Optimal Radiation Dose for Stage III Lung Cancer-Should "Definitive" Radiation Doses Be Used in the Preoperative Setting?

Embracing a new era of echocardiography-guided percutaneous and non-fluoroscopical procedure for structure heart disease

The advancement of catheter-based interventional techniques represents a significant evolution in cardiovascular medicine. However, traditional methods that rely on fluoroscopic guidance present considerable limitations including radiation exposure and contrast agent-related risks and the heavy load-caused lead suits. In response, zero or low X-ray emerge, including percutaneous and non-fluoroscopical (PAN) procedure coming as a transformative solution, particularly in treating congenital heart disease, valvular disease, and arrhythmias. These methods minimize the risk of iatrogenic injuries associated with radiative procedures. Innovative PAN procedures and methodologies have been developed to enhance imaging, transcatheter interventions, safety, and accuracy, overcoming previous limitations. By eliminating radiation and expanding accessibility, PAN procedures offer a safe, effective, and economically viable alternative to traditional methods, ushering in a new era of minimally invasive cardiovascular treatment.

Immunotherapy After Chemotherapy and Radiation for Clinical Stage III Lung Cancer

IMPORTANCE

The 2017 international PACIFIC trial established a role for immunotherapy after chemoradiation for unresectable stage III non-small cell lung cancer (NSCLC). However, in the US, patients with NSCLC commonly differ from clinical trial populations in terms of age, health, access to care, and treatment course, which may all factor into the efficacy of immunotherapy.

OBJECTIVE

To determine the outcomes of immunotherapy use in unresectable stage III NSCLC in the general US population.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed the National Cancer Database for patients diagnosed with clinical stage III NSCLC between 2015 and 2017 with follow-up through the end of 2018 who were treated with chemotherapy and radiation. Data were analyzed January 2022.

MAIN OUTCOMES AND MEASURES

Mortality hazard in a multivariable Cox proportional hazards model and survival among a propensity-matched sample treated with chemotherapy and radiation, with and without immunotherapy.

RESULTS

A total of 23 811 patients with clinical stage III NSCLC with median (IQR) age 66 (59-72) years met inclusion criteria (10 454 [43.9%] women; 564 [2.4%] Asian, 2930 [12.3%] Black, 20 077 [84.3%] White patients), including 209 (16.1%) patients with multiple comorbidities and 1297 (5.4%) immunotherapy recipients. Immunotherapy after chemotherapy and radiation was associated with reduced mortality (hazard ratio [HR], 0.74; 95% CI, 0.67-0.82; P < .001). Among a propensity-matched sample, immunotherapy was associated with superior 3-year survival (52% [1297 patients at 0 months, 56 patients at 36 months] vs 44% [2594 patients at 0 months, 173 patients at 36 months]; P < .001). The treatment of 833 patients who received immunotherapy (64.2%) differed from the PACIFIC trial protocol, including 221 patients (17.0%) who received radiation doses outside of the protocol range and 731 patients (56.4%) who started immunotherapy more than 6 weeks after radiation was completed. The survival advantage of immunotherapy persisted when initiated up to 12 weeks after radiation was completed (HR, 0.75; 95% CI, 0.61-0.92). Among patients who received radiation outside the PACIFIC protocol range, the survival advantage of immunotherapy was not significant (HR, 0.87; 95% CI, 0.69-1.01).

CONCLUSIONS AND RELEVANCE

In this cohort study, immunotherapy after chemotherapy and radiation for stage III NSCLC was associated with a survival advantage in the general US population despite two-thirds of patients treated differently than the PACIFIC protocol. The findings suggest there may be flexibility in the timing of immunotherapy initiation after radiation; further study is warranted to clarify the clinical benefits of immunotherapy.