A randomized trial of delayed thoracic radiotherapy in complete responder patients with small-cell lung cancer. Petites Cellules Group

Clinical trial of post-chemotherapy consolidation thoracic radiotherapy for extensive-stage small cell lung cancer

BACKGROUND AND PURPOSE

To define the rate of development of symptomatic chest failures in extensive stage small cell lung cancer (ES-SCLC) after undergoing post-chemotherapy chest radiotherapy (RT).

MATERIALS AND METHODS

Patients had ES-SCLC, attained an objective response to chemotherapy and signed study consent. Target accrual was 33 patients. Patients were offered prophylactic cranial irradiation (PCI) as per department policy. PCI (25 Gy/10 fractions) and chest RT (40 Gy/15 fractions) were given simultaneously 4-8 weeks after chemotherapy completion. Thoracic target volume was the post-chemotherapy residual chest disease plus margin. Patients were evaluated for RT toxicities, local control, disease-free and overall survival.

RESULTS

Thirty-two patients were evaluable. Twenty-nine patients completed RT without delay. There were 4 complete responses and 28 partial responses to chemotherapy. All study patients received PCI. Maximal acute RT toxicity was grade 2 esophagitis (18 patients). There were no RT-related deaths. Median time to disease progression and overall survival were 4.2 and 8.3 months, respectively (median follow-up=21.8 months). Of 16 chest recurrences, 7 were in the irradiated region and 5 were symptomatic.

CONCLUSIONS

Post-chemotherapy consolidation chest RT for ES-SCLC patients on this trial was well tolerated and associated with symptomatic chest recurrences in only 5/32 treated patients.

SCLC extensive disease--treatment guidance by extent or/and biology of response?

In extensive disease of small cell lung cancer a doubling of the one-year-survival rate was reported in August 2007 by prophylactic cranial irradiation applied to patients who experienced any response to initial chemotherapy. We discuss the treatment concept of extensive disease in the face of the latest results and older studies with additional thoracic irradiation in this subgroup. A randomized trial with prophylactic cranial irradiation published in 1999 demonstrated an improvement of 5-year-overall-survival for complete responders (at least at distant levels) receiving additional thoracic radiochemotherapy compared to chemotherapy alone (9.1% vs. 3.7%). But, these results were almost neglected and thoracic radiotherapy was not further investigated for good responders of extensive disease. However, in the light of current advances by prophylactic cranial irradiation these findings are noteworthy on all accounts. Considering both, a possible interpretation of these data could be a survival benefit of local control by simultaneous thoracic radiochemotherapy in the case of improved distant control due to chemotherapy and prophylactic cranial irradiation. Furthermore the question arises whether the tumor biology indicated by the response to chemotherapy should be integrated in the present classification.

Evidence for management of small cell lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

PURPOSES

This systematic review addressed the following key questions on managing small cell lung cancer (SCLC): the sequence, timing, and dosing characteristics of primary thoracic radiotherapy (TRTx) for limited-stage disease; primary TRTx for extensive-stage disease; effect of prophylactic cranial irradiation (PCI); positron emission tomography (PET) for staging; treatment of mixed histology tumors; surgery; and second-line and subsequent-line treatment for relapsed/progressive disease.

METHODS

The review methods were defined prospectively in a written protocol. We primarily sought randomized controlled trials that compared the interventions of interest.

RESULTS

Robust evidence was lacking for all questions except PCI, for which a patient-level metaanalysis showed that PCI improves survival of SCLC patients who achieved complete response after primary therapy from 15.3 to 20.7% (p = 0.01). The case for concurrent over sequential radiation delivery rests largely on a single multicenter trial. Support for early concurrent therapy comes from one multicenter trial, but two other multicenter trials found no advantage. Metaanalysis did not find significant reductions in 2-year and 3-year mortality rates for early TRTx. Favorable results from a single-center trial on TRTx for extensive stage disease need replication in a multicenter setting. Relevant comparative studies were nonexistent for management of mixed histology disease and surgery for early limited SCLC. PET may be more sensitive in detecting extracranial disease than conventional staging modalities, but studies were of poor quality.

