1 and 2 years was 1.05 (0.7-1.5 CI) and 0.82 (0.5-1.3 CI), with a reduction in mortality of 5% and 18%, respectively. However, no significant differences were found between the percentage of survival and the CI at 3 and 5 years using the point estimates.

CONCLUSIONS

These results favor combined cisplatin-based chemotherapy and radiotherapy, although it was not so at 3 and 5 years of survival. These data must, however, be considered in the light of their clinical relevance and of the balance between quality of life, toxicity, and costs of chemotherapy.