1
|
Li H, Zhao Y, Ma T, Shao H, Wang T, Jin S, Liu Z. Radiotherapy for extensive-stage small-cell lung cancer in the immunotherapy era. Front Immunol 2023; 14:1132482. [PMID: 37701437 PMCID: PMC10493776 DOI: 10.3389/fimmu.2023.1132482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 08/01/2023] [Indexed: 09/14/2023] Open
Abstract
Currently, chemoimmunotherapy is the first-line treatment for extensive-stage small-cell lung cancer (ES-SCLC). However, only 0.8%-2.5% of the patients presented complete response after chemoimmunotherapy. Considering that ES-SCLC is highly sensitive to radiotherapy, the addition of radiotherapy after first-line treatment for ES-SCLC could further improve local control, which may be beneficial for patients' survival. Prior studies have shown that consolidative thoracic radiotherapy (cTRT) can decrease disease progression and improve overall survival in patients with ES-SCLC who respond well to chemotherapy. However, the efficacy and safety of cTRT in the immunotherapy era remain unclear owing to a lack of prospective studies. Prophylactic cranial irradiation (PCI) has been shown to decrease brain metastasis (BM) and prolong survival in patients with limited-stage SCLC in previous reports. However, according to current guidelines, PCI is not commonly recommended for ES-SCLC. Immunotherapy has the potential to reduce the incidence of BM. Whether PCI can be replaced with regular magnetic resonance imaging surveillance for ES-SCLC in the era of immunotherapy remains controversial. Whole brain radiation therapy (WBRT) is the standard treatment for BM in SCLC patients. Stereotactic radiosurgery (SRS) has shown promise in the treatment of limited BM. Considering the potential of immunotherapy to decrease BM, it is controversial whether SRS can replace WBRT for limited BM in the immunotherapy era. Additionally, with the addition of immunotherapy, the role of palliative radiotherapy may be weakened in patients with asymptomatic metastatic lesions. However, it is still indispensable and urgent for patients with obvious symptoms of metastatic disease, such as spinal cord compression, superior vena cava syndrome, lobar obstruction, and weight-bearing metastases, which may critically damage the quality of life and prognosis. To improve the outcome of ES-SCLC, we discuss the feasibility of radiotherapy, including cTRT, PCI, WBRT/SRS, and palliative radiotherapy with immunotherapy based on existing evidence, which may offer specific prospects for further randomized trials and clinical applications.
Collapse
Affiliation(s)
- Huanhuan Li
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Yangzhi Zhao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Tiangang Ma
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Hao Shao
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Tiejun Wang
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Shunzi Jin
- NHC Key Laboratory of Radiobiology, Jilin University, Changchun, China
| | - Zhongshan Liu
- Department of Radiation Oncology, The Second Affiliated Hospital of Jilin University, Changchun, China
| |
Collapse
|
2
|
Kassik MT, Vordermark D, Kornhuber C, Medenwald D. Factors associated with overall survival, progression-free survival and toxicity in patients with small cell lung cancer and thoracic irradiation in a clinical real-world setting. Radiat Oncol 2023; 18:70. [PMID: 37072833 PMCID: PMC10114406 DOI: 10.1186/s13014-023-02252-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 03/29/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Small-cell lung cancer (SCLC) is a malignant tumor known for its poor prognosis. In addition to chemotherapy and immunotherapy irradiation plays a big role especially in inoperability. This study evaluated prognostic factors in patients with SCLC, receiving chemotherapy and thoracic irradiation, that may affect overall survival (OS), progression-free survival (PFS) and toxicity. METHODS Patients with limited disease (LD) SCLC (n = 57) and extensive disease (ED) SCLC (n = 69) who received thoracic radiotherapy were analyzed retrospectively. The prognostic factors sex, age, Karnofsky performance status (KPS), tumor-, nodal-stage and timepoint of start of irradiation in relation to the first cycle of chemotherapy were evaluated. Start of irradiation was stratified as early ([Formula: see text] 2 cycles of chemotherapy), late (3 or 4 cycles) and very late ([Formula: see text] 5 cycles). Results were analyzed by Cox univariate and multivariate as well as logistic regression analysis. RESULTS The median OS of LD-SCLC patients was 23.7 months in early, and 22.0 months in late start of irradiation. In very late start, median OS was not reached. PFS was 11.8, 15.2 and 47.9 months, respectively. In patients with ED-SCLC OS was 4.3 months in early, 13.0 months in late and 12.2 months in very late start of irradiation. PFS was 6.7, 13.0 and 12.2 months, respectively. Prognosis of patients with LD- or ED-SCLC receiving late or very late start of irradiation was significantly prolonged in OS and PFS compared to an early start (p < 0.05). KPS [Formula: see text] 80 shows a significant increase of OS and PFS in ED-SCLC. Female sex and smaller mean lung dose were associated with lower risk of toxicity. CONCLUSION Late or very late start of irradiation is a prognosis-enhancing factor in LD-SCLC and ED-SCLC for OS and PFS. KPS [Formula: see text] 80 increases prognosis of OS and PFS in ED-SCLC as well. Toxicity is less common in female sex and patients with low mean lung dose in LD-SCLC.