CONCLUSIONS

PCI improves survival among those with a complete remission to primary therapy. A research agenda is needed to optimize the effectiveness of TRTx and its components.

Study of Paclitaxel, Etoposide, and Cisplatin Chemotherapy Combined With Twice-Daily Thoracic Radiotherapy for Patients With Limited-Stage Small-Cell Lung Cancer: A Radiation Therapy Oncology Group 9609 Phase II Study

Purpose

To determine the response rate, progression-free survival and overall survival, and toxicity of paclitaxel, etoposide, and cisplatin combined with accelerated hyperfractionated thoracic radiotherapy in patients with limited-disease (LD) small-cell lung cancer (SCLC).

Patients and Methods

LD-SCLC patients with measurable disease, Karnofsky performance score of ≥ 70, and adequate organ function who were previously untreated were eligible for the study. Treatment was as follows. In cycle 1 of chemotherapy, concurrent thoracic radiation therapy was administered. In cycles 2 to 4, chemotherapy was administered alone. In cycle 1, chemotherapy consisted of paclitaxel 135 mg/m2 intravenous over 3 hours on day 1, etoposide 60 mg/m2 intravenous on day 1 and 80 mg/m2 orally on days 2 and 3, and cisplatin 60 mg/m2 intravenous on day 1. In cycles 2 to 4, the paclitaxel dose was increased to 175 mg/m2, with the etoposide and cisplatin doses remaining the same as in cycle 1. The thoracic radiation therapy consisted of 1.5 Gy in 30 fractions (total dose, 45 Gy) administered 5 days a week for 3 weeks.

Results

Fifty-five patients were enrolled onto the study, and 53 were assessable. The major toxicities included grade 3 and 4 acute neutropenia (32% and 43%, respectively) and grade 3 and 4 esophagitis (32% and 4%, respectively). Two patients died as a result of therapy (one died of acute respiratory distress syndrome, and one died of sepsis). There was one late fatal pulmonary toxicity. The median survival time was 24.7 months. The 2-year survival rate was 54.7%. The median progression-free survival time was 13 months, with a 2-year progression-free survival rate of 26.4%.

Conclusion

Although this therapeutic regimen is effective in the treatment of patients with LD-SCLC, it is unlikely that the three-drug combination with thoracic radiation therapy will improve the survival times compared with the etoposide plus cisplatin chemotherapy regimen with thoracic radiation therapy in LD-SCLC patients.

Standard combination versus alternating chemotherapy in small cell lung cancer: a randomised clinical trial including 394 patients. 'Petites Cellules' Group

PURPOSE

to compare standard and alternating administration of chemotherapy combinations in small cell lung cancer (SCLC) patients.

MATERIAL AND METHODS

in a multicenter clinical trial, 394 previously untreated SCLC patients were randomised to receive, every 4 weeks, eight courses of either a standard regimen with CCNU, cyclophosphamide, adriamycin (CCA) and VP16 or an alternating regimen (CCA regimen alternating with cisplatin-vindesine-VP16).

RESULTS

overall response rate was higher in the standard group (78%) than in the alternating group (64%) (P = 0.0001). Complete response rate was also higher in the standard group (32%) than in the alternating group (18%) (P = 0.004). The median survival in the overall SCLC population was 306 days in the standard group and 272 days in the alternating group (P = 0.08). In limited SCLC patients, median survival was higher in the standard group (421 days) than in the alternating group (328 days) (P = 0.01). Grade III/IV haematological toxicity was lower in patients in the alternating group (25 versus 47%) (P < 0.001).

CONCLUSION

the standard regimen was better than the alternating regimen for patients with limited forms of SCLC. The alternating regimen, associated with better haematological safety and ensuring a fairly similar survival, may be considered in patients with extensive SCLC. Pleiomorphic resistance mechanisms to chemotherapy make it difficult to define a non-cross-resistant chemotherapy regimen.

