Definitive radiotherapy alone over 60 Gy for patients unfit for combined treatment to stage II-III non-small cell lung cancer: retrospective analysis

Prospective multicentre analysis of the therapeutic approach and prognostic factors determining overall survival in elderly patients with non-small-cell lung carcinoma treated with curative intent

Objective

To analyse patterns of treatment with curative intent commonly used in elderly patients with locally advanced non-small-cell lung carcinoma (NSCLC) and predictive factors of overall survival in routine clinical practice.

Methods

This multicentre prospective study included consecutive patients aged ≥65 years old diagnosed with NSCLC between February 2014 and January 2018. Inclusion criteria: age ≥65 years, stage IIIA/IIIB NSCLC. Treatment decisions were taken by a multidisciplinary committee. Kaplan-Meier curves and log-rank test were used to identify which clinical/treatment-associated variables, or pre-treatment quality of life (QOL) considering EORTC QLQ-C30 (and LC13 module) were predictive of overall survival.

Results

A total of 139 patients were recruited. Median follow-up was 9.9 months (1.18-57.36 months) with a median survival of 14 months (range 11-17 months). In the group>75-year-old patients, the committee recommended chemotherapy and sequential radiotherapy (55.6%) or radiotherapy alone (22.2%), rather than surgery (3.7%) or concomitant radiochemotherapy (16.5%). However, in 65- to 75-year-old patients, surgery and concomitant radiochemotherapy were recommended in half of cases (p=0.003). Regarding multivariate analysis, the risk of death was higher in patients with pre-existing heart disease (p=0.002), low score for physical functioning (p=0.0001), symptoms of dysphagia (p=0,01), chest pain (p=0.001), and those not undergoing surgical treatment (p=0.024).

Conclusions

Patients >75 years received more conservative treatments. Surgery improved survival and should be carefully considered, regardless of patient age. Comorbidities and poor baseline QOL are predictive of shorter survival.

Advances in knowledge

Measuring these parameters before treatment may help us to define a population of frail patients with a poorer prognosis to facilitate decision making in clinical practice.

Spontaneous regression of ALK fusion protein-positive non-small cell lung carcinoma: a case report and review of the literature

BACKGROUND

ALK-rearrangement is observed in < 5% non-small cell lung cancer (NSCLC) cases and prior to the advent of oral tyrosine kinase inhibitors, the natural history of oncogenic NSCLC was typically poor. Literature relating to regression of treatment-naïve NSCLC is limited, and regression without treatment has not been noted in the ALK-rearranged sub-population.

CASE PRESENTATION

A 76 year old 'never smoker' female with an ALK-rearranged left upper lobe T2 N0 NSCLC experienced a stroke following elective DC cardioversion for new atrial fibrillation. Following a good recovery, updated imaging demonstrated complete regression of the left upper lobe lesion and a reduction of the previously documented mediastinal lymph node. Remaining atelectasis was non-avid on repeat PET-CT imaging, 8 months from the baseline PET-CT. When the patient developed new symptoms 6 months later a further PET-CT demonstrated FDG-avid local recurrence. She completed 55 Gy in 20 fractions but at 18 months post-radiotherapy there was radiological progression in the lungs with new pulmonary metastases and effusion and new bone metastases. Owing to poor performance status, she was not considered fit for targeted therapy and died 5 months later.

CONCLUSION

All reported cases of spontaneous regression in lung cancer have been collated within. Documented precipitants of spontaneous regression across tumour types include biopsy and immune reconstitution; stroke has not been reported previously. The favourable response achieved with radical radiotherapy alone in this unusual case of indolent oncogenic NSCLC reinforces the applicability of radiotherapy in locally advanced ALK-rearranged tumours, in cases not behaving aggressively. As a common embolic event affecting the neurological and pulmonary vasculature is less likely, an immune-mediated mechanism may underpin the phenomenon described in this patient, implying that hitherto unharnessed principles of immuno-oncology may have relevance in oncogenic NSCLC. Alternatively, high electrical voltage applied percutaneously adjacent to the tumour during cardioversion in this patient may have induced local tumour cell lethality.

