Improving outcomes in non-small cell lung cancer; population analysis of radical radiotherapy

Service Improvements and Workload Increases: Royal College of Radiologists (RCR) Re-Audit of Curative Intent Radiotherapy for Non-Small Cell Lung Cancer (NSCLC)

AIMS

The Royal College of Radiologists (RCR) audit of radical radiotherapy (RR) for patients with non-small cell lung cancer (NSCLC) in 2013 concluded that there was under-treatment compared to international comparators and marked variability between cancer networks. Elderly patients were less likely to receive guideline recommended treatments. Access to technological developments was low. Various national and local interventions have since taken place. This study aims to re-assess national practice.

MATERIALS AND METHODS

Radiotherapy departments completed one questionnaire for each patient started on RR for 4 weeks in January 2023.

RESULTS

Ninety-three percent of centres returned data on 295 patients. RR has increased 70% since 2013 but patients on average wait 20% longer to start treatment (p = 0.02). Staging investigations were often outside a desirable timeframe (79% of PET/CT scans). Advanced planning techniques are used more frequently: 4-dimensional planning increased from 33% to 90% (P < 0.001), cone beam imaging from 67% to 97% (p < 0.001) and colleague led peer review increased from 41% to 73% (P < 0.001).

CONCLUSION

There have been significant improvements in care. There has been a considerable increase in clinical oncology workload with evidence of stress on the system that requires additional resourcing.

Utilisation of radiotherapy in lung cancer: A scoping narrative literature review with a focus on the introduction of evidence-based therapeutic approaches in Europe

Background and purpose

The aim of this study was to review the published studies on the utilisation of radiotherapy in lung cancer (both small and non-small cell lung cancer, SCLC and NSCLC) patients in European countries with a population-based perspective.

Material and methods

A literature search since January 2000 until December 2022 was carried out. Only English-published papers were included, and only European data was considered. PRISMA guidelines were followed. A scoping narrative review was undertaken due to the hetereogeneity of the published papers.

Results

38 papers were included in the analysis, with the majority from the Netherlands (52.6%) and the UK (18.4%). Large variability is observed in the reported radiotherapy utilisation, around 40% for NSCLC in general and between 26 and 42% in stage I NSCLC. Stereotactic body radiotherapy (SBRT) shows a wide range of utilisation across countries and over time, from 8 to 63%. Similary, in stage III lung cancer, chemoradiotherapy (CRT) utilisation varied considerably (11-70%). Eleven studies compared radiotherapy utilisation between older and younger age-groups, showing that younger patients receive more CRT, while the opposite applies for SBRT. An widespreadlack of data on relevant covariates such as comorbidty and health-services related variables is observed.

Conclusion

The actual utilisation of radiotherapy for lung cancer reported in patterns-of-care studies (POCs) is notably lower than the evidence-based optimal utilisation. Important variability is observed by country, time period, stage at diagnosis and age. A wider use of POCs should be promoted to improve our knowledge on the actual application of evidence-based treatment recommendations.

Improving Outcomes in NSCLC: Optimum Dose Fractionation in Radical Radiotherapy Matters

INTRODUCTION

We analyzed a comprehensive national radiotherapy data set to compare outcomes of the most frequently used moderate hypofractionation regimen (55 Gy in 20 fractions) and conventional fractionation regimen (60-66 Gy in 30-33 fractions).

METHODS

A total of 169,863 cases of NSCLC registered in England from January 2012 to December 2016 obtained from the Public Health England were divided into cohort 1 (training set) diagnosed in 2012 to 2013 and cohort 2 (validation set) diagnosed in 2014 to 2016. Radiotherapy data were obtained from the National Radiotherapy Dataset and linked by National Health Service number to survival data from the Office of National Statistics and Hospital Episode Statistics, from which surgical data and Charlson comorbidity index were obtained. Of 73,186 patients with stages I to III NSCLC, 12,898 received radical fractionated radiotherapy (cohort 1-4894; cohort 2-8004). The proportional hazards model was used to investigate overall survival from time of diagnosis. Survival was adjusted for the prognostic factors of age, sex, stage of disease, comorbidity, other radical treatments, and adjuvant chemotherapy, and the difference between the treatment schedules was summarized by hazard ratio (HR) and 95% confidence interval. The significance of any difference was evaluated by the log likelihood test.