Collapse
Affiliation(s)
- Marie-Theres Kassik
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Dirk Vordermark
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Christine Kornhuber
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Daniel Medenwald
- Department of Radiation Therapy, University Hospital Halle/Saale, Ernst-Grube-Str. 40, 06120, Halle, Germany.
| |
Collapse
|
3
|
Stokes M, Berfeld N, Gayle A, Descoteaux A, Rohrmoser O, Franks A. A systematic literature review of real-world treatment outcomes of small cell lung cancer. Medicine (Baltimore) 2022; 101:e29783. [PMID: 35777024 PMCID: PMC9239604 DOI: 10.1097/md.0000000000029783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Robust evidence from real-world studies is needed to aid decision-makers and other stakeholders in choosing the best treatment options for patients. The objective of this work was to assess real-world outcomes of treatment strategies for limited- and extensive-stage small cell lung cancer (SCLC) prior to the global introduction of immunotherapies for this disease. METHODS Searches were conducted in MEDLINE and Embase to identify articles published in English from October 1, 2015, through May 20, 2020. Searches were designed using a combination of Medical Subject Heading (Medline), Emtree (Embase subject headings), and free-text terms such as SCLC. Observational studies reporting data on outcomes of initial treatment strategies in patients with limited- and extensive-stage SCLC were included. Studies with limited sample sizes (<100 patients), enrolled all patients prior to 2010, or did not report outcomes for limited- and extensive-stage SCLC separately were excluded. Data were extracted into a predesigned template by a single researcher. All extractions were validated by a second researcher, with disagreements resolved via consensus. RESULTS Forty articles were included in this review. Most enrolled patients from the United States (n = 18 articles) or China (n = 12 articles). Most examined limited-stage (n = 27 articles) SCLC. All studies examined overall survival as the primary outcome. Articles investigating limited-stage SCLC reported outcomes for surgery, chemotherapy and/or radiotherapy, and adjuvant prophylactic cranial irradiation. In studies examining multiple treatment strategies, chemoradiotherapy was the most commonly utilized therapy (56%-82%), with chemotherapy used in 18% to 44% of patients. Across studies, median overall survival was generally higher for chemoradiotherapy (15-45 months) compared with chemotherapy alone (6.0-15.6 months). Studies of extensive-stage SCLC primarily reported on chemotherapy alone, consolidative thoracic radiotherapy, and radiotherapy for patients presenting with brain metastases. Overall survival was generally lower for patients receiving chemotherapy alone (median: 6.4-16.5 months; 3 years, 5%-14.9%) compared with chemotherapy in combination with consolidative thoracic radiotherapy (median: 12.1-18.0 months; 3 years, 15.0%-18.1%). Studies examining whole-brain radiotherapy for brain metastases reported lower median overall survival (5.6-8.7 months) compared with stereotactic radiosurgery (10.0-14.5 months). CONCLUSIONS Under current standard of care, which has remained relatively unchanged over the past few decades, prognosis remains poor for patients with SCLC.
