Palliative thoracic radiotherapy for non-small-cell lung cancer: a systematic review

Effect of thoracic radiotherapy dose on the prognosis of advanced lung adenocarcinoma harboring EGFR mutations

Background

The aim of this study was to investigate the effects of different thoracic radiotherapy doses on OS and incidence of radiation pneumonia which may provide some basis for optimizing the comprehensive treatment scheme of these patients with advanced EGFR mutant lung adenocarcinoma.

Methods

Data from 111 patients with EGFR-mutant lung adenocarcinoma who received thoracic radiotherapy were included in this retrospective study. Overall survival (OS) was the primary endpoints of the study. Kaplan–Meier method was used for the comparison of OS. The Cox proportional-hazard model was used for the multivariate and univariate analyses to determine the prognostic factors related to the disease.

Results

The mOS rates of the patients, who received radiotherapy dose scheme of less than 50 Gy, 50–60 Gy (including 50 Gy), and 60 Gy or more were 29.1 months, 34.4 months, and 51.0 months, respectively (log-rank P = 0.011). Although trend suggested a higher levels of pneumonia cases with increasing radiation doses, these lack statistical significance (χ2 = 1.331; P = 0.514). The multivariate analysis showed that the thoracic radiotherapy dose schemes were independently associated with the improved OS of patients (adjusted hazard ratio [HR], 0.606; 95% CI, 0.382 to 0.961; P = 0.033).

Conclusions

For the patients with advanced EGFR-mutant lung adenocarcinoma, the radical thoracic radiotherapy dose scheme (≥ 60 Gy) could significantly prolong the OS of patients during the whole course management.

Early High-Grade Thoracic Toxicity After Palliative Radiotherapy for Non-Small Cell Lung Cancer

INTRODUCTION

Palliative radiotherapy or chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) may cause thoracic toxicities due to the radiation dose delivered to the lungs, heart, and esophagus. We studied severe thoracic toxicities resulting in hospitalization or death during the acute and sub-acute phase, i.e., three months from commencing radiotherapy. In addition, risk factors were identified.  Methods: A retrospective review of 165 patients treated with three-dimensional conformal palliative radiotherapy or CRT was performed. The prescribed total dose was equivalent to at least 30 Gy in 10 fractions. Uni- and multivariate analyses were employed.

RESULTS

Twelve patients (7%) were hospitalized within three months from the start of radiotherapy or CRT. Six patients were hospitalized for esophagitis, three for dyspnea most likely caused by pneumonitis, and three for cardiac arrhythmia. Fatal toxicity was not observed. However, 19% of the 165 patients died from tumor-related causes during the time period of interest. In multivariate analysis, the only esophageal dose was significantly associated with the risk of hospitalization.  Conclusion: The safety profile of palliative radiotherapy or CRT in the acute and subacute phases was satisfactory. The hospitalization rate can be reduced by lowering the esophageal dose, as long as safe lung and heart doses can be maintained.

Death due to a bronchus-pulmonary artery fistula developed 19 years after radiotherapy: A forensic autopsy case report

Radiotherapy, one of the standard therapies for lung cancer management, may cause severe late complications. In this case report, we describe the forensic autopsy report of a middle-aged man who died from a massive hemoptysis due to a bronchus-pulmonary artery fistula that developed 19 years after radiotherapy. The man, in his 50 s, suddenly developed hemoptysis at home and collapsed. He was in complete remission with no signs of recurrence. Autopsy revealed massive hemorrhage from the bronchus-pulmonary artery fistula, where radiotherapy had been focused. Histopathological findings showed chondronecrosis of the bronchus, disruption of elastic fibers of the pulmonary artery, and marked thickening of the intima of the small arteries around the fistula, which were compatible with radiation reaction. Neither cancer recurrence nor infection was evident. This case suggests that a late complication of radiotherapy should be considered in the differential diagnosis of a patient who was previously received radiotherapy and presents with massive hemoptysis. In such cases, a detailed history on previous therapies and careful examination of the origin of hemorrhage are necessary to determine the cause of death.

Radiation Oncology Emergencies

This article reviews the most common oncologic emergencies encountered by the radiation oncologist, including malignant spinal cord compression, intramedullary spinal cord metastasis, superior vena cava syndrome, hemoptysis, and airway compromise caused by tumor. Important trials evaluating different treatments for these emergencies are reviewed. The role of corticosteroids, surgery, chemotherapy, and radiation therapy in these patients is discussed and patient-specific treatment guidelines are suggested.

