Palliative Thoracic Radiotherapy for Lung Cancer: What Is the Impact of Total Radiation Dose on Survival?

Nieder, Carsten; Tollåli, Terje; Yobuta, Rosalba; Reigstad, Anne; Flatøy, Liv Randi; Pawinski, Adam

doi:10.14740/jocmr2980w

Cited by 25 publications

(26 citation statements)

References 21 publications

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“…Multimodality treatment of non-small cell lung cancer (NSCLC) has become more effective in recent years, e.g., due to stereotactic ablative radiotherapy for stage I disease [1,2] and oligometastatic stage IV disease [3][4][5], and immunotherapy for stage III and IV disease [6,7]. Patients with stage III disease who are unfit for radical chemoradiotherapy should be considered for reduced-intensity palliative chemoradiotherapy [8][9][10]. One of the downsides of chemoradiotherapy is its potential to induce painful acute esophagitis [11][12][13].…”

Section: Introductionmentioning

confidence: 99%

Risk factors for esophagitis after hypofractionated palliative (chemo) radiotherapy for non-small cell lung cancer

et al. 2020

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Introduction: Esophagitis influences quality of life and might cause treatment interruption and hospitalization. Previous studies of risk factors focused on curative treatment for non-small cell lung cancer (NSCLC), which often involves concomitant chemoradiation (CRT). Given the uncertainty around extrapolation of dose constraints, we analyzed risk factors in patients treated with hypofractionated palliative regimens. Patients and methods: A retrospective review of 106 patients treated with palliative radiotherapy or CRT between 2009 and 2017 was performed. Inclusion criteria: prescribed total dose 30-54 Gy, dose per fraction 2.5-4 Gy, esophageal dose > 1 Gy. Uni-and multivariate analyses were performed in 97 eligible patients to identify predictive factors for acute esophagitis grade ≥ 1 (CTCAE 5.0). Results: Forty percent of patients were treated with 15 fractions of 2.8 Gy (42 Gy) and 28% also received chemotherapy according to the CONRAD study regimen (induction and concomitant Carboplatin/Vinorelbine) published by the Norwegian Lung Cancer Group. Thirty-four percent were treated with 10 fractions of 3 Gy. Stage IV NSCLC was present in 47%. Esophagus Dmax was 39 Gy (population median) and Dmean 15 Gy. Overall 31% of patients developed esophagitis (26% grade 2-3, no grade 4-5). Several dosimetric parameters correlated with the risk of esophagitis (Dmax, Dmean, D5cc, V20, V30, V35, V40). Dmax outperformed other dosimetric variables in multivariate analysis. Furthermore, concomitant chemotherapy significantly increased the risk of esophagitis, while oral steroid medication reduced it. In patients with Dmax ≥40 Gy a reduced Dmean (≤20 Gy) was beneficial. Conclusion: In order to reduce esophagitis after hypofractionated palliative treatment lower doses than those recommended in curative NSCLC settings are preferable. Besides esophageal dose, CRT is the main risk factor for esophagitis. Additional work is needed to confirm that steroids are able to modify the risk (or to rule out confounding effects of baseline variables not included in our database).

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Section: Introductionmentioning

confidence: 99%

Risk factors for esophagitis after hypofractionated palliative (chemo) radiotherapy for non-small cell lung cancer

et al. 2020

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“…Palliative radiotherapy has evolved into a highly individualized treatment concept, which provides symptom palliation and, in selected patients, improves overall survival (1,6,18,19). However, the management of patients with reduced PS (ECOG 3-4) is among several unsolved problems.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, survival time should be estimated, e.g. on the basis of validated prognostic scores or nomograms, in order to avoid a mismatch between treatment intensity and duration, or resource utilization, on one hand and the benefit and remaining lifespan on the other hand (5)(6)(7). One of the established tools that have been implemented by several oncology care providers is the Edmonton Symptom Assessment System (ESAS) (8)(9)(10)(11)(12)(13)(14).…”

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Symptom Burden in Patients With Reduced Performance Status at the Start of Palliative Radiotherapy