Collapse
Affiliation(s)
| | | | - Alicia Gayle
- AstraZeneca, Cambridge, United Kingdom
- *Correspondence: Alicia Gayle, Epidemiology, AstraZeneca, OBU, Global Medical Affairs, Global Real World Evidence Generation, City House, 126–130 Hills Road, Cambridge CB2 1RY, United Kingdom (e-mail: )
| | | | | | - April Franks
- AstraZeneca, Gaithersburg, Maryland, United States
| |
Collapse
|
4
|
Radiation therapy for extensive-stage small-cell lung cancer in the era of immunotherapy. Cancer Lett 2022; 541:215719. [PMID: 35597478 DOI: 10.1016/j.canlet.2022.215719] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 12/23/2022]
Abstract
Unlike non-small-cell lung cancer (NSCLC), the progression of small-cell lung cancer (SCLC) is slow. Extensive-stage SCLC (ES-SCLC) is a serious threat to human health, with a 5-year survival rate of <7%. Chemotherapy has been the first-line treatment for the past 30 years. The anti-PD-L1 checkpoint blockades durvalumab and atezolizumab have greatly prolonged overall survival and have become the standard first-line therapy for ES-SCLC since the CASPIAN and IMpower133 trials. In the era of chemotherapy, radiation therapy (RT), including thoracic radiation therapy (TRT) and brain radiation therapy (BRT), has shown clinical effects in randomized and retrospective studies on ES-SCLC. RT-immunotherapy has shown exciting synergistic effects in NSCLC. For ES-SCLC, the clinical effects of combining TRT/BRT with immunotherapy have not yet been systematically explored. In this review, we found that studies on RT-immunotherapy in ES-SCLC are relatively few and limited to early phase studies focusing on toxicity. The efficacy and safety profiles of early phase studies encourage prospective clinical trials. In this review, we discuss the best population, optimum TRT dose, proper TRT time, and strategies for reducing radiation-induced neurotoxicity. Furthermore, we suggest that biomarkers and patient performance status should be fully assessed before RT-immunotherapy treatment. Prospective trials are needed to provide more evidence for RT-immunotherapy applications in ES-SCLC.
Collapse
|
5
|
Niu Z, Guo S, Cao J, Zhang Y, Guo X, Grossi F, Ichiki Y, Li Y, Wang Z. Immune checkpoint inhibitors for treatment of small-cell lung cancer: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:705. [PMID: 33987403 PMCID: PMC8106042 DOI: 10.21037/atm-21-1423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background Small cell lung cancer (SCLC) is a very aggressive and proliferative disease, with little progress being having made for its treatment in decades. Our goal was to evaluate the effect of immune checkpoint inhibitors (ICIs) and identify optimal first-line interventions for the treatment of SCLC. Methods A systematic literature search of the Cochrane Library, PubMed and oncology conference proceedings were conducted. Randomized trials evaluating ICIs for SCLC were included. We use the risk of bias tool in RevMan 5.3 to assess the quality of studies. We used Stata version 15.0 to carry out data direct comparison and R version 4.0.2 to conduct the Bayesian network analysis. Results A total of 16 relevant clinical trials comprising 4,476 patients were included. We found the magnitude of efficacy for ICIs as first-line therapy conferred a statistically significant benefit in overall survival (OS) and progression-free survival compared to chemotherapy alone. The results were 0.82 (95% CI, 0.76–0.89, P<0.001) and 0.80 (95% CI, 0.74–0.86, P<0.001). For objective response rate (ORR), the result (1.13, 95% CI, 0.97–1.31, P=0.109) was not significant. In the second-line and maintenance treatment, no additional benefit was observed. With regard to safety, results showed that for all grades of AEs and grades 3–4 AEs, the pooled results were 1.36 (95% CI: 0.50–3.70; P=0.543) and 1.35 (95% CI: 0.58–3.15; P=0.484) respectively. In addition, the indirect comparison results showed that nivolumab combined with chemotherapy led to the most significant improvement in OS, while durvalumab combined with chemotherapy was a more efficacious therapy for improving ORR compared with the other interventions; the probability were the best treatments was 73.93% and 81% respectively. Discussion Our results showed ICIs combined with etoposide and platinum-based drugs as first-line treatment of SCLC have benefits for patients and there was no evidence of a significant difference in efficacy among the different ICI drugs used for the first-line therapy. As for toxicity, the ICIs did not increase the frequency AEs for patients. However, as some studies are ongoing and the full data have still not been reported, our conclusions may not be completely representative.
