Postoperative Radiation Therapy Is Associated With Improved Overall Survival in Incompletely Resected Stage II and III Non–Small-Cell Lung Cancer

Wang, Elyn H.; Corso, Christopher D.; Rutter, C.E.; Park, Henry S.; Chen, Aileen B.; Kim, Anthony W.; Wilson, Lynn D.; Decker, Roy H.; Yu, James B.

doi:10.1200/jco.2015.61.1517

Cited by 94 publications

(53 citation statements)

References 21 publications

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“…Wang reported slightly longer survival in patients completing a full regime of PORT at 50–74 Gy post-operatively. 25 Key differences in our study may explain the conflicting results.…”

Section: Discussionmentioning

confidence: 72%

“…25 Specifically, Wang excluded all patients who died within 120 days of surgery, and only included patients who completed optimal-dose radiation. A less optimal classification of PORT use is more pragmatic and provides better information for treatment of patients, whose ability to receive a full treatment regime of PORT cannot be known at the time of treatment decision.…”

Section: Discussionmentioning

confidence: 99%

“…We used a 6-month eligibility window, as others have done in these types of analyses, to reflect the practical reality that some patients start adjuvant therapy late. 18,25 The median time to onset of PORT alone was 52 days, and 75% of patients initiated therapy within 74 days. This suggests that PORT was used adjuvantly, and not for salvage therapy after disease progression.…”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Survival impact of postoperative therapy modalities according to margin status in non–small cell lung cancer patients in the United States

Smeltzer

Lin

Kong

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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Objective Unlike complete (R0) resection guidelines, current National Comprehensive Cancer Network (NCCN) adjuvant therapy guidelines after incomplete (R1/R2) resection of non-small cell lung cancer (NSCLC) are based on low-level evidence. We attempted to validate them. Methods Patients with pathologic stage I-IIIA NSCLC from 2004–2011 in the National Cancer Data Base were stratified by margin status, NCCN-specified stage groupings and adjuvant therapy exposure (none, radiotherapy, chemotherapy or both). Five-year overall survival (OS) and hazard ratios, adjusted for patient and institutional characteristics, were compared. We used a parallel analysis of R0 resections to validate our methodology. Results We analyzed 3461 R1/R2, and 78,929 R0 resections. After R0 resection, the NCCN-recommended option was associated with the best survival across all stage groups, supporting our analytic approach. R1/R2 stage IA patients treated with radiation had a 26% OS, compared to 58% with no treatment (p=0.003). In stage IB/IIA (N0) R1/R2 patients, radiation was associated with a 25% OS compared to 47% with no treatment (p=0.025) and 62% with chemotherapy (p<0.007). Chemoradiation was not associated with a survival benefit in either group. Patients with IIA (N1)/IIB and IIIA had better survival with chemotherapy or chemoradiation. No group had a survival benefit with radiation alone. Conclusions NCCN adjuvant therapy guidelines after complete resection, based on high-level evidence, are validated, but not guidelines for patients with incompletely resected early stage NSCLC, which are based on low-level evidence. Monomodality postoperative radiotherapy was not validated for any stage. Specific studies are needed to determine optimal management after incomplete resection.

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“…Wang reported slightly longer survival in patients completing a full regime of PORT at 50–74 Gy post-operatively. 25 Key differences in our study may explain the conflicting results.…”

Section: Discussionmentioning

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Survival impact of postoperative therapy modalities according to margin status in non–small cell lung cancer patients in the United States

Smeltzer

Lin

Kong

et al. 2017

The Journal of Thoracic and Cardiovascular Surgery

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“…At our institution, POCT and PORT currently are routinely recommended for patients with R1/R2 resection, consistent with NCCN guidelines and recent observational data 10, 17. For patients with an R0 resection, initial POCT is recommended, followed by restaging and multidisciplinary discussion regarding the role of PORT.…”

Section: Discussionmentioning

confidence: 63%

“…PORT is considered on a case-by-case basis and may be recommended particularly for patients with good performance status, close margins, advanced T stage, limited lymph node dissection, and/or multiple station N2 disease. However, further studies are needed to better define patient subsets that are more likely to derive benefit from PORT 17, 18. Additionally, molecular markers are needed to identify patients who are at a higher risk for LRR versus DM recurrence.…”

Section: Discussionmentioning

confidence: 99%

Predictors of relapse and evaluation of the role of postoperative radiation therapy in a modern series of patients with surgically resected stage III (N2) non–small cell lung cancer