The experience of providing hospice care concurrent with cancer treatment in the VA

PURPOSE

Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer.

METHODS

From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18).

RESULTS

Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care.

CONCLUSIONS

While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.

Malignant tracheal necrosis and fistula formation following palliative chemoradiotherapy: a case report

Concurrent chemoradiotherapy is an essential treatment strategy for inoperable locally advanced non-small cell lung cancer (NSCLC). Although supportive care has improved, unexpected complications due to the disease or treatment can occur. Tracheomediastinal fistulas are very rare but can be a serious problem. Herein, we report a case of severe chondronecrosis of the distal trachea with formation of a fistula into a metastatic lymphadenopathy in a patient with stage IIIB NSCLC. The patient received external beam radiotherapy with a total dose of 35 Gy in 14 fractions, which was approximately half of the conventional therapeutic radiotherapy dose, along with concurrent cisplatin based chemotherapy. Careful evaluation, early detection, and timely intervention are essential to prevent and appropriately treat chondronecrosis, even in cases of low-dose radiotherapy application to central tumors.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Prevalence and Predictors of Inappropriate Delivery of Palliative Thoracic Radiotherapy for Metastatic Lung Cancer

BACKGROUND

High-level evidence has established well-recognized standard treatment regimens for patients undergoing palliative chest radiotherapy (RT) for stage IV non-small cell lung cancer (NSCLC), including treating with fewer than 15 fractions of RT, and not delivering concurrent chemoradiation (CRT) because of its increased toxicity and limited efficacy in the palliative setting.

METHODS

The study included patients in the National Cancer Database from 2004 to 2012 with stage IV lung cancer who received palliative chest radiation therapy. Logistic regression was performed to determine predictors of standard vs nonstandard regimens (>15 fractions or CRT). All statistical tests were two-sided.

RESULTS

There were 46 803 patients in the analysis and 49% received radiotherapy for longer than 15 fractions, and 28% received greater than 25 fractions. Approximately 19% received CRT. The strongest independent predictors of long-course RT were private insurance (odds ratio [OR] = 1.40 vs uninsured, 95% confidence interval [CI] = 1.28 to 1.53) and treatment in community cancer programs (OR = 1.49, 95% CI = 1.38 to 1.58) compared with academic research programs. The strongest factors that predicted for concurrent chemoradiotherapy were private insurance (OR = 1.38 95% CI = 1.23 to 1.54) compared with uninsured patients and treatment in community cancer programs (OR = 1.44, 95% CI = 1.33 to 1.56) compared with academic programs.

CONCLUSIONS

Approximately half of all patients with metastatic lung cancer received a higher number of radiation fractions than recommended. Patients with private insurance and treated in community cancer centers were more likely to receive longer courses of RT or CRT. This demonstrates that a substantial number of patients requiring palliative thoracic radiotherapy are overtreated and further work is necessary to ensure these patients are treated according to evidenced-based guidelines.

Comparative effectiveness of aggressive thoracic radiation therapy and concurrent chemoradiation therapy in metastatic lung cancer

PURPOSE

We aimed to determine the comparative effectiveness of radiation dose escalation and concurrent chemoradiation therapy (CCRT) in a population-based cohort of patients with stage IV non-small cell lung cancer who underwent palliative thoracic radiation therapy (RT).

METHODS AND MATERIALS

The cohort consisted of 27,063 patients in the National Cancer Database with stage IV non-small cell lung cancer treated with thoracic RT between 20 and 55 Gy in 2004 to 2011. High- versus intermediate- vs low-dose (HD vs ID vs LD, respectively) RT was defined as biologically effective dose above 50 Gy, between 35 and 50 Gy, and below 35 Gy, respectively. Among patients who received any chemotherapy, separate analyses were performed to examine the impact of CCRT on overall survival (OS).