Collapse
Affiliation(s)
- Zhicheng Niu
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shenghu Guo
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jing Cao
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yuehua Zhang
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaojin Guo
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Francesco Grossi
- Medical Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Yoshinobu Ichiki
- Department of General Thoracic Surgery, National Hospital Organization, Saitama Hospital, Wako, Japan.,Second Department of Surgery, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - You Li
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiyu Wang
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
6
|
Couñago F, de la Pinta C, Gonzalo S, Fernández C, Almendros P, Calvo P, Taboada B, Gómez-Caamaño A, Guerra JLL, Chust M, González Ferreira JA, Álvarez González A, Casas F. GOECP/SEOR radiotherapy guidelines for small-cell lung cancer. World J Clin Oncol 2021; 12:115-143. [PMID: 33767969 PMCID: PMC7968106 DOI: 10.5306/wjco.v12.i3.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Small cell lung cancer (SCLC) accounts for approximately 20% of all lung cancers. The main treatment is chemotherapy (Ch). However, the addition of radiotherapy significantly improves overall survival (OS) in patients with non-metastatic SCLC and in those with metastatic SCLC who respond to Ch. Prophylactic cranial irradiation reduces the risk of brain metastases and improves OS in both metastatic and non-metastatic patients. The 5-year OS rate in patients with limited-stage disease (non-metastatic) is slightly higher than 30%, but less than 5% in patients with extensive-stage disease (metastatic). The present clinical guidelines were developed by Spanish radiation oncologists on behalf of the Oncologic Group for the Study of Lung Cancer/Spanish Society of Radiation Oncology to provide a current review of the diagnosis, planning, and treatment of SCLC. These guidelines emphasise treatment fields, radiation techniques, fractionation, concomitant treatment, and the optimal timing of Ch and radiotherapy. Finally, we discuss the main indications for reirradiation in local recurrence.
Collapse
Affiliation(s)
- Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, Hospital La Luz, Universidad Europea de Madrid, Madrid 28223, Madrid, Spain
| | - Carolina de la Pinta
- Department of Radiation Oncology, Hospital Universitario Ramón y Cajal, Madrid 28034, Spain
| | - Susana Gonzalo
- Department of Radiation Oncology, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, GenesisCare Madrid, Madrid 28043, Spain
| | - Piedad Almendros
- Department of Radiation Oncology, Hospital General Universitario, Valencia 46014, Spain
| | - Patricia Calvo
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Begoña Taboada
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - Antonio Gómez-Caamaño
- Department of Radiation Oncology, Hospital Clínico Universitario Santiago de Compostela, Santiago de Compostela 15706, Spain
| | - José Luis López Guerra
- Department of Radiation Oncology, Hospital Universitario Virgen del Rocío, Sevilla 41013, Spain
| | - Marisa Chust
- Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología, Valencia 46009, Spain
| | | | | | - Francesc Casas
- Department of Radiation Oncology, Thoracic Unit, Hospital Clinic, Barcelona 08036, Spain
| |
Collapse
|
7
|
Han J, Fu C, Li B. Clinical outcomes of extensive-stage small cell lung cancer patients treated with thoracic radiotherapy at different times and fractionations. Radiat Oncol 2021; 16:47. [PMID: 33663551 PMCID: PMC7934361 DOI: 10.1186/s13014-021-01773-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Objective The purpose of this study was to assess whether thoracic radiotherapy (TRT) combined with chemotherapy (CHT) showed promising anti-tumour activity in extensive-stage small cell lung cancer (ES-SCLC), to explore practice patterns for the radiation time and dose/fractionation and to identify prognostic factors for patients who would benefit from CHT/TRT. Methods A total of 492 ES-SCLC patients were included from January 2010 to March 2019, 244 of whom received CHT/TRT. Propensity score matching was performed to minimize bias between the CHT/TRT and CHT-alone groups. Patients in the CHT/TRT group were categorized into four subgroups based on the number of