Nieder

Kämpe

2020

In Vivo

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Background/Aim: Previous research has suggested that palliative radiotherapy is a useful measure, unless short survival reduces the time spent without active treatment, and in the case of a low likelihood of experiencing a net benefit in quality of life. Patients with reduced performance status (PS) may be especially at risk of futile treatment, despite having a relatively high symptom burden and thus a potential benefit. Therefore, we analyzed the symptom burden of patients with Eastern Cooperative Oncology Group (ECOG) PS 3-4 in our center. Patients and Methods: A retrospective study was performed of 102 consecutive patients who received palliative radiotherapy for different indications. The Edmonton Symptom Assessment Scale (ESAS) was employed to assess the pre-radiotherapy symptoms. Results: When applying the lowest threshold (ESAS ≥1), up to 97% of patients with PS 3-4 reported symptoms, such as fatigue and dry mouth. When focusing on moderate/severe symptoms (ESAS ≥4), still up to 77% of patients with PS 3-4 reported such a burden. The largest differences between patients with PS 3-4 and those with 0-1 were seen with regard to nausea, fatigue, dry mouth and reduced appetite. The median survival of patients with PS 3-4 was 2 months. Conclusion: Given that many of the symptoms reported by patients with PS 3-4 tend to worsen temporarily after radiotherapy, patients with short survival may not experience a net benefit during the few weeks before death. However, if other symptoms such as dyspnea or pain prevail, short-course radiotherapy may result in worthwhile palliation and should, therefore, be considered on a case-bycase basis and after estimation of the remaining lifespan. 735

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“…OS values after the 1st and the 2nd year were similar between the high-dose and low-dose groups. In another retrospective study [11] involving 232 patients with NSCLC, the most frequently recommended dose was 2 fractions of 8.5 Gy (34%), followed by 10 fractions of 3 Gy or equivalent doses (30%, EQD2 approx. 33 Gy).…”

Section: Discussionmentioning

confidence: 99%

Long-term survival in patients with NSCLC treated with single fraction vs multi-fraction palliative radiotherapy in the case of lung tumor, brain metastases, and bone metastases.

Szablewska

Adamczak-Sobczak

Roszkowska

et al. 2017

JCO

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e20082 Background: Patients with advanced non-small cell lung cancer (NSCLC) are candidates for different types of treatment, including chemotherapy and radiotherapy or supportive care. Despite the fatal prognosis in advanced disease, many experienced radiation oncologists will apply radiation at low doses with the intention of palliative care. Choosing an effective radiation dose that does not cause significant complications remains under discussion. Methods: We used an extensive database of medical patients diagnosed with NSCLC, treated with palliative radiotherapy at the Oncology Centre in Bydgoszcz, Poland, from June 1998 to December 2013. A group of 3202 patients was divided into subgroups: A) 1762 patients irradiated on the lung tumor (without distant metastases): Total dose: A1) 6 Gy/1 fr.(n = 19); A2) 8 Gy/1 fr.(n = 276); A3) 20 Gy/5 fr.(n = 1349); A4) 30 Gy/10 fr.(n = 118). B) 548 patients irradiated on the central nervous system (CNS) metastases: B1) 20 Gy/5 fr.(n = 476); B2) 30 Gy/10 fr.(n = 72). C) 892 patients irradiated on the bone metastases: C1) 8 Gy/1 fr.(n = 452); C2) 10 Gy/1 fr.(n = 30); C3) 20 Gy/5 fr.(n = 341); C4) 30 Gy/10 fr.(n = 69). Date of death was obtained from medical records. Patients who were alive or whose date of death could not be determined were censored at the date of their last encounter. Survival was calculated from the start of treatment to the date of death or censorship. Results: Overall Survival (in months) for each group was: A1) = 6; A2) = 5; A3) = 7; A4) = 7. B1) = 4; B2) = 4. C1) = 5; C2) = 4; C3) = 4; C4) = 5. There was no significant difference in survival between patients treated with single fraction pRT or multi-fractionation schedules in all groups of patients. Conclusions: The patients who were prescribed single fraction palliative radiotherapy did not have poorer prognoses or experience shorter survival than patients who were prescribed multi-fraction pRT in the case of lung tumor, brain metastases and bone metastases.

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Palliative Thoracic Radiotherapy for Lung Cancer: What Is the Impact of Total Radiation Dose on Survival?

Cited by 25 publications

References 21 publications

Risk factors for esophagitis after hypofractionated palliative (chemo) radiotherapy for non-small cell lung cancer

Risk factors for esophagitis after hypofractionated palliative (chemo) radiotherapy for non-small cell lung cancer

Symptom Burden in Patients With Reduced Performance Status at the Start of Palliative Radiotherapy

Long-term survival in patients with NSCLC treated with single fraction vs multi-fraction palliative radiotherapy in the case of lung tumor, brain metastases, and bone metastases.

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