Population-based analysis of curative therapies in stage II non-small cell lung cancer: the role of radiotherapy in medically inoperable patients

OBJECTIVES

Curative intent therapy of stage II NSCLC may include surgical resection or definitive radiotherapy. Primary management with surgery or radiotherapy may be influenced by patient and disease characteristics. We sought to perform a comparison of patients receiving surgery or radical radiation therapy as their curative treatment, and explore the impact of known prognostic factors on outcome.

MATERIALS AND METHODS

A retrospective review was completed of all patients with stage II NSCLC referred to the BC Cancer Agency from 2005 to 2012. Cases were filtered to identify those receiving curative intent therapy including surgery or radiotherapy. Information was collected on known prognostic and predictive factors. The primary outcome measure was overall survival. We compared survival among patients receiving curative intent radiotherapy versus surgical intervention.

RESULTS

A total of 535 patients were referred. Of these, 245 (46%) received curative intent surgery, 132 (25%) curative intent radiotherapy, and 158 (30%) did not receive curative therapy. There were significant differences between cohorts with respect to median age, histology, ECOG PS, smoking status, and weight loss. Median OS was significantly different between cohorts: 61.4 m surgery, 26.5 m curative RT, and 13.1 m non-curative therapy. In a case-matched analysis, median OS remained superior for surgery at 101.6 m vs 28.1 m for curative RT. In a multivariate analysis, ECOG PS, weight loss, and treatment cohort all influenced survival. Among patients receiving curative intent radiotherapy, the use of concurrent chemotherapy and RT dose > = 60Gy were associated with improved outcomes.

CONCLUSIONS

Among patients with stage II NSCLC, many are unable to undergo standard of care surgical resection. Radiotherapy provides an inferior yet still curative option in the management of inoperable patients. Further work is needed to optimize outcomes in this population.

Moderately Hypofractionated Radiotherapy Alone for Stage I-IIB Non-small Cell Lung Cancer

INTRODUCTION

The optimal management of patients with early non-small cell lung cancer (NSCLC) not amenable to surgical resection or stereotactic body radiotherapy (SBRT) or those with hilar nodal involvement ineligible for surgery or concurrent chemoradiotherapy is unclear. This report describes survival outcomes and toxicity profiles of patients treated with hypofractionated radiotherapy (HRT) alone.

METHODS

A total of 52 patients with Stage I-IIB NSCLC treated with HRT alone between 2010-2018 were reviewed. Patients were categorized as having ultracentral tumors if the planning target volume contacted or overlapped the proximal bronchial tree, esophagus, pulmonary vein or artery. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method and the competing risk cumulative incidence of locoregional failure (LRF) and distant failure (DF) were estimated using death without failure as a competing risk. Pneumonitis and esophagitis rates were evaluated as per Acute Common Terminology Criteria for Adverse Events (CTCAE) version 4.0.

RESULTS

Of the 52 patients analyzed, 50 patients were treated with radiotherapy alone to a dose of 70.2 Gy in 26 fractions, one patient was treated with 68 Gy in 25 fractions and one patient was treated with 65 Gy in 26 fractions. The median age was 72 (range 48-89), 42% of patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 2-3, 46% were stage I and 54% were stage II. Hilar nodal involvement was present in 21% of patients and 74% of node-negative patients had ultracentral primary tumors. Median OS was 39.6 months and the median PFS was 21.0 months. Overall three-year cumulative incidence of LRF and DF were 32% and 34%, respectively. Grade 3 pneumonitis occurred in two (4%) patients. No grade 3+ acute esophagitis or grade 4-5 toxicities were observed.

CONCLUSION

Hypofractionated thoracic radiotherapy consisting of 70.2 Gy is well-tolerated and results in favorable locoregional control for stage I-IIB patients who are not candidates for SBRT, surgery, or concurrent chemoradiotherapy.

