Inoperable non-small cell lung cancer: radiation with or without chemotherapy

Combined Modality Treatment of Locally Advanced Lung Cancer

This paper describes the mechanisms of action of ionizing radiations combined with antineoplastic drugs. Some relevant drugs for the combined modality treatments of locally advanced lung cancer are reported. The meta-analyses including randomized trials comparing single agent (radiotherapy or chemotherapy) versus combined chemoterapy and radiotherapy in patients with unresectable non small cell lung cancer and limited small cell lung cancer are then reviewed. The clinical outcome in relation to different schedules of chemoradiotherapy (sequential, alternating and concurrent) is also focussed.

A Pilot Study (SWOG S0429) of Weekly Cetuximab and Chest Radiotherapy for Poor-Risk Stage III Non-Small Cell Lung Cancer

PURPOSE

Stage III non-small cell lung cancer (NSCLC) patients with poor performance status (PS) or co-morbidities are often not candidates for standard chemoradiotherapy (chemoRT) due to poor tolerance to treatments. A pilot study for poor-risk stage III NSCLC patients was conducted combining cetuximab, a chimeric monoclonal antibody targeting epidermal growth factor receptor (EGFR), with chest radiation (RT).

METHODS

Stage III NSCLC patients with Zubrod PS 2, or Zubrod PS 0-1 with poor pulmonary function and co-morbidities prohibiting chemoRT were eligible. A loading dose of cetuximab (400 mg/m(2)) was delivered week 1, followed by weekly cetuximab (250 mg/m(2))/RT to 64.8 Gy in 1.8 Gy daily fractions, and maintenance weekly cetuximab (250 mg/m(2)) for 2 years or until disease progression. H-score for EGFR protein expression was conducted in available tumors.

RESULTS

Twenty-four patients were enrolled. Twenty-two were assessed for outcome and toxicity. Median survival was 14 months and median progression-free survival was 8 months. The response rate was 47% and disease control rate was 74%. Toxicity assessment revealed 22.7% overall ≥Grade 3 non-hematologic toxicities. Grade 3 esophagitis was observed in one patient (5%). The skin reactions were mostly Grade 1 or 2 except two of 22 (9%) had Grade 3 acne and one of 22 (5%) had Grade 3 radiation skin burn. Grade 3-4 hypomagnesemia was seen in four (18%) patients. One patient (5%) had elevated cardiac troponin and pulmonary emboli. H-score did not reveal prognostic significance. An initially planned second cohort of the study did not commence due to slow accrual, which would have added weekly docetaxel to cetuximab/RT after completion of the first cohort of patients.

CONCLUSION

Concurrent weekly cetuximab/chest RT followed by maintenance cetuximab for poor-risk stage III NSCLC was well tolerated. Further studies with larger sample sizes will be useful to establish the optimal therapeutic ratio of this regimen.

Predicting 2-year survival for radiation regimens in advanced non-small cell lung cancer

AIMS

Total dose, dose per fraction, number of fractions and treatment time are important determinants of the biological effect of a radiation regimen. Several randomised clinical trials (RCTs) have tested a variety of dosing regimens in advanced unresected non-small cell lung cancer, but survival remains poor. This work used past RCT data to develop and validate a predictive model that could help in designing new radiation regimens for successful testing in RCTs.

MATERIALS AND METHODS

Eleven RCTs that compared radiation regimens alone were used to define the relationship between radiation regimens and 2-year survival. On the basis of this relationship, predictive models were developed. Predicted values were internally and externally validated against observed values from the same 11 RCTs and 21 other RCTs. Scatter plots and Pearson's correlation coefficient (r) were used for validation. Finally, regimens were explored that could improve survival.

RESULTS

Increments in the total dose, dose per day and the number of treatment days were associated with improved survival; increments in dose-squared and treatment weeks were associated with reduced survival. The observed and predicted values were similar on internal (r = 0.96) and external validation (r = 0.76). Regimens that delivered a higher total dose over a shorter time had higher survival rates compared with the standard (60 Gy, 30 fractions, 6 weeks); survival may be improved by delivering the standard treatment in 5 weeks rather than 6 weeks.

CONCLUSION

The developed model can predict the effect of thoracic radiation on survival in advanced non-small cell lung cancer patients. It is a useful tool for designing new radiation regimens for clinical trials.

Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

OBJECTIVES

Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients.

METHODS

Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews.