RESULTS

Of patients with stages I to III NSCLC, 17% to 18% received radical fractionated radiotherapy. After adjustment for independent prognostic factors of age, stage, comorbidity, and other radical and adjuvant treatments, patients in cohort 1 treated with the 2.75 Gy per fraction regimen had a median survival of 25 months compared with 29 months for patients treated with the 2 Gy per fraction regimen (HR = 1.16, p = 0.001). Similarly, in cohort 2, the respective median survival values were 25 and 28 months (HR = 1.10, p = 0.02).

CONCLUSIONS

Big data analysis of a comprehensive national cohort of patients with NSCLC treated in England suggests that compared with a 4-week regimen of 55 Gy in 20 fractions, a 6-week regimen of conventional daily fractionation to a dose of 60 to 66 Gy at 2 Gy per fraction is associated with a survival benefit. Within the limitations of the retrospective big data analysis with potential selection bias and in the absence of randomized trials, the results suggest that conventional fractionation regimens should remain the standard of care.

Optimal and actual rates of Stereotactic Ablative Body Radiotherapy (SABR) utilisation for primary lung cancer in Australia

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Stereotactic Ablative Body Radiotherapy (SABR) plays a major role in the management of early-stage non-small cell lung cancer (NSCLC).

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An evidence-based model is developed to estimate optimal rates of lung SABR utilisation within the Australian population.

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Optimal utilisation rates are compared against actual utilisation rates to evaluate service provision.

Background and purpose

Radiotherapy utilisation rates considerably vary across different countries and service providers, highlighting the need to establish reliable benchmarks against which utilisation rates can be assessed. Here, optimal utilisation rates of Stereotactic Ablative Body Radiotherapy (SABR) for lung cancer are estimated and compared against actual utilisation rates to identify potential shortfalls in service provision.

Materials and Methods

An evidence-based optimal utilisation model was constructed after reviewing practice guidelines and identifying indications for lung SABR based on the best available evidence. The proportions of patients likely to develop each indication were obtained, whenever possible, from Australian population-based studies. Sensitivity analysis was performed to account for variations in epidemiological data. Practice pattern studies were reviewed to obtain actual utilisation rates.

Results

A total of 6% of all lung cancer patients were estimated to optimally require SABR at least once during the course of their illness (95% CI: 4–6%). Optimal utilisation rates were estimated to be 32% for stage I and 10% for stage II NSCLC. Actual utilisation rates for stage I NSCLC varied between 6 and 20%. For patients with inoperable stage I, 27–74% received SABR compared to the estimated optimal rate of 82%.

Conclusion

The estimated optimal SABR utilisation rates for lung cancer can serve as useful benchmarks to highlight gaps in service delivery and help plan for more adequate and efficient provision of care. The model can be easily modified to determine optimal utilisation rates in other populations or updated to reflect any changes in practice guidelines or epidemiological data.

Identification and Prognostic Value Exploration of Radiotherapy Sensitivity-Associated Genes in Non-Small-Cell Lung Cancer

Background

Non-small-cell lung cancer (NSCLC) is a prevalent malignancy with high mortality and poor prognosis. The radiotherapy is one of the most common treatments of NSCLC, and the radiotherapy sensitivity of patients could affect the individual prognosis of NSCLC. However, the prognostic signatures related to radiotherapy response still remain limited. Here, we explored the radiosensitivity-associated genes and constructed the prognostically predictive model of NSCLC cases.

Methods

The NSCLC samples with radiotherapy records were obtained from The Cancer Genome Atlas database, and the mRNA expression profiles of NSCLC patients from the GSE30219 and GSE31210 datasets were obtained from the Gene Expression Omnibus database. The Weighted Gene Coexpression Network Analysis (WGCNA), univariate, least absolute shrinkage and selection operator (LASSO), multivariate Cox regression analysis, and nomogram were conducted to identify and validate the radiotherapy sensitivity-related signature.

