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

BACKGROUND: Effective symptom palliation can be achieved with low-dose palliative thoracic radiotherapy. In several studies, median survival was not improved with higher doses of radiation. More controversy exists regarding the impact of higher doses on 1- and 2-year survival rates. Therefore, a comparison of survival outcomes after radiotherapy with different biologically equivalent doses (equivalent dose in 2-Gy fractions, EQD2) was performed. METHODS: This was a retrospective single-institution study of 232 patients with small or non-small cell lung cancer. Most commonly 2 fractions of 8.5 Gy were prescribed (34%), followed by 10 fractions of 3 Gy or equivalent regimens (30%, EQD2 circa 33 Gy). The highest EQD2 consisted of 45 Gy. Intention-to-treat analyses were performed. RESULTS: Survival was significantly shorter with regimens of intended EQD2 < 33 Gy, e.g., 2 fractions of 8.5 Gy (median 2.5 months compared to 5.0 and 7.5 months with EQD2 of circa 33 and 45 Gy, respectively). The 2-year survival rates were 0%, 7% and 11%, respectively. In 128 prognostically favorable patients, median survival was comparable for the three different dose levels (6 - 8.3 months). The 2-year survival rates were 0%, 10%, and 13%, respectively (not statistically significant). CONCLUSION: Although most of the observed survival differences diminished after exclusion of poor prognosis patients with reduced performance status and/or progressive extrathoracic disease, a slight increase in 2-year survival rates with higher EQD2 cannot be excluded. Because of relatively small improvements, a confirmatory randomized trial in this subgroup would have to include a large number of patients.

External Validation of a Prognostic Score for Patients Receiving Palliative Thoracic Radiotherapy for Lung Cancer.

BACKGROUND: Palliative thoracic radiotherapy is a common treatment for patients with incurable lung cancer. A recent study suggested that a prognostic score based on performance status and N and M stage predicts survival and might support decision-making (eg, when deciding about fractionation). Our aim was to perform a validation study in an independent, larger dataset. PATIENTS AND METHODS: This was a retrospective single-institution study of 232 patients with small- or non-small-cell lung cancer, with methodology comparable with that of the original study. Three subgroups were created, based on the point sum resulting from assessment of performance status and N and M stage (10-11, 12-14, 15-17 points). RESULTS: Performance status and N and M stage were significantly associated with overall survival after palliative radiotherapy in uni- and multivariate analyses. An unfavorable prognosis (10-11 points) was predicted in 56 patients (24%). Their median survival was 1.2 months. The intermediate group consisted of 137 patients (59%) with a median survival of 5.3 months. A favorable prognosis (15-17 points) was predicted in 39 patients (17%), whose median survival was 8.2 months. The difference between the intermediate and favorable subgroups did not reach statistical significance (P = .1, as compared with P = .0001 for the remaining 2 comparisons). CONCLUSION: In the original study, the median survival of patients in the 3 different prognostic strata was 2, 6, and 38 months. Except for the favorable subgroup, the validation study confirmed these results. Given the large, clinically highly relevant discrepancy (8 vs. 38 months), additional studies are needed in order to inform therapeutic decisions in patients with favorable point sum of 15 to 17.

Impact of early palliative interventions on the outcomes of care for patients with non-small cell lung cancer.

PURPOSE: The aim of this study is to address the question "does early palliative care in addition to standard oncology care or late additional palliative care improve patterns of terminal care in patients who died from non-small cell lung cancer (NSCLC)?" METHODS: We performed retrospective single-institution study of 286 patients. Palliative care was provided by a dedicated multidisciplinary palliative care team (PCT). An arbitrarily defined cutoff of 3 months before death was chosen to distinguish between early and late additional palliative care. Referral was at the discretion of the treating physicians who provided standard anticancer treatments. RESULTS: Patients who received early (8 %) or late (27 %) additional palliative care were significantly younger than those who did not receive additional palliative care. The likelihood of active anticancer treatment in the last month of life was lowest in the early additional palliative care group, p = 0.03. Patients who received early or late additional palliative care were significantly less likely to lack a documented resuscitation preference, p = 0.0001. Patients who received early additional palliative care were significantly less likely to become hospitalized in the last 3 months of life, p = 0.003. Place of death was also numerically different, with hospital death occurring in 33 % of patients who received early additional palliative care, as compared to 48 % in the late and 50 % in the no PCT group, p = 0.35. Anticancer treatment intensity was not reduced if the PCT contributed to the overall management. CONCLUSION: Early additional palliative care resulted in relevant improvements. The optimal timing of this intervention should be examined prospectively.