RESULTS

For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy alone. Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate. The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival.

CONCLUSIONS

Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation.

ACR appropriateness criteria nonsurgical treatment for non-small-cell lung cancer: poor performance status or palliative intent

Radiation therapy plays a potential curative role in the treatment of patients with non-small-cell lung cancer with locoregional disease who are not surgical candidates and a palliative role for patients with metastatic disease. Stereotactic body radiation therapy is a relatively new technique in patients with early-stage non-small-cell lung cancer. A trial from RTOG(®) reported >97% local control at 3 years. For patients with locally advanced disease, thoracic radiation to a dose of 60 Gy remains the standard of care. Sequential chemotherapy or radiation alone can be used for patients with poor performance status who cannot tolerate more aggressive approaches. Chemotherapy should be used for patients with metastatic disease. Radiation therapy is useful for palliation of symptomatic tumors, and a dose of approximately 30 Gy is commonly used. Endobronchial brachytherapy is useful for patients with symptomatic endobronchial tumors. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Combined radio- and chemotherapy for non-small cell lung cancer: systematic review of landmark studies based on acquired citations

The important role of combined chemoradiation for several groups of patients with non-small cell lung cancer (NSCLC) is reflected by the large number of scientific articles published during the last 30 years. Different measures of impact and clinical relevance of published research are available, each with its own pros and cons. For this review, article citation rate was chosen. Highly cited articles were identified through systematic search of the citation database Scopus. Among the 100 most often cited articles, meta-analyses (n = 5) achieved a median of 203 citations, guidelines (n = 7) 97, phase III trials (n = 29) 168, phase II trials (n = 21) 135, phase I trials (n = 7) 88, and others combined 115.5 (p = 0.001). Numerous national and international cooperative groups and several single institutions were actively involved in performing often cited, high-impact trials, reflecting the fact that NSCLC is a world-wide challenge that requires research collaboration. Platinum-containing combinations have evolved into a standard of care, typically administered concurrently. The issue of radiotherapy fractionation and total dose has also been studied extensively, yet with less conclusive results. Differences in target volume definition have been addressed. However, it was not possible to test all theoretically possible combinations of radiotherapy regimens, drugs, and drug doses (lower radiosensitizing doses compared to higher systemically active doses). That is why current guidelines offer physicians a choice of different, presumably equivalent treatment alternatives. This review identifies open questions and strategies for further research.

Inoperable stage III non-small cell lung cancer: Current treatment and role of vinorelbine

Most lung cancer patients are diagnosed with a non-resectable disease; and around 40% in advanced stages. Stage III non-small cell lung cancer (NSCLC) is a heterogeneous disease with great variations in its clinical extent which presents a major therapeutic challenge. Although chemo-radiotherapy treatment has become the most widely used, there is currently no consensus on the best standard treatment and the experience of the therapy team plays an important role in the decision taking. We review the treatment of inoperable stage III NSCLC and the role of concomitant vinorelbine in this clinical scenario.

Combined Modality Treatment of Non-Small-Cell Lung Cancer

Among all nonmetastatic non-small-cell lung cancer (NSCLC) patients, the best survival rates are observed in patients who undergo surgery. Nevertheless, 5-year survival rates vary between 20% and 60% depending on the stage of the disease. Several combined modality treatments have been investigated to improve outcome in localized NSCLC. These include local treatment, systemic before local treatment, concomitant systemic and local treatments, and systemic after local treatment. Preoperative irradiation was shown to be of no benefit on local recurrence rates or overall survival. Even doses of radiation >/=40 grays (Gy) were associated with lower survival rates. Postoperative irradiation did not influence survival in stage III disease and seemed to be deleterious in stages I and II disease. Modern radiotherapy techniques might be of interest in this setting but have been insufficiently tested. The early phase III studies of preoperative chemotherapy versus primary surgery in stage III NSCLC showed a tremendous difference in favor of chemotherapy. A larger study did not confirm these results but suggested that preoperative chemotherapy might have a greater effect in stages I and II of the disease. In locally advanced disease, chemotherapy followed by radiotherapy was shown to increase survival when compared with radiotherapy alone. Studies comparing concurrent chemoradiation with radiotherapy only were in favor of the concomitant schedule, which improved local control. Promising results have been reported with chemoradiation followed by surgery in stage IIIa and even stage IIIb disease. Randomized studies of postoperative chemotherapy demonstrated a 5% improvement in 5-year survival over adjuvant-free treatment. Postoperative chemoradiation showed no advantage over postoperative radiotherapy. Several trials that are ongoing or whose accrual was recently completed should further define the role of perioperative chemotherapy in resectable NSCLC and of trimodality treatments in advanced disease. Targeted agents are being developed in the postoperative setting. New schedules of chemoradiation with higher therapeutic indexes are also being investigated in nonresectable stage III NSCLC.

