Continuous Hyperfractionated Accelerated Radiotherapy (CHART) for Non-small Cell Lung Cancer (NSCLC): 7 Years' Experience From Nine UK Centres

AIM

Continuous hyperfractionated accelerated radiotherapy (CHART) remains an option to treat non-small cell lung cancer (NSCLC; NICE, 2011). We have previously published treatment outcomes from 1998-2003 across five UK centres. Here we update the UK CHART experience, reporting outcomes and toxicities for patients treated between 2003 and 2009.

MATERIALS AND METHODS

UK CHART centres were invited to participate in a retrospective data analysis of NSCLC patients treated with CHART from 2003 to 2009. Nine (of 14) centres were able to submit their data into a standard database. The Kaplan-Meier method estimated survival and the Log-rank test analysed the significance.

RESULTS

In total, 849 patients had CHART treatment, with a median age of 71 years (range 31-91), 534 (63%) were men, 55% had undergone positron emission tomography-computed tomography (PET-CT) and 26% had prior chemotherapy; 839 (99%) patients received all the prescribed treatment. The median overall survival was 22 months with 2 and 3 year survival of 47% and 32%, respectively. Statistically significant differences in survival were noted for stage IA versus IB (33.2 months versus 25 months; P = 0.032) and IIIA versus IIIB (20 months versus 16 months; P = 0.018). Response at 3 months and outcomes were significantly linked; complete response showing survival of 34 months against 19 months, 15 months and 8 months for partial response, stable and progressive disease, respectively (P < 0.001). Age, gender, performance status, prior chemotherapy and PET-CT did not affect the survival outcomes. Treatment was well tolerated with <5% reporting ≥grade 3 toxicity.

CONCLUSION

In routine practice, CHART results for NSCLC remain encouraging and we have been able to show an improvement in survival compared with the original trial cohort. We have confirmed that CHART remains deliverable with low toxicity rates and we are taking a dose-escalated CHART regimen forward in a randomised phase II study of sequential chemoradiotherapy against other accelerated dose-escalated schedules.

Results of a phase I study to evaluate the feasibility, safety, and biological effects of intravenous administration of wild-type reovirus with docetaxel to patients with advanced malignancies

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Background: Reovirus has minimal pathogenicity in humans but selectively replicates in cells with activated Ras. Wild- type reovirus serotype 3 Dearing strain (Reolysin) has selective antitumor activity in vitro, in murine models, and after systemic delivery in humans in phase 1 trials. Synergistic tumour kill has been observed combining reovirus with taxanes in a range of cancer cell lines and in vivo. Methods: Patients were treated in an open-label, dose-escalating, phase I trial and received 3- weekly 75mg/m2 docetaxel i.v. and reovirus i.v. (day 1–5 of first week inclusive). Reovirus was administered at a starting dose of 3x109 tissue culture infectious dose (TCID50) and then increased to 1 x 1010 and 3 x 1010 TCID50. Primary endpoints were to determine the maximum tolerated dose (MTD), dose limiting toxicity (DLT) and to recommend a dose and schedule for future investigation. Secondary endpoints were to evaluate pharmacokinetics, neutralizing antibody development, cell- mediated immune response and anti-tumour activity. Results: 17 patients were treated (15 males, median age 60 years). No MTD has been reached. DLT's observed were G4 neutropenia (and a recurrent perianal abcess) and G3 rise in AST. Other toxicities observed were fatigue, hypotension and neutropenic sepsis. At present, 5 patients remain on treatment. We have observed 2 partial responses (breast and gastric carcinoma) and 10 patients had stable disease as best response. Conclusions: Reovirus is well tolerated when administered in combination with intravenous docetaxel, with predictable toxicity observed. The recommended dose has been defined at 3x1010 TCID50 and phase II studies are planned. Objective radiological evidence of anticancer activity for this combination has been observed.

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Reovirus: viral therapy for cancer 'as nature intended'

Oncolytic viruses are tumour selective and able to lyse cancer cells after infection. Reovirus is an example of a wild-type oncolytic virus and is currently being investigated as a potential novel therapy for cancer. This overview gives a brief description of what is known about reovirus biology and summarises the preclinical data related to its oncolytic ability. The completed and ongoing clinical trials involving reovirus, both as a single agent and in combination with chemotherapy and radiotherapy, will be reviewed and their results discussed. Many of these clinical studies are being conducted by centres in the UK.

Results of a UK survey on methods for compensating for unscheduled treatment interruptions and errors in treatment delivery

In order to obtain a preliminary overview of the current national status regarding the management of both unintentional interruptions to radiotherapy treatments and inadvertent errors in treatment delivery, a short questionnaire was sent to 60 UK radiotherapy departments, of which 35 (58%) responded. The study was initiated by the authors and was not commissioned by any professional body. Amongst the centres which responded the majority (86%) currently have standardized protocols in place for dealing with treatment interruptions and many have extended the enactment of compensation methods to cover a wider range of tumour types than are encompassed within the Royal College of Radiologists (RCR)-defined Categories 1 and 2. Fewer of the respondents (60%) have standardized methods for dealing with treatment errors. Given that 42% of centres did not respond it is difficult to assess the fuller national picture. Some smaller departments may seek protocols or advice from larger adjacent centres, but the overall percentage of centres with systems in place may be lower than indicated from the survey results. The desirability of providing training in the radiobiological methods pertaining to treatment compensation was raised by a number of respondents.