induction CHT cycles. For effective dose fractionation calculations, we introduced the time-adjusted biological effective dose (tBED). Categorical variables were analysed with chi-square tests and Fisher’s exact tests. Kaplan–Meier curves were generated to estimate survival rates using the R-project. Multivariate prognostic analysis was performed with Cox proportional hazards models. Results Patients who received CHT/TRT experienced improved overall survival (OS) (18.1 vs 10.8 months), progression-free survival (PFS) (9.3 vs 6.0 months) and local recurrence-free survival (LRFS) (12.0 vs 6.6 months) before matching, with similar results after matching. In the CHT/TRT group, the median LRFS times for the groups based on the radiation time were 12.7, 12.0, 12.0, and 9.0 months, respectively. Early TRT had a tendency to prolong PFS (median 10.6 vs 9.8 vs 9.0 vs 7.7 months, respectively, p = 0.091) but not OS (median 17.6 vs 19.5 vs 17.2 vs 19.0 months, respectively, p = 0.622). Notably, patients who received TRT within 6 cycles of CHT experienced prolonged LRFS (p = 0.001). Regarding the radiation dose, patients in the high-dose group (tBED > 50 Gy) who achieved complete response and partial response (CR and PR) to systemic therapy had relatively short OS (median 27.1 vs 22.7, p = 0.026) and PFS (median 11.4 vs 11.2, p = 0.032), but the abovementioned results were not obtained after the exclusion of patients who received hyperfractionated radiotherapy (all p > 0.05). Conclusion CHT/TRT could improve survival for ES-SCLC patients. TRT performed within 6 cycles of CHT and hyperfractionated radiotherapy (45 Gy in 30 fractions) may be a feasible treatment scheme for ES-SCLC patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01773-x.
Collapse
Affiliation(s)
- Jinmin Han
- Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China
| | - Chengrui Fu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.,Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, 300060, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong, China.
| |
Collapse
|
8
|
Li AM, Zhou H, Xu YY, Ji XQ, Wu TC, Yuan X, Jiang CC, Zhu XX, Zhan P, Shen ZT. Role of thoracic radiotherapy in extensive stage small cell lung cancer: a systemic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:299. [PMID: 33708926 PMCID: PMC7944300 DOI: 10.21037/atm-20-5765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background The role of thoracic consolidation radiotherapy in patients with extensive stage small cell lung cancer (ES-SCLC) remains controversial. This study aimed to evaluate the efficacy of thoracic radiotherapy (TRT) in these patients. Methods A systematic literature search was performed in PubMed, Embase, and the Cochrane library to identify qualified clinical studies. The hazard ratios (HRs) and 95% confidence intervals (CIs) of overall survival (OS), progression-free survival (PFS) and local recurrence-free survival (LRFS) were extracted, and toxicity of the TRT group versus non-TRT group was analyzed. Results A total of 12 studies were included in this meta-analysis, including 936 patients in the TRT group and 1,059 patients in the non-TRT group. The combined results showed that TRT significantly improved OS (HR =0.65; 95% CI: 0.55–0.77, P<0.00001), PFS (HR =0.64; 95% CI: 0.56–0.72, P<0.00001) and LRFS (HR =0.38, 95% CI: 0.26–0.53, P<0.00001). Subgroup analysis showed that OS benefits were observed in patients receiving sequential TRT (HR =0.67; 95% CI: 0.54–0.84, P=0.0006). The addition of TRT significantly improved OS in patients over 65 years of age (HR =0.55; 95% CI: 0.40–0.74, P=0.0001). For patients with only one organ metastasis, there was no significant difference in OS between the two groups (HR =0.61; 95% CI: 0.36–1.01, P=0.06). There was no statistical difference in hematologic toxicity (leukopenia, thrombocytopenia, anemia) and non-hematologic toxicity (nausea or vomiting) between the two groups. The incidence of grade ≥3 esophageal toxicity was 4.6% in the TRT group and 0% in the non-TRT group (P=0.0001). Grade ≥3 bronchopulmonary toxicity was 2.9% in the TRT group and 0.8% in the non-TRT group (P=0.02). Conclusions TRT improves OS, PFS and LRFS in patients with ES-SCLC, with a low increase in esophageal and bronchopulmonary toxicity. More randomized controlled trials (RCTs) are expected to confirm our conclusions. PROSPERO registration number CRD42020190575.