Assessment and management of radiotherapy induced toxicity in older patients

Radiotherapy is an attractive treatment option for older adults, especially where surgery and chemotherapy pose too great a risk. Radiotherapy toxicity may be divided into acute/early and late effects of treatment. The latter may have limited relevance to an older patient with competing causes of mortality due to significant comorbidity. Altered fractionation regimes have been employed in numerous sites, with no significant toxicity impact. These offer greater convenience in the elderly, especially those with limited social support or in active caregiving roles. As radiotherapy toxicity is site specific, it's important to assess baseline function via Comprehensive Geriatric Assessment (CGA), and any pre-existing comorbidities that may influence toxicity. With modern radiotherapy technology and capabilities, these are less of an issue and radiotherapy is a very suitable treatment option for the older adult. When evaluating the literature on toxicity in older patients, it's important to recognise that older studies do not represent modern day radiotherapy techniques and capabilities. Advanced technology may simultaneously deliver enhanced target coverage and reduced toxicity. More research is required related to the predictive power of CGA in linking radiotherapy toxicity to frailty. What little evidence exists shows that CGA has a role in treatment of older patients with radiotherapy and that, in general, radiotherapy appears to be well tolerated in older adults. The purpose of this review is to provide a broad overview of the mechanisms of normal tissue reactions to radiotherapy and how radiation induced toxicity may affect older patients.

Radical Treatment of Stage II Non-small-cell Lung Cancer With Nonsurgical Approaches: A Multi-institution Report of Outcomes

INTRODUCTION

Standard management of stage II non-small-cell lung cancer (NSCLC) is surgery, often followed by adjuvant chemotherapy. However, some patients do not undergo surgery for various reasons. We examined outcomes in this defined patient group.

METHODS

We reviewed the records of patients with stage II NSCLC treated nonsurgically with curative intent from 2002 to 2012 across 3 academic cancer centers. Data collected included demographics, comorbidities, staging, treatments, and survival. The primary endpoint was overall survival (OS). We assessed factors associated with treatment choice and OS.

RESULTS

A total of 158 patients were included: the median age was 74 years (range, 50-91 years), 44% were female, and 68% had a performance status of 0 to 1. The stage II groupings of the patients were T2b-T3 N0 in 55% and N1 in 45%. The most common reasons for inoperability were inadequate pulmonary reserve (27%) and medical comorbidities (24%). All patients received radical radiotherapy (RT) (median, 60 Gy [range, 48-75 Gy]). Seventy-three percent received RT alone; 24% received concurrent and 3% sequential chemoradiotherapy (CRT). In multivariate analyses, CRT was less likely in older patients (≥ 70 years) (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11-0.70; P = .006) and in patients with higher (> 5) Charlson comorbidity scores (OR, 0.34; 95% CI, 0.13-0.90; P = .03) or normal (< 10 × 10⁹/L) white blood cell counts (OR, 0.26; 95% CI, 0.09-0.73; P = .01). At the time of our analysis, 74% have died. The median OS was 22.9 months (range, 17.1-26.6 months). Patients who had undergone CRT had a significantly longer median OS than those receiving RT alone (39.1 vs. 20.5 months; P = .0019), confirmed in multivariate analysis (hazard ratio, 0.38; 95% CI, 0.21-0.69; P = .001).

CONCLUSION

Nonsurgical approaches to management of stage II NSCLC are varied. Treatment with CRT was associated with significantly longer survival compared with RT alone. A randomized trial may be warranted.

Radical hypo-fractionated radiotherapy with volumetric modulated arc therapy in lung cancer : A retrospective study of elderly patients with stage III disease

BACKGROUND

This study aimed to analyse the feasibility and acute toxicity of radical hypo-fractionated radiotherapy (RT) for elderly patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We conducted a retrospective evaluation of treatment with volumetric modulated arc therapy (VMAT) of elderly patients affected by stage III inoperable NSCLC. The dose prescription was 56 Gy in 20 fractions, 55 Gy in 22 fractions, or 50 Gy in 20 fractions. Target volume included only the primary lesion and the infiltrated lymph nodes. The primary end point was acute and late toxicity, while secondary end points were progression-free survival (PFS), and overall survival (OS).

