Palliative thoracic radiotherapy in lung cancer: An American Society for Radiation Oncology evidence-based clinical practice guideline

Abstract

PurposeTo provide guidance to physicians and patients with regard to the use of external beam radiotherapy, endobronchial brachytherapy, and concurrent chemotherapy in the setting of palliative thoracic treatment for lung cancer, based on available evidence complemented by expert opinion.Methods and MaterialsA Task Force authorized by the American Society for Radiation Oncology (ASTRO) Board of Directors synthesized and assessed evidence from 3 systematic reviews on the following topics: (1) dose fractionation in thoracic external beam radiotherapy (EBRT); (2) clinical utility of initial and salvage endobronchial brachytherapy (EBB); and (3) use of concurrent chemotherapy (CC) with palliative thoracic radiotherapy. Practice guideline recommendations were produced and are contained herein.ResultsStudies suggest that higher dose/fractionation palliative EBRT regimens (eg, 30 Gy/10 fraction equivalent or greater) are associated with modest improvements in survival and total symptom score, particularly in patients with good performance status. As these improvements are associated with an increase in esophageal toxicity, various shorter EBRT dose/fractionation schedules (eg, 20 Gy in 5 fractions, 17 Gy in 2 weekly fractions, 10 Gy in 1 fraction), which provide good symptomatic relief with fewer side effects, can be used for patients requesting a shorter treatment course and/or in those with a poor performance status. No defined role for EBB in the routine initial palliative treatment of chest disease has been demonstrated; however, EBB can be a reasonable option for the palliation of endobronchial lesions causing obstructive symptomatology including lung collapse, or for hemoptysis after EBRT failure. The integration of concurrent chemotherapy with palliative intent/fractionated radiotherapy is not currently supported by the medical literature.ConclusionThis Guideline is intended to serve as a guide for the use of EBRT, EBB, and CC in thoracic palliation of lung cancer outside the clinical trial setting. Further prospective clinical investigations with relevant palliative endpoints into the respective roles of EBB and CC/targeted therapy in the thoracic palliation of lung cancer are warranted, given the current state of the medical literature in these areas.

Use of Radiation Therapy in the Last 30 Days of Life Among a Large Population-Based Cohort of Elderly Patients in the United States

“…16 Similar guidelines for palliation of thoracic lesions support use of regimens of 10 fractions or fewer for patients with limited life expectancy. 32,33 Quality indicators reflecting these recommended palliative radiation dosing schedules could be derived from these guidelines, which would offer metrics for future study of palliative radiotherapy practice. Future administrative data research efforts could be aided by incorporation of diagnosis and claims codes that specifically included codes for anatomic sites of metastases as well as palliative radiotherapy procedures (eg, whole-brain radiation therapy) in the International Classification of Disease-10 and Common Procedural Terminology code repertoires.…”

Palliative Radiation Therapy Practice in Patients With Metastatic Non–Small-Cell Lung Cancer: A Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

“…[38][39][40][41][42] Although such guidelines have the potential to improve radiation oncology practice by better educating practitioners, our observation that practice may vary according to reimbursement structure suggests that realignment of financial incentives for treatment may also be warranted.…”

A review of palliative radiotherapy for lung cancer and lung metastases

“…The authors found that there was a greater likelihood of symptom improvement and a modest benefit in overall survival with radiotherapy schedules of 35 Gy 10 BED (i.e., 30 Gy in ten fractions) or greater. These findings informed various consensus papers including the American Society for Radiation Oncology (ASTRO) practice guideline [21], and an international consensus statement [22]. The general recommendations from the above reviews and guidelines are that radiotherapy schedules of 35Gy 10 BED (i.e., 30 Gy in ten fractions) or greater should be considered for patients with good performance status.…”