Collapse
Affiliation(s)
- Ao-Mei Li
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Han Zhou
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang-Yang Xu
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Qin Ji
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tian-Cong Wu
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xi Yuan
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chang-Chen Jiang
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xi-Xu Zhu
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ping Zhan
- Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing Medical University, Nanjing, China.,Department of Respiratory and Critical Care Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ze-Tian Shen
- Department of Radiation Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| |
Collapse
|
9
|
Consolidation radiotherapy for patients with extended disease small cell lung cancer in a single tertiary institution: impact of dose and perspectives in the era of immunotherapy. Radiol Oncol 2020; 54:353-363. [PMID: 32726294 PMCID: PMC7409599 DOI: 10.2478/raon-2020-0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/04/2020] [Indexed: 12/22/2022] Open
Abstract
Background Consolidation radiotherapy (cRT) in extended disease small cell lung cancer (ED-SCLC) showed improved 2-year overall survival in patients who responded to chemotherapy (ChT) in CREST trial, however results of two meta - analysis were contradictive. Recently, immunotherapy was introduced to the treatment of ED-SCLC, making the role of cRT even more unclear. The aim of our study was to access if consolidation thoracic irradiation improves survival of ED-SCLC patients treated in a routine clinical practice and to study the impact of cRT dose on survival. We also discuss the future role of cRT in the era of immunotherapy. Patients and methods We retrospectively reviewed 704 consecutive medical records of patients with small cell lung cancer treated at the Institute of Oncology Ljubljana from January 2010 to December 2014 with median follow up of 65 months. We analyzed median overall survival (mOS) of patients with ED-SCLC treated with ChT only and those treated with ChT and cRT. We also compared mOS of patients treated with different consolidation doses and performed univariate and multivariate analysis of prognostic factors. Results Out of 412 patients with ED-SCLC, ChT with cRT was delivered to 74 patients and ChT only to 113 patients. Patients with cRT had significantly longer mOS compared to patients with ChT only, 11.1 months (CI 10.1-12.0) vs. 7.6 months (CI 6.9-8.5, p < 0.001) and longer 1-year OS (44% vs. 23%, p = 0.0025), while the difference in 2-year OS was not significantly different (10% vs. 5%, p = 0.19). The cRT dose was not uniform. Higher dose with 45 Gy (in 18 fractions) resulted in better mOS compared to lower doses 30-36 Gy (in 10-12 fractions), 17.2 months vs. 10.3 months (p = 0.03) and statistically significant difference was also seen for 1-year OS (68% vs. 30%, p = 0.01) but non significant for 2-year OS (18% vs. 5%, p = 0.11). Conclusions Consolidation RT improved mOS and 1-year OS in ED-SCLC as compared to ChT alone. Higher dose of cRT resulted in better mOS and 1-year OS compared to lower dose. Consolidation RT, higher number of ChT cycles and prophylactic cranial irradiation (PCI) were independent prognostic factors for better survival in our analysis. For patients who received cRT, only higher doses and PCI had impact on survival regardless of number of ChT cycles received. Role of cRT in the era of immunotherapy is unknown and should be exploited in further trials.
Collapse
|
10
|
Zhang R, Li P, Li Q, Qiao Y, Xu T, Ruan P, Song Q, Fu Z. Radiotherapy improves the survival of patients with extensive-disease small-cell lung cancer: a propensity score matched analysis of Surveillance, Epidemiology, and End Results database. Cancer Manag Res 2018; 10:6525-6535. [PMID: 30555258 PMCID: PMC6278721 DOI: 10.2147/cmar.s174801] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background The survival advantage of radiotherapy for patients with extensive-disease small-cell lung cancer (ED-SCLC) has not been adequately evaluated. Methods We analyzed stage IV SCLC patients enrolled from the Surveillance, Epidemiology, and End Results (SEER) registry through January 2010 and December 2012. Propensity score analysis with 1:1 matching was performed to ensure well-balanced characteristics of all comparison groups. Kaplan-Meier and Cox proportional hazardous model were used to evaluate the overall survival (OS), cancer-specific survival (CSS), and corresponding 95% CI. Results Overall, for all metastatic ED-SCLC, receiving radiotherapy was associated with both improved OS and CSS. Radiotherapy for thoracic lesion and any metastatic sites could significantly improve the OS and CSS, except for brain metastasis. For M1a-SCLC patient, radiotherapy, most likely to the primary site, significantly improved the survival (P<0.001). Furthermore, for those ED-SCLC patients with ≥ 2 metastatic sites, that is, polymetastatic ED-SCLC patients, radiation also significantly improved the median OS from 6.0 to 8.0 months (P=0.015) and the median CSS from 7.0 to 8.0 months (P=0.020). Conclusion The large SEER results support that radiotherapy in addition to chemotherapy might improve the survival of patients with metastatic ED-SCLC.
