Applying the QUARTZ Trial Results in Clinical Practice: Development of a Prognostic Model Predicting Poor Outcomes for Non-small Cell Lung Cancers with Brain Metastases

AIMS

The role of whole brain radiotherapy (WBRT) in patients with brain metastases from non-small cell lung cancers (NSCLC) has been questioned. However, no reliable criteria exist to identify patients who do not benefit from WBRT. The objective of the current study was to develop a prognostic model to identify such patients whose survival matches that of the Quality of Life after Treatment for Brain Metastases (QUARTZ) study.

MATERIALS AND METHODS

Outcome data of patients with NSCLC with brain metastases undergoing WBRT enrolled in a prospective observational study in a tertiary cancer centre were used to develop a prognostic model. Baseline clinico-radiological factors were used for development of the model. The model was internally validated and calibration accuracy was checked for prediction of 70 day mortality. The generated prognostic model was presented as a nomogram.

RESULTS

The median overall survival of 140 patients enrolled in the study was 166 days (95% confidence interval 108-242 days). The prognostic model identified gender, Karnofsky performance status and epidermal growth factor receptor activating mutation status as significant factors influencing overall survival. The model showed a modest discriminative ability with an optimism-corrected C-index of 0.64. However, model calibration error did reveal a moderate degree of calibration error. The high-risk subgroup identified by the model had a median overall survival of 67 days (95% confidence interval 56-101 days), which was similar to that observed in the QUARTZ trial.

CONCLUSION

This prognostic model derived from traditional clinico-radiological features had a modest ability to identify patients with poor prognosis who may not benefit from WBRT. However, the high-risk subgroup identified using this prognostic model had a survival similar to that observed for patients in the QUARTZ trial.

Assessment of compliance to treatment and efficacy of a resource-sparing hypofractionated radiotherapy regimen in patients with poor-prognosis high-grade gliomas

INTRODUCTION

The optimal radiotherapeutic management of poor-prognosis (elderly and/or poor performance status) high-grade gliomas (HGG) remains controversial. Hypofractionated radiotherapy (hypoRT) has been shown to be non-inferior to daily conventionally fractionated radiotherapy. This study aimed to assess the compliance to treatment and efficacy of a resource-sparing hypoRT regimen in this subset.

MATERIALS AND METHODS

The resource-sparing hypoRT regimen was delivered once weekly (5Gy/fraction) for seven fractions to a total dose of 35Gy in seven fractions over six weeks. Compliance to planned treatment and factors that could potentially influence it were analyzed.

RESULTS

Between January 2004 and October 2009, 63 patients with poor-prognosis HGG (age range 40-78 years; Karnofsky performance score ≤70) were offered resource-sparing hypoRT regimen. Twenty eight of 63 patients completed planned course of treatment giving a treatment compliance rate of 44%. Six (9.5%) patients did not receive even a single fraction of radiation after simulation/planning. Thirty eight patients (60%) received ≥3 fractions and were on treatment for at least two weeks. Performance status (P = 0.05) and grade (P = 0.04) significantly impacted upon compliance. Median overall survival for the cohort of 28 patients who completed planned course of treatment was 7.4 months (95% confidence interval: 4.4-10.5 months).

CONCLUSIONS

The treatment compliance to a resource-sparing once-weekly hypoRT regimen in poor-prognosis HGG has been somewhat suboptimal and discouraging, possibly due to the protracted scheduling over six weeks. Over 60% of patients were on treatment for two weeks, suggesting that short-course schedules could more likely ensure compliance.

Validation of recursive partitioning analysis classification in patients with brain metastases from non-small cell lung cancer treated with short-course accelerated radiotherapy

AIMS

To study various prognostic factors affecting outcome and to validate Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class in non-small cell lung cancer (NSCLC) with brain metastases treated with short-course accelerated radiotherapy (SCAR).

MATERIALS AND METHODS

The case records of 100 patients with NSCLC consecutively treated at Tata Memorial Hospital from August 2006 to August 2009 were studied for various patient, tumour and treatment-related prognostic factors. Patients received whole-brain radiotherapy to a dose of 20 Gy/five fractions over 1 week (n=90) or 30 Gy/10 fractions over 2 weeks (n=10). The Kaplan-Meier estimate was used for survival analysis in SPSS v15.

RESULTS

The median overall survival was 4.0 months (range 0.5-30.0 months). The 6-, 12-, 18- and 24-month survival rates were 35.8, 18.0, 9.3 and 6.2%, respectively. Of the various prognostic factors, RPA class (II versus III, P value=0.023), Karnofsky performance score (<70 versus ≥70, P value=0.039) and the use of systemic therapy (yes versus no, P value=0.00) emerged as significant on univariate analysis. RPA classification effectively separated the patient population into prognostically distinct subgroups. The median overall survival for RPA class II and RPA class III was 6 and 4 months, respectively. The use of systemic therapy prolonged overall survival by 6 months (3 months versus 9 months).

CONCLUSION

The SCAR regimen is an effective and resource-sparing palliative strategy for brain metastases in NSCLC. The results validate the usefulness of RPA classification in this specific subset of patients treated with SCAR.