Results

WGCNA revealed that 365 genes were significantly correlated with radiotherapy response. LASSO Cox regression analysis identified 8 genes, including FOLR3, SLC6A11, ALPP, IGFN1, KCNJ12, RPS4XP22, HIST1H2BH, and BLACAT1. The overall survival (OS) of the low-risk group was better than that of the high-risk group separated by the Risk Score based on these 8 genes for the NSCLC patients. Furthermore, the immune infiltration analysis showed that monocytes and activated memory CD4 T cells had different relative proportions in the low-risk group compared with the high-risk group. The Risk Score was correlated with immune checkpoints, including CTLA4, PDL1, LAG3, and TIGIT.

Conclusion

We identified 365 genes potentially correlated with the radiotherapy response of NSCLC patients. The Risk Score model based on the identified 8 genes can predict the prognosis of NSCLC patients.

Mucoadhesive and pH responsive fucoidan-chitosan nanoparticles for the oral delivery of methotrexate

Considering the potential of mucoadhesive properties of nanoparticles in oral delivery, this work describes the preparation and characterization of fucoidan/chitosan nanoparticles loaded with methotrexate (MTX) intended to lung cancer therapy. The nanoparticles were produced and characterized in terms of size, surface charge, entrapment efficiency, and morphology. The size of the developed nanoparticles was around 300 nm, the zeta potential value was negative (ca. -30 mV), revealing a low tendency to aggregate. The self-assembled fucoidan/chitosan nanoparticles were stable at acidic pH (1.6-5.2), without disintegration under pH 6-7.4, revealing resistance through the gastrointestinal tract, and were found to be mucoadhesive suggesting ability to enhance drug oral bioavailability. Lung cancer cells quickly internalized the developed nanoparticles. Moreover, MTX-loaded fucoidan/chitosan nanoparticles up to 245 μg mL-1 in polymer equivalent to 23.5 μg mL-1 of MTX were safe towards fibroblasts but hampered lung cancer cell proliferation mediated by an apoptotic process. MTX-loaded nanoparticles were 7-fold more effective in inhibiting lung cancer cells proliferation than the free drug, showing the potential of fucoidan-chitosan nanoparticles to improve the cytotoxicity of free methotrexate on A549 lung cancer cells. These results also demonstrate that fucoidan/chitosan nanoparticles may provide a suitable platform for poor-water soluble compounds' oral delivery.

What is the optimal radiotherapy utilization rate for lung cancer?-a systematic review

Lung cancer is a major cause of morbidity and mortality globally. Although radiotherapy (RT) may be beneficial in the radical and/or palliative management of many lung cancer patients, it is underutilized worldwide. Population-level development of RT resources requires estimates of optimal radiotherapy utilization rates (ORUR) and actual radiotherapy utilization rate (ARUR). A systematic review of PubMed database for English-language articles from January 2009 to January 2019 was performed. Keywords included utilization, underutilization, demand, epidemiologic, benchmark, RT and cancer. Data abstracted included: study population, diagnosis, stage, year of diagnosis, timing of RT, intent of RT, ARUR, and ORUR. Eligible studies provided ARUR or ORUR for lung cancer, small cell lung cancer (SCLC), or non-small cell lung cancer (NSCLC). Included ARUR were based on at least 1,000 patients who were diagnosed or treated in 2009 or later. Included ORUR were based on evidence review or ARUR in 2009 or later. The initial search strategy yielded 1,627 unique abstracts. After review, 105 articles were determined appropriate for full-text review. From these, a final set of 21 articles met all inclusion criteria. In eight papers, ORUR was estimated. Estimated lifetime ORUR ranged from 61% to 82%. Methods for estimation included the evidence-based guideline model, Malthus model, and criterion-based benchmarking (CBB) model. The majority of estimates (6/8) used the evidence-based guideline model. Fifteen papers provided ARUR on lung cancer, inclusive of SCLC and NSCLC. ARUR within 9 months to 1 year of diagnosis ranged from 39% to 46%. Lifetime ARUR was an estimated 52% in Ontario, Canada. Palliative intent ARUR ranged from 12% in Central Poland to 46% in Ontario, Canada. RT is underutilized for lung cancer globally, and there is wide geographical variation in the level of underutilization.