RESULTS

The median follow-up was 3.9 months for the entire cohort and 18 months for surviving patients. The 5 most common treatment schemes were 30/10 (Gy/fraction, 23% of entire cohort), 35/14 (8%), 37.5/15 (7%), 40/20 (3%), and 50/20 (3%). On multivariable analysis, the survival hazard ratios (HRs) for HD and ID compared with LD RT were 0.37 and 0.51, respectively (P < .0001). Propensity score matching found a superior survival benefit for ID and HD (HR, 0.41 and 0.57 for HD and ID RT, respectively, vs LD, P < .0001). Among those who received any chemotherapy (59% of total), the median OS for patients treated with CCRT (19% of total) was 5.3 versus 5.6 months (P = .667). On multivariable analysis, the HR for CCRT was 1.01 (P = .46).

CONCLUSIONS

The delivery of higher-dose RT but not concurrent chemotherapy was associated with a significant improvement of OS. This population-based study supports higher-dose palliative regimens and motivates prospective study of escalation beyond a biologically effective dose of 35 Gy.

The International Atomic Energy Agency (IAEA) randomized trial of palliative treatment of incurable locally advanced non small cell lung cancer (NSCLC) using radiotherapy (RT) and chemotherapy (CHT) in limited resource setting

BACKGROUND

To optimize palliation in incurable locally advanced non-small cell lung cancer (NSCLC), the International Atomic Energy Agency conducted a prospective randomized study (NCT00864331) comparing protracted palliative radiotherapy (RT) course with chemotherapy (CHT) followed by short-course palliative RT.

METHODS AND MATERIALS

Treatment-naive patients with histologically confirmed NSCLC, stage IIIA/IIIB, received either 39Gy in 13 fractions as RT alone (arm A, n=31) or 2-3 platinum-based CHT cycles followed by 10Gy in a single fraction or 16Gy in 2 fractions separated by one week (arm B, n=34). Primary outcome was overall survival.

RESULTS

Treatment groups were balanced with respect to various variables. Median survival for all 65 patients was 8months, while median survival was 7.1 and 8.1months for the two arms, respectively (log-rank p=0.4 by study arm, and p=0.6 by Cox regression and stratified by country and sub-stage). One and three year survival rates for the two arms were 29%, and 9% and 41%, and 6%, respectively. There were no differences in any of the following endpoints: any failure, local failure, regional failure, contralateral thoracic failure, and distant failure between the two arms. High-grade (⩾3) toxicity was similar between the two arms. Symptoms, adverse events of any kind, KPS and body-mass index, were not different during treatment and during follow-up. There was no grade 5 toxicity.

CONCLUSIONS

This incomplete and underpowered trial only hinted similar outcome between the treatment arms. Therefore, combined CHT-RT can perhaps be considered, in limited resource setting, where access to RT remains inadequate.

The Refusal of Palliative Radiation in Metastatic Non-Small Cell Lung Cancer and Its Prognostic Implications

CONTEXT

Patients with metastatic non-small cell lung cancer (NSCLC) have limited survival. Population studies have evaluated the impact of radiation refusal in the curative setting; however, no data exist concerning the prognostic impact of radiation refusal in the palliative care setting.

OBJECTIVES

To investigate the patterns of radiation refusal in newly diagnosed patients with metastatic NSCLC.

METHODS

Patients with Stage IV NSCLC diagnosed between 1988 and 2010 were identified in the Surveillance, Epidemiology, and End Results database. Univariate and multivariate analyses were used to identify predictors for refusal of radiation and the impact of radiation and refusal on survival in the palliative setting.

RESULTS

A total of 285,641 patients were initially included in the analysis. Palliative radiation was recommended in 42% and refused by 3.1% of patients. Refusal rates remained consistent across included years of study. On multivariate analysis, older, nonblack/nonwhite, unmarried females were more likely to refuse radiation (P < 0.001 in all cases). Median survival for patients refusing radiation was three months vs. five months for those receiving radiation and two months for those whom radiation was not recommended.

CONCLUSION

Patients with metastatic NSCLC who refuse recommended palliative radiation have a poor survival. Radiation refusal or the recommendation against treatment can serve as a trigger for integrating palliative care services sooner and contributes greatly to prognostic awareness. Further investigation into this survival difference and the factors behind refusal are warranted.