Prognostic significance of supraclavicular lymph nodes in small cell lung cancer: a study from four consecutive clinical trials, including 1,370 patients. "Petites Cellules" Group

STUDY OBJECTIVE

To determine the prognostic significance of supraclavicular lymph node (SCLN) involvement in small cell lung cancer.

MATERIALS AND METHODS

Patients (1,370) with small cell lung cancer were included in four consecutive clinical trials and classified as having either limited or extensive forms of disease using the Veterans Administration staging system.

RESULTS

SCLN was present in 17% of patients (n = 234). Median survival was 258 days for patients with SCLN (n = 234) and 297 days for patients without SCLN (n = 1136) (p = 0.002). SCLN involvement was correlated with the presence of distant metastases at baseline (169 vs 65, p = < 0.001). Median survival was 375 days for patients with limited forms without SCLN (n = 529), 332 days for those with limited forms with SCLN (n = 65) (p = 0.12), 244 days for those with extensive forms without SCLN (n = 604), and 228 days for those with extensive forms with SCLN (n = 169) (p = 0.94). The 2-year survival rates were 17%, 12%, 2%, and 4%, respectively. Cox models confirmed that SCLN did not provide any significant additional prognostic information.

CONCLUSION

SCLN is highly correlated with extensive forms explaining its overall prognostic value. In limited disease, SCLN is only a minor poor prognostic factor, not justifying any amendment to the staging system currently used.

A survey of the ethical considerations in randomised trials for lung cancer

BACKGROUND

In order to promote a more productive debate on the ethics of randomised clinical trials (RCTs), we present a survey on the ethical aspects of published RCTs for lung cancer.

METHODS

Data from 92 published reports of RCTs for lung cancer, as identified from the Cancerlit 1993-1995 database were supplemented by a questionnaire mailed to the authors of those publications. The analysis focused on respect of autonomy, non-maleficence, beneficence, and justice as the ethical principles applicable to society, patients in trials, patients not included in RCTs and physicians. ETHICAL ANALYSIS: The benefits to society include an objective evaluation of new treatments. The principle of autonomy was often violated for patients who were inadequately informed about the disease or about RCT. In some trials with prolonged recruitment, the principle of non-maleficence was not fully respected since patients continued to be randomised in spite of an obvious advantage of one of the treatments. When compared to those not included in a trial, patients in RCTs were reported to benefit from more precise standards, superior quality assurance of diagnostic and therapeutic procedures, more attention from the physician, easier appointments and easier access to hospitalisation. However, these benefits diminish patients' autonomy and lead to injustice towards patients not included in the trials. While benefits to physicians were usually modest and in proportion to their contribution, an influence upon their autonomy cannot be excluded.

CONCLUSION

More attention to the aforementioned ethical caveats of RCTs should alleviate the ethical costs and might also bring more patients into future trials.

The role of thoracic radiotherapy in the management of limited-stage small cell lung cancer: past, present, and future

The role of thoracic radiation therapy in the management of limited-stage small cell lung cancer (SCLC) is reviewed. Although chest irradiation has been used to treat SCLC for over four decades, its standard role in the management of limited-stage disease was established only during the last decade. Multiple prospective randomized trials have shown that the addition of thoracic radiation therapy to chemotherapy usually halves local failure rates, from >60% with chemotherapy alone to about 30% with chemoradiation therapy. Additionally, survival at 3 years is also improved by 50%, from 10% with chemotherapy alone to about 15% with chemoradiation therapy. However, issues relating to the timing, volume (ie, prechemotherapy vs postchemotherapy), and the dose fractionation scheme of thoracic radiation therapy in the treatment of limited-stage SCLC still remain unresolved. Recent review of the literature indicates the most optimal timing of thoracic radiation therapy appears to be concurrent with chemotherapy vs either a sequential or an alternating approach. Studies are currently under way evaluating the optimal volume and dose fractionation scheme to use in the delivery of thoracic radiation therapy. In summary, thoracic radiation therapy significantly improves both local chest control and survival in the treatment of limited-stage SCLC.

