ASTRO guideline: Concurrent chemo now recommended for some patients with stage III NSCLC

Chemotherapy should be added to thoracic external beam radiation therapy (EBRT) as palliative therapy for certain patients with incurable stage III non small-cell lung cancer (NSCLC), including those who are able to tolerate chemotherapy and have a life expectancy longer than 3 months. These recommendations are included in an updated guideline from the American Society for Radiation Oncology (ASTRO) published in Practical Radiation Oncology.

The new guideline language is a departure from the 2011 ASTRO guideline, which stated that there was no added benefit of concurrent chemoradiation in the palliation of lung cancer symptoms.

The update was based on a systematic literature review of studies published from March 2010 through July 2016; ultimately, 31 randomized controlled trials, meta-analyses, and prospective studies were evaluated. The eight-member guideline task force was comprised of radiation oncologists who specialize in lung cancer, a medical oncologist, and a community practice representative. 

The recommendation to add chemotherapy to EBRT for some stage III patients is supported by evidence from two randomized controlled trials in patients with incurable stage III NSCLC that were published after the 2011 guideline was released, the task force indicated.

In particular, a 2013 study by Strom et al, showed an improvement in median survival and overall survival at both 1 and 2 years and better quality of life (QOL), social functioning, and physical functioning scores in a group of patients treated with concurrent chemoradiation—despite an increase in the rate of grade 3 esophagitis—when compared with patients treated with EBRT alone.

The new recommendation applies to the following stage III patients:

• Candidates for chemotherapy
• Patients with an Eastern Cooperative Oncology Group (ECOG) Performance Score of 0 to 2
• Patients with a life expectancy of at least 3 months.

In such patients, “administration of a platinum-containing chemotherapy doublet concurrently with moderately hypofractionated palliative thoracic radiation therapy is recommended over treatment with either modality alone,” according to the guideline.

The strength of the recommendation was considered strong, the quality of evidence was graded as moderate, and 100% of panel members reached consensus on the recommendation.

“Patients in this setting typically receive 2 to 3 weeks of daily radiation, during which they might expect to have one to two weeks of clinically significant, treatment-related side effects—most commonly inflammation of the esophagus,” said Benjamin Moeller, MD, PhD, chair of the guideline task force and a radiation oncologist at the Levine Cancer Institute in Charlotte, NC. “Following treatment, however, these patients experience a more robust and durable stabilization of their quality of life, including less pain and fewer symptoms.”

Two of the three clinical trials in the stage III patients reported significantly increased rates of esophagitis with concurrent chemotherapy, with rates of high-grade esophagitis varying from 2% to 30%.

“Toxicity concerns merit careful attention when patients are being treated with palliative intent; however, the QOL data from the Strom study place these toxicity findings in an important context, suggesting there is a temporary tradeoff in QOL during chemoradiation that is offset by gains in global QOL scores over time, presumably related to improved durability of symptom palliation from more aggressive therapy,” the guideline task force wrote. “These gains will be larger for those with longer survival times, underscoring the importance of not extrapolating these findings beyond those patients matching key eligibility criteria in these studies.”

For all other patients with incurable NSCLC, including those with stage IV disease, the evidence remains insufficient to support concurrent thoracic chemoradiation.

To read more about this update, click here.