Efficacy of 3D conformal thoracic radiotherapy for extensive-stage small-cell lung cancer: A retrospective study

The aim of the present study was to evaluate the effect of 3-dimensional conformal thoracic radiotherapy (TRT) on extensive-stage small-cell lung cancer (ES-SCLC). A total of 165 patients with ES-SCLC were enrolled in the present study, including 82 patients receiving chemotherapy combined with TRT (the ChT/TRT group) and 83 patients receiving chemotherapy alone (the ChT group). The overall survival (OS) and progression-free survival (PFS) rates were compared between the ChT/TRT and ChT groups, and the prognostic factors for OS rate were identified. It was found that the patients had a median OS time of 15 months, and 2- and 5-year OS rates of 31.5 and 2.4%, respectively. The 2- and 5-year OS rates were 35.3 and 2.4% in the ChT/TRT group, and 14.5 and 2.4% in the ChT group, respectively (P<0.05). The 1- and 2-year PFS rates were 35.4 and 6.0% in the ChT/TRT group, and 20.5 and 6.0% in the ChT group, respectively (P<0.05). The median PFS was 11 months in the 20 patients receiving TRT at 45 Gy/30 fractions twice daily, and 9 months in the 22 patients receiving TRT at 60 Gy/30 fractions daily (P=0.043). Multivariate analysis revealed that receiving ≥4 cycles of chemotherapy (P=0.001) and TRT (P=0.008) were favorable prognostic factors for OS. It was concluded that the addition of TRT improves the OS and PFS rates of patients with ES-SCLC, and TRT administration at 45 Gy/30 fractions twice daily is feasible and tolerable for the treatment of ES-SCLC. Thus, TRT and receiving ≥4 cycles of chemotherapy are independent, favorable prognostic factors for OS in patients with ES-SCLC.

0-7-21 hypofractionated palliative radiotherapy: an effective treatment for advanced head and neck cancers

OBJECTIVE

We report our experience in providing palliative radiotherapy (RT) to patients with head and neck cancers (HNCs). Our hypofractionated regimen, "0-7-21", treats patients with 24 Gy in three fractions.

METHODS

Patients, disease and response data were retrieved for candidates of 0-7-21 from 2005 to 2012. Primary end points included symptom and tumour size responses to RT based on response evaluation criteria in solid tumours (RECIST) guidelines. Secondary end points included progression-free survival (PFS) within the irradiated field, overall survival (OS) and symptomatic PFS (SPFS), calculated using Kaplan-Meier method and adverse events. Cox proportional hazards regression and logistic regression were used to investigate for prognostic factors.

RESULTS

A total of 110 patients were included. Among the patients, 40% and 31% had complete response for symptoms and tumour size, respectively; 42% and 50% had partial response for symptoms and tumour size, respectively; and 15% had stability of symptoms and tumour size. Median 6-month OS was 51%, and PFS within the irradiated field was 39%. Planning target volume was predictive of OS (p < 0.001), PFS (p < 0.001) and SPFS (p < 0.005), while higher TNM stage was associated with poorer tumour response (p = 0.02).

CONCLUSION

0-7-21 is an effective and well-tolerated palliative RT regimen for patients with HNC. There was excellent symptom and local control with acceptable toxicity profile in these patients.

ADVANCES IN KNOWLEDGE

This is the first study to describe the outcomes of 0-7-21 in treating advanced HNCs. The positive results suggest that 0-7-21 provides excellent palliation with minimal toxicity, with significantly less on-treatment time than current published palliative RT regimen.

Palliative radiation therapy practice in patients with metastatic non-small-cell lung cancer: a Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

PURPOSE

Randomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression.

RESULTS

Of 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associated with younger age at diagnosis and receipt of chemotherapy and surgery to metastatic sites. Among patients receiving palliative bone RT, only 6% received single-fraction treatment. Among patients receiving palliative chest RT, 42% received more than 20 fractions. Patients treated in integrated networks were more likely to receive lower doses and fewer fractions to the bone and chest.

CONCLUSION

When palliative RT is used in patients with metastatic NSCLC, a substantial proportion of patients receive a greater number of treatments and higher doses than supported by current evidence, suggesting an opportunity to improve care delivery.

Clinical management of pain in advanced lung cancer

Lung cancer is the most common cancer in the world and pain is its most common symptom. Pain can be brought about by several different causes including local effects of the tumor, regional or distant spread of the tumor, or from anti-cancer treatment. Patients with lung cancer experience more symptom distress than patients with other types of cancer. Symptoms such as pain may be associated with worsening of other symptoms and may affect quality of life. Pain management adheres to the principles set out by the World Health Organization's analgesic ladder along with adjuvant analgesics. As pain can be caused by multiple factors, its treatment requires pharmacological and non-pharmacological measures from a multidisciplinary team linked in with specialist palliative pain management. This review article examines pain management in lung cancer.