Breen

Merrell

Mansfield

et al. 2017

Advances in Radiation Oncology

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PurposeFor patients with stage III (N2) non–small cell lung cancer (NSCLC) treated with surgical resection, postoperative chemotherapy improves overall survival (OS), but the role of postoperative radiation therapy (PORT) is controversial. The purpose of this study was to evaluate risk factors for local-regional recurrence and to evaluate the impact of PORT on local-regional control (LRC) and OS in a modern series of patients with surgically resected stage III (N2) NSCLC.Methods and materialsA retrospective review was performed of patients with Stage III (N2) NSCLC who underwent curative intent resection at our institution between February 1999 and January 2012. OS, LRC, and metastasis-free survival were estimated from the date of surgery using the Kaplan Meier method.ResultsA total of 71 patients were included in the study. Patient median age was 63 years. Histology was adenocarcinoma in 69% of patients. Pretreatment positron emission tomography/computed tomography staging was performed for 90% of patients, and preoperative chemotherapy was administered in 23%. The rate of R0 resection was 96%. Forty-one patients (58%) received PORT and the median PORT dose was 50 Gy (range, 41.4-60 Gy). The median follow-up time for living patients was 5.0 years. Five-year OS for all patients was 66%. OS at 5 years for patients who received PORT compared with patients who did not receive PORT was 71% versus 60%, respectively (hazard ratio [HR], 0.61; 95% CI, 0.30-1.44; P = .28). LRC at 5 years for patients who received PORT compared with patients who did not receive PORT was 89% versus 76%, respectively (HR, 0.44; 95% CI, 0.13-1.45; P = .17). Factors associated with decreased LRC were male sex (P = .011) and primary tumor (pT) stage (pT3/4 vs. pT1/2, P = .006). Metastasis-free survival at 5 years for patients who received PORT compared with those who did not receive PORT was 62% versus 63%, respectively (HR, 1.07; 95% CI, 0.51-2.40; P = .86).ConclusionsIn this modern series of patients with resected stage III (N2) NSCLC, patients who received PORT had higher rates of OS and LRC, but these differences were not statistically significant.

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Trends in Postoperative Intensity-Modulated Radiation Therapy Use and Its Association With Survival Among Patients With Incompletely Resected Non–Small Cell Lung Cancer

Jun

Waldman

et al. 2022

JAMA Netw Open

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IMPORTANCE National guidelines allow consideration of postoperative radiation therapy (PORT)among patients with incompletely resected non-small cell lung cancer (NSCLC). However, there is a paucity of prospective data because recently completed trials excluded patients with positive surgical margins. In addition, unlike for locally advanced NSCLC, the role of intensity-modulated radiation therapy (IMRT) for PORT remains unclear. OBJECTIVETo evaluate trends of IMRT use for PORT in the US and the association of IMRT with survival outcomes among patients with incompletely resected NSCLC. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the National Cancer Database for patients diagnosed between January 2004 and December 2019 with incompletely resected NSCLC who underwent upfront surgery with positive surgical margins followed by PORT. EXPOSURES IMRT vs 3D conformal radiation therapy (3DCRT) for PORT. MAIN OUTCOMES AND MEASURES The main outcome was overall survival. Multivariable Cox proportional hazards regression assessed the association of IMRT vs 3DCRT with overall survival. Multivariable logistic regression identified variables associated with IMRT. Propensity score matching (1:1) was performed based on variables of interest. RESULTS A total of 4483 patients (2439 men [54.4%]; median age, 67 years [IQR, 60-73 years])were included in the analysis. Of those, 2116 (47.2%) underwent 3DCRT and 2367 (52.8%) underwent IMRT. Median follow-up was 48.5 months (IQR, 31.1-77.2 months). The proportion of patients who underwent IMRT increased from 14.3% (13 of 91 patients) in 2004 to 70.7% (33 of 471 patients) in 2019 (P < .001). IMRT was associated with improved overall survival compared with 3DCRT (adjusted hazard ratio, 0.84; 95% CI, 0.78-0.91; P < .001). Similar findings were observed for 1463 propensity score-matched pairs; IMRT was associated with improved 5-year overall survival compared with 3DCRT (37.3% vs 32.2%; hazard ratio, 0.88; 95% CI, 0.80-0.96; P = .003). IMRT use was associated with receipt of treatment at an academic facility (adjusted odds ratio [aOR], 1.15; 95%

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Postoperative Radiation Therapy Is Associated With Improved Overall Survival in Incompletely Resected Stage II and III Non–Small-Cell Lung Cancer

Cited by 94 publications

References 21 publications

Survival impact of postoperative therapy modalities according to margin status in non–small cell lung cancer patients in the United States

Survival impact of postoperative therapy modalities according to margin status in non–small cell lung cancer patients in the United States

Predictors of relapse and evaluation of the role of postoperative radiation therapy in a modern series of patients with surgically resected stage III (N2) non–small cell lung cancer

Trends in Postoperative Intensity-Modulated Radiation Therapy Use and Its Association With Survival Among Patients With Incompletely Resected Non–Small Cell Lung Cancer

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