Thoracic irradiation of limited small cell lung cancer: have we defined optimal dose, time, and fractionation?

There is a general agreement that patients with limited small cell lung cancer (L-SCLC) are better treated with a combination of thoracic radiation therapy (TRT) and systemic chemotherapy (CT) than with either modality alone. There is little agreement, however, and few data from prospective trials, to define optimal ways of combining these modalities. This article will review available data on radiation dose, timing, fractionation, and volume issues in an attempt to develop standards for current practice and suggest appropriate questions for future prospective clinical trials.

Indications, Results and Techniques of Radiotherapy in the Treatment of Small-Cell Lung Cancer

Aims and background

To define the role of radiotherapy in the treatment of small-cell lung cancer (SCLC) on the basis of clinical data reported in the medical literature.

Methods

Published reports are critically reviewed, with particular attention to randomized trials.

Results

Thoracic radiotherapy has an important role in improving local control and 3-year survival in limited-stage SCLC; radiation should be delivered early in the course of the chemotherapy program, avoiding large volumes and total doses exceeding 40-50 Gy. Thoracic radiotherapy probably has no role in resected patients treated with adjuvant chemotherapy and may even be detrimental in patients with extensive SCLC. Prophylactic cranial irradiation has been shown to reduce the risk of brain relapse, but it is not associated with a consistent increase in survival or cure rate: its use in clinical practice is therefore not advised.

Conclusions

Survival rates approaching 50% at 2 years are now possible in limited SCLC with the integrated effort of the surgeon, the medical oncologist and the radiation oncologist; their strict cooperation appears to be of the utmost importance in the earliest phase of treatment planning.

Subcutaneous heparin treatment increases survival in small cell lung cancer. "Petites Cellules" Group

BACKGROUND

A positive influence of anticoagulant treatment in small cell lung cancer (SCLC) has been suggested by experimental and clinical data.

METHODS

In a multicenter clinical trial, 277 patients with SCLC were randomized either to receive or not to receive subcutaneous heparin injections for 5 weeks at effective doses, which were monitored by blood coagulation tests. All patients received one of the two chemotherapy regimens studied in this trial, for eight courses in the case of patients with complete or partial response, and subsequently were randomized to receive delayed thoracic radiotherapy after these eight courses.

RESULTS

In comparison to the 139 patients who did not receive heparin, the 138 patients who received anticoagulant treatment obtained better complete response rates (37% vs. 23%, P = 0.004), better median survival (317 days vs. 261 days, P = 0.01), and better survival rates at 1, 2, and 3 years (40% vs. 30%, 11% vs. 9% and 9% vs. 6%, respectively). At subgroups analysis, the results on survival were obtained for limited forms (P = 0.03) but not for extensive diseases (P = 0.31). No important bleeding or thrombocytopenia was related to heparin treatment.

CONCLUSIONS

These results confirm the value of anticoagulant treatment in SCLC, already suspected for warfarin and now proven for heparin, but the modes of administration and the biologic explanations for this activity still warrant further investigation.

[Treatment of small cell bronchopulmonary cancers]

nn small cell lung cancer, the main treatment modality is chemotherapy, combinated with early thoracic radiation therapy for patients with complete response. The treatment of relapse with chemotherapy is efficient. The precocity of the response after initiating multimodality treatment is the main prognosis factor. The prophylactic cranial irradiation reduce the frequency of brain metastases, but has no significant effect on survival. Patients with very limited small cell lung cancer (TNM stage I and II) can be managed by surgery. Association with colony stimulating factors can lessen the severity of neutropenic and infectious episodes. The role of maintenance therapy by interferon alpha in clinically disease free patients is suggested.