Patterns of care and course of symptoms in palliative radiotherapy: a multicenter pilot study analysis

BACKGROUND AND PURPOSE

To evaluate patterns of care as well as effectiveness and side effects of palliative treatment in four German radiation oncology departments.

PATIENTS AND METHODS

All referrals in four German radiation oncology departments (two university hospitals, one academic hospital, one private practice) were prospective documented for 1 month in 2008 (2 months at one of the university hospitals). In palliatively irradiated patients, treatment aims and indications as well as treated sites and fractionation schedules were recorded. In addition, symptoms and side effects were analyzed with standardized questionnaires before and at the end of radiotherapy.

RESULTS

During the observation period, 603 patients underwent radiation therapy in the four centers and 153 (24%, study population) were treated with palliative intent. Within the study, patients were most frequently treated for bone (34%) or brain (27%) metastases. 62 patients reported severe or very severe pain, 12 patients reported severe or very severe dyspnea, 27 patients reported neurological deficits or signs of cranial pressure, and 43 patients reported a poor or very poor sense of well-being. The most frequent goals were symptom relief (53%) or prevention of symptoms (46%). Life prolongation was intended in 37% of cases. A wide range of fractionation schedules was applied with total doses ranging from 3-61.2 Gy. Of the patients, 73% received a slightly hypofractionated treatment schedule with doses of > 2.0 Gy to ≤ 3.0 Gy per fraction and 12% received moderate to highly hypofractionated therapy with doses of > 3.0 Gy to 8.0 Gy. Radiation therapy led to a significant improvement of well-being (35% of patients) and reduction of symptoms, especially with regard to pain (66%), dyspnea (61%), and neurological deficits (60%). Therapy was very well tolerated with only 4.5% grade I or II acute toxicities being observed. Unscheduled termination was observed in 19 patients (12%).

CONCLUSIONS

Palliative radiation therapy is effective in reducing symptoms, increases subjective well-being, and has minimal side effects. More studies are necessary for subgroup analyses and for clarifying the different goals in palliative radiotherapy.

Palliative thoracic radiotherapy for lung cancer: a systematic review

PURPOSE

The optimal dose of radiotherapy (RT) to palliate symptomatic advanced lung cancer is unclear. We systematically reviewed randomized controlled trials (RCTs) of palliative thoracic RT.

METHODS

RCTs comparing two or more dose fractionation schedules were reviewed using the random-effects model of a freely available information management system. The relative risk and 95% CI for each outcome were presented in Forrest plots. Exploratory analysis comparing dose schedules after conversion to the time-adjusted biologically equivalent dose (BED) was performed to investigate for a dose-response relationship.

RESULTS

A total of 13 RCTs involving 3,473 randomly assigned patients were identified. Outcomes included symptom palliation, overall survival, toxicity, and reirradiation rate. For symptom control in assessable patients, lower-dose (LD) RT was comparable with higher-dose (HD), except for the total symptom score (TSS): 65.4% of LD and 77.1% of HD patients had improved TSS (P = .003). Greater likelihood of symptom improvement was seen with schedules of 35 Gy(10) versus lower BED. At 1 year after HD and LD RT, 26.5% versus 21.7% of patients were alive, respectively (P = .002). Sensitivity analysis suggests this survival improvement was seen with 35 Gy(10) BED schedules compared with LDs. Physician-assessed dysphagia was significantly greater in the HD arm (20.5% v 14.9%; P = .01), and the likelihood of reirradiation was 1.2-fold higher after LD RT.

CONCLUSION

No significant differences were observed for specific symptom-control end points, although improvement in survival favored HD RT. Consideration of palliative thoracic RT of at least 35 Gy(10) BED may therefore be warranted, but must be weighed against increased toxicity and greater time investment.

Use of palliative radiotherapy trials for clinical biomarker development

INTRODUCTION

Approximately one quarter of all cancer patients will require palliative radiation treatment at some point during the course of their disease, but only a minority of these patients are entered in clinical trials.