Preclinical and pilot clinical studies of docetaxel chemoradiation for Stage III non-small-cell lung cancer

PURPOSE

Local and distant failure rates remain high despite aggressive chemoradiation (CRT) treatment for Stage III non-small-cell lung cancer. We conducted preclinical studies of docetaxel's cytotoxic and radiosensitizing effects on lung cancer cell lines and designed a pilot study to target distant micrometastasis upfront with one-cycle induction chemotherapy, followed by low-dose radiosensitizing docetaxel CRT.

METHODS AND MATERIALS

A preclinical study was conducted in human lung cancer cell lines NCI 520 and A549. Cells were treated with two concentrations of docetaxel for 3 h and then irradiated immediately or after a 24-h delay. A clonogenic survival assay was conducted and analyzed for cytotoxic effects vs. radiosensitizing effects of docetaxel. A pilot clinical study was designed based on preclinical study findings. Twenty-two patients were enrolled with a median follow-up of 4 years. Induction chemotherapy consisted of 75 mg/m(2) of docetaxel and 75 mg/m(2) of cisplatin on Day 1 and 150 mg/m(2) of recombinant human granulocyte colony-stimulating factor on Days 2 through 10. Concurrent CRT was started 3 to 6 weeks later with twice-weekly docetaxel at 10 to 12 mg/m(2) and daily delayed radiation in 1.8-Gy fractions to 64.5 Gy for gross disease.

RESULTS

The preclinical study showed potent cytotoxic effects of docetaxel and subadditive radiosensitizing effects. Delaying radiation resulted in more cancer cell death. The pilot clinical study resulted in a median survival of 32.6 months for the entire cohort, with 3- and 5-year survival rates of 50% and 19%, respectively, and a distant metastasis-free survival rate of 61% for both 3 and 5 years. A pattern-of-failure analysis showed 75% chest failures and 36% all-distant failures. Therapy was well tolerated with Grade 3 esophagitis observed in 23% of patients.

CONCLUSIONS

One-cycle full-dose docetaxel/cisplatin induction chemotherapy with recombinant human granulocyte colony-stimulating factor followed by pulsed low-dose docetaxel CRT is promising with regard to its antitumor activity, low rates of distant failure, and low toxicity, suggesting that this regimen deserves further investigation.

Induction chemotherapy followed by concurrent chemoradiation for patients with non-operable stage III non-small-cell lung cancer

Combined modality treatment with chemotherapy (CT) and radiotherapy (RT) in stage III non-small-cell lung cancer is considered as standard therapy. As concomitant CT appears to be beneficial, the choice of anticancer agents and the role of induction chemotherapy is still unresolved. We present our experience based on an induction CT scheme with carboplatin plus paclitaxel followed by RT and concomitant CT. 31 patients with non-operable stage IIIA or IIIB NSCLC without pleural effusion were included in this study: 30 males, 1 female; median age 66 years (range: 50-81); 32% with non-operable stage IIIA and 68% with stage IIIB without pleural effusion; 61% squamous cell carcinoma, 32% adenocarcinoma and 7% other histologies. Regarding performance status (PS), 9.7% PS 0 and 90% PS 1 were included. Patients received 3 courses of induction CT with carboplatin AUC=6 and paclitaxel 175 mg/m(2), administrated i.v. on day 1 of each 21-day cycle, followed by thoracic irradiation (total dose 60-65 Gy, daily fractions 1.8-2 Gy) with two concurrent courses of carboplatin/paclitaxel. 16.2% of the patients achieved complete response, 48.4% partial response, 25.8% stable disease and 9.6% progression of disease. Median progression-free and overall survival was 12 and 18 months, respectively. The most frequent haematological toxicities were grade (G) 3 anaemia in 19.3%, G3 neutropenia in 9.6% and G4 neutropenia in 12.9%. Esophageal G2 toxicity (RTOG) was observed in 28.1% of cases. The induction CT followed by concomitant chemoradiation used in this study appears feasible, safe and effective when administered to an unselected inoperable NSCLC stage III patient cohort in the everyday routine clinical practice. Further, our results are comparable to previously published phase III studies.

