Patients’ preference for radiotherapy fractionation schedule in the palliation of symptomatic unresectable lung cancer†

Abstract

The palliative radiotherapeutic management of unresectable non-small-cell lung cancer is controversial, with various fractionation (Fx) schedules available. We aimed to determine patient's choice of Fx schedule after involvement in a decision-making process using a decision board. A decision board outlining the various advantages and disadvantages apparent in the Medical Research Council study of Fx schedules (17 Gy in two fractions vs 39 Gy in 13 fractions) was discussed with patients who met Medical Research Council eligibility criteria. Patients were then asked to indicate their preferred Fx schedules, reasons and their level of satisfaction with being involved in the decision-making process. Radiation oncologists (RO) could prescribe radiotherapy schedules irrespective of patients' preferences. Of 92 patients enrolled, 55% chose the longer schedule. English-speaking patients were significantly more likely to choose the longer schedule (P = 0.02, 95% confidence interval: 1.2-7.6). Longer Fx was chosen because of longer survival (90%) and better local control (12%). Shorter Fx was chosen for shorter overall treatment duration (80%), cost (61%) and better symptom control (20%). In all, 56% of patients choosing the shorter schedule had their treatment altered by the treating RO, whereas only 4% of patients choosing longer Fx had their treatment altered (P < 0.001). Despite this, all (100%) patients were satisfied with being involved in the decision-making process. The decision board was useful in aiding decision-making, with both Fx schedules being acceptable to patients. Interestingly, despite the longer average survival associated with longer Fx, nearly half of the patients believed that this was not as important as a shorter duration of treatment and lower cost. Despite patients' preferences, there were significant alterations of preferred schedules because of RO's own biases.

Palliative thoracic radiotherapy in non-small cell lung cancer. An analysis of 1250 patients. Palliation of symptoms, tolerance and toxicity

“…Table 4 presents that the most commonly used methods of PTR are hypofractionation schedules: 10 Gy in 1 fraction, 16-17 Gy in 2 weekly fractions, 2 series of 20 Gy in 5 fractions; 4 weeks apart, 30 Gy in 10 fractions, 39 Gy in 13 fractions and 45 Gy in 15 fractions. Conventional fractionation (40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50) Gy in 15-25 fractions) is used rarely and rather in patients with good performance status. Despite many studies considering the most appropriate method of PTR in patients with advanced NSCLC, the optimal schedule has not yet been established [46,47].…”

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

“…Practice guidelines and consensus statements have been previously prepared to provide guidance to practitioners and patients with regard to treatment options 1-8 . In addition, investigations into treatment selection from the practitioner, 9 patient, 10 and economic viewpoints 11 have been undertaken to provide guidance.…”

The Refusal of Palliative Radiation in Metastatic Non-Small Cell Lung Cancer and Its Prognostic Implications

“…Nearly half of the patients feel that extended survival is less important than shorter treatment duration and lower costs. 39 An abbreviated but equally effective course may be offered to address such concerns. 5,10,40e42 One must consider the appropriateness of treatment when life expectancy is limited.…”