RESULTS

In all, 41 patients were included in this analysis. The mean age of the patients was 78.6 years, and 22 patients had staged IIIA while 19 patients had stage IIIB disease. All but one patient had pathological nodal involvement; 15 patients received chemotherapy before RT. Acute grade 1-2 toxicity was recorded in 25 (61%) patients. Late toxicity was recorded in 13 (32%) patients. No cases of G3 or G4 toxicity were recorded. Complete response was obtained in two (5%) patients, 26 (63%) showed a partial response, and two (5%) experience disease progression. At a mean follow-up of 9.9 months (range, 1.1-25.4), 17 patients had died from disease progression, one died from other causes, and 23 were alive. Median OS was 13.7 ± 1.5 months (95% CI: 10.7-16.7), OS at 12 and 18 months was 51.3 ± 9.5% and 35.1 ± 10.1%, respectively. Median PFS was 13.7 ± 2.3 months (95% CI: 9.1-18.2), and PFS at 12 and 18 months was 50.1 ± 9.9% and 38.9 ± 10.4%, respectively.

CONCLUSION

Radical hypo-fractionated VMAT is a promising treatment for locally advanced NSCLC in the elderly. The use of hypo-fractionated radiotherapy for lung cancer in older patients can be considered a valuable approach, particularly for patients with poor performance status or refusing other treatment approaches.

Stage III Non-Small Cell Lung Cancer in the elderly: Patient characteristics predictive for tolerance and survival of chemoradiation in daily clinical practice

BACKGROUND

In unselected elderly with stage III Non-Small Cell Lung Cancer (NSCLC), evidence is scarce regarding motives and effects of treatment modalities.

METHODS

Hospital-based multicenter retrospective study including unresectable stage III NSCLC patients aged ⩾70 and diagnosed between 2009 and 2013 (N=216). Treatment motives and tolerance (no unplanned hospitalizations and completion of treatment), and survival were derived from medical records and the Netherlands Cancer Registry.

RESULTS

Patients received concurrent chemoradiation (cCHRT, 33%), sequential chemoradiation (sCHRT, 24%), radical radiotherapy (RT, 16%) or no curative treatment (27%). Comorbidity, performance status (58%) and patient refusal (15%) were the most common motives for omitting cCHRT. Treatment tolerance for cCHRT and sCHRT was worse in case of severe comorbidity (OR 6.2 (95%CI 1.6-24) and OR 6.4 (95%CI 1.8-22), respectively). One-year survival was 57%, 50%, 49% and 26% for cCHRT, sCHRT, RT and no curative treatment, respectively. Compared to cCHRT, survival was worse for no curative treatment (P=0.000), but not significantly worse for sCHRT and RT (P=0.38).

CONCLUSION

Although relatively fit elderly were assigned to cCHRT, treatment tolerance was worse, especially for those with severe comorbidity. Survival seemed not significantly better as compared to sCHRT or RT. Prospective studies in this vital and understudied area are needed.

Approach to the non-operative management of patients with stage II non-small cell lung cancer (NSCLC): A survey of Canadian medical and radiation oncologists

BACKGROUND AND OBJECTIVES

Standard management of stage II non-small cell lung cancer (NSCLC) is surgery, often followed by adjuvant chemotherapy. However, some patients do not undergo surgery for various reasons. The optimal non-surgical management of stage II NSCLC is undefined. We surveyed Canadian oncologists to understand current practices.

MATERIALS AND METHODS

Canadian oncologists specializing in the management of lung cancer were invited by email to complete an anonymous, online survey developed by the research team. Physician demographics were recorded. Physicians were asked to comment on their practice and make treatment choices in eight clinical scenarios of inoperable stage II NSCLC.

RESULTS

Responses were received from 81/194 physicians (42% response rate), 57% medical and 42% radiation oncologists. Most physicians (90%) had a practice with at least 25% lung cancer patients and 85% were based at an academic institution. Across eight clinical patient scenarios, radical therapy was selected 79-98% of the time. Radical radiotherapy alone and concurrent chemoradiotherapy were the preferred options for these patients, while sequential chemoradiation was less favoured. Nodal status (N0 vs N1) did not influence choice of therapy (p 0.31), but the reason for patient inoperability did (p<0.0001). There was no significant difference in choice of therapy when comparing responses between medical vs radiation oncologists, academic vs community physicians, and physicians with high vs low proportion of lung cancer patients.

CONCLUSION

Most lung cancer physicians manage inoperable stage II NSCLC patients with curative intent, but consensus on how to optimally employ radiotherapy and/or chemotherapy is lacking. Future prospective, randomized trials are warranted.