Collapse
Affiliation(s)
- Rui Zhang
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Ping Li
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Qin Li
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Yunfeng Qiao
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Tangpeng Xu
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Peng Ruan
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Qibin Song
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| | - Zhenming Fu
- Cancer Center, Renmin Hospital of Wuhan University, Wuhan 430060, China,
| |
Collapse
|
11
|
Dose escalation and associated predictors of survival with consolidative thoracic radiotherapy in extensive stage small cell lung cancer (SCLC): A National Cancer Database (NCDB) propensity-matched analysis. Lung Cancer 2018; 124:283-290. [PMID: 30268474 DOI: 10.1016/j.lungcan.2018.08.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/16/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE Randomized studies have demonstrated a survival benefit for consolidative thoracic radiotherapy (TRT) in extensive stage (ES) small cell lung cancer (SCLC), however the radiation dose and optimal selection criteria are often debated. METHODS We analyzed 3280 stage IV SCLC treated with double-agent chemotherapy and TRT within the National Cancer Data Base (NCDB) and evaluated the differences in selection patterns and survival outcomes for patients who received at least 45 Gy of TRT and those who received <45 Gy. Univariable and multivariable analyses identified characteristics predictive of overall survival. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias between the two dose arms. RESULTS There were 1621 patients in the <45 Gy group (most common 30 Gy) and 1659 patients in the 45 Gy or higher group (most common 45 Gy). White patients, T1-T3 lesions, an absence of brain/liver/bone metastases, and starting TRT after 12 weeks of chemotherapy were associated with the higher dose group. With multivariable analysis, TRT to at least 45 Gy was an independent predictor of improved survival (HR = 0.78, P < 0.001) along with female gender, age <65, lower comorbidity score, starting TRT 12 weeks after chemotherapy, and the absence of brain/liver/bone metastases (P < 0.01). Propensity adjusted regression model showed a persistent correlation between a higher dose and survival (HR = 0.74, P < 0.001). Survival at 1 and 2 years for the 45 Gy or higher arm was 58.1% and 25.2% compared to 43.8% and 15.1% for the <45 Gy arm (P < 0.001). CONCLUSION In the largest analysis of consolidative thoracic radiotherapy in ES-SCLC to date, dose escalation to at least 45 Gy was an independent predictor for increased survival. These findings may be validated in ongoing prospective studies.
Collapse
|
12
|
Glatzer M, Schmid S, Radovic M, Früh M, Putora PM. The role of radiation therapy in the management of small cell lung cancer. Breathe (Sheff) 2017; 13:e87-e94. [PMID: 29928456 PMCID: PMC6003267 DOI: 10.1183/20734735.009617] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Small cell lung cancer (SCLC) is a very aggressive form of lung cancer. SCLC treatment requires multidisciplinary management and timely treatment. Radiation therapy is an important part of management of all stages of SCLC, in the curative as well as in the palliative setting. The role of radiation therapy in all stages of SCLC has changed in recent years; this article describes these changes and highlights the role of radiation therapy in the management of SCLC.
Collapse
Affiliation(s)
- Markus Glatzer
- Dept of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Sabine Schmid
- Dept of Oncology and Haematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marco Radovic
- Dept of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Martin Früh
- Dept of Oncology and Haematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Paul Martin Putora
- Dept of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| |
Collapse
|