ETHICAL ASSESSMENT OF BIOMARKERS IN PALLIATIVE RADIOTHERAPY TRIALS

We review the literature debating the ethics of inclusion of "palliative" patients on clinical trials. We suggest that these patients provide a potentially valuable resource that can be leveraged to facilitate the discovery and validation of biomarkers predictive of radiation response and toxicity. In addition, this patient population offers valuable opportunities to test combination of radiation and targeted therapies to screen for activity, toxicity and biomarkers in a relatively safe manner.

CONCLUSION

Patients undergoing palliative radiation therapy may provide new opportunities for the development and testing of predictive radiotherapy biomarkers as well as affording opportunities to test combinations of radiation and targeted therapies.

Regional Cancer Pain Syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.

Radiation Oncology Emergencies

Radiation therapy is an important and effective treatment modality when used in the management of oncologic emergencies. For any patient who has MSCC, ISCM, SVC syndrome, or life-threatening hemoptysis/obstruction, optimal management hinges on efficient multidisciplinary evaluation and communication to arrive at a treatment plan tailored to the individual patient. Optimal management may include steroids, surgery, chemotherapy, or bronchoscopic intervention. When radiation therapy is used, the total dose and fractionation schedule should be tailored to the disease setting and life expectancy of the patient.

Weekly docetaxel with concurrent radiotherapy in locally advanced non-small cell lung cancer: a phase I/II study with 5 years' follow-up

This Phase I/II study investigated weekly docetaxel (Taxotere) with concurrent radiotherapy in 42 patients with untreated stage III non-small cell lung cancer (NSCLC). All patients were treated with chest irradiation: 2Gy administered 5 days/week for 5 weeks, to a total of 50Gy. Docetaxel (1-h infusion) was administered on days 1, 8, 22, and 29< or =2 h before radiation fractions 1, 6, 16, and 21 (i.e. every week excluding the third week of treatment). In the Phase I study (n=12), docetaxel was started at 20 mg/m2 per week (n=3) and escalated in 10 mg/m2 increments (30 mg/m2, n=3; 40 mg/m2, n=6). Dose-limiting toxicity (grade 3-4 esophagitis) occurred with docetaxel 40 mg/m2. The Phase II study (n=30), therefore, evaluated docetaxel 30 mg/m2 (considered recommended dose). All patients except one experienced asymptomatic grade 3-4 lymphopenia; four patients (9.5%) had grade 3-4 esophagitis. The overall response rate was 45.5%, with eight (24.2%) complete responses. The median time to progression at the recommended dose of 30 mg/m2 (n=33) was 12.0 months and the median survival time was 13.6 months. The 1-year survival rate was 60.6%. Five patients (one from Phase I and four from Phase II) were alive after >5 years. In conclusion, weekly docetaxel 30 mg/m2 plus radiotherapy is active and well tolerated in stage III NSCLC.

Immediate or delayed radiotherapy in advanced non-small cell lung cancer (NSCLC)? Data from a prospective randomised study

BACKGROUND AND PURPOSE

To compare the course of symptoms and health-related quality-of-life (HRQOL) after immediate thoracic radiotherapy (TRT) between symptomatic (S) and non-symptomatic (NS) patients with advanced NSCLC.

PATIENTS AND METHODS

407 stage III/IV patients were initially treated with immediate TRT within a randomised phase III trial comparing different fractionation schedules. At inclusion, patients were prospectively stratified according to presence (S) or absence (NS) of tumour-related chest/airway symptoms to facilitate comparison between these groups. The EORTC QLQ-C30 and LC-13 were used for symptom and HRQOL assessments at baseline and at regular intervals up to 1 year (N=395).

RESULTS

NS patients had significantly more favourable baseline characteristics when compared to S patients with a median survival of 11.8 versus 6.0 months (P<0.0001), respectively. At baseline, S patients demonstrated HRQOL scores inferior to those of NS patients (P<0.01) for most scales. Until week 14, NS patients developed more symptoms while S patients experienced symptom relief in most scales. After week 14, no significant differences could be observed between the groups.

CONCLUSION

This study indicates that immediate TRT, given to patients with minimal/none chest symptoms, does not prevent development of disease-related symptoms and diminished HRQOL. A wait-and-see policy appears to be acceptable.