Induction Concurrent Chemoradiotherapy Using Paclitaxel and Carboplatin Combination Followed by Surgery in Locoregionally Advanced Non-Small Cell Lung Cancer – Asian Experience

Introduction: It has been established that combined chemoradiotherapy treatment benefits selected patients with stage III Non Small Cell Lung Cancer (NSCLC). However, locoregional recurrence still poses a problem. The addition of surgery as the third modality may provide a possible solution. We report our experience of using the triple-modality approach in this group of patients. Materials and Methods: This is a retrospective review of 33 patients with stage III NSCLC treated between 1997 and 2005. Patients have good performance status and no significant weight loss. There were 26 males (79 %) with median age of 63 years (range, 43 to 74) and median follow-up of 49 months. Seventy-six percent had Stage IIIA disease. Chemotherapy consisted of paclitaxel at 175 mg/m2 over 3 hours followed by carboplatin at AUC of 5 over 1 hour. Thoracic radiotherapy was given concurrently with the second and third cycles of chemotherapy. All patients received 50 Gray in 25 fractions over 5 weeks. Results: The main toxicities were grade 3/4 neutropenia (30%), grade 3 infection (15 %) and grade 3 oesophagitis (9%). Twenty-five patients (76%) underwent surgery. Of the 8 who did not undergo surgery, 1 was deemed medically unfit after induction chemoradiotherapy and 4 had progressive disease; 3 declined surgery. Nineteen patients (58 %) had lobectomy and 6 had pneumonectomy. The median overall survival was 29.9 months and 12 patients are still in remission. Conclusion: The use of the triple-modality approach is feasible, with an acceptable tolerability and resectability rate in this group of patients. Key words: Chemoradiotherapy, Neoadjuvant treatment, Surgery

Phase II Multicenter Trial with Carboplatin and Gemcitabine Induction Chemotherapy Followed by Radiotherapy Concomitantly with Low-Dose Paclitaxel and Gemcitabine for Stage IIIA and IIIB Non-small Cell Lung Cancer

INTRODUCTION

The optimal combination of concomitant radiotherapy (RT) and chemotherapy in stage III unresectable non-small cell lung cancer (NSCLC) remains unclear. The role of induction chemotherapy with carboplatin/gemcitabine regimen has not been established in stage III NSCLC.

METHODS

Forty-two stage III NSCLC patients, 41 assessable, with a median age of 60 years and good performance status, entered this trial between January 2003 and November 2004. They received carboplatin area under the curve 5 on day 1 and gemcitabine 1000 mg/m2 on days 1 + 8 every 3 weeks for two cycles, followed on day 50 by RT 60 Gy, concomitantly with paclitaxel 50 mg/m2 and gemcitabine 100 mg/m2 on days 1 + 8 every 3 weeks for two cycles.

RESULTS

After induction, the partial response (PR) was 73.1% and stable disease was 24.4%. Disease progressed in one patient. After RT and paclitaxel/gemcitabine, 22% achieved a complete response and 73% a PR, and 5% had disease progression. The median survival was 25 months, the 1-year survival rate was 73.2%, and the 2-year survival rate was 50.5%. During concomitant RT and chemotherapy, grade 3 neutropenia, thrombocytopenia, and anemia occurred in eight, three, and three patients, respectively, and grade 4 neutropenia and thrombocytopenia in one patient each. One patient developed an esophageal fistula and died shortly after, which was considered a grade 5 toxicity; one patient developed grade 4 interstitial pneumonitis, and three patients developed grade 3 esophagitis.

CONCLUSION

This regimen appears to be effective and was well tolerated. Further studies using this approach are warranted in patients with stage III NSCLC.

Treatment of Non-small Cell Lung Cancer-Stage IIIA

STUDY OBJECTIVES

Stage IIIA non-small cell lung cancer represents a relatively heterogeneous group of patients with metastatic disease to the ipsilateral mediastinal (N2) lymph nodes and also includes T3N1 patients. Presentations of disease range from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky multistation nodal disease. This review explores the published clinical trials to make treatment recommendations in this controversial subset of lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

Systematic searches were made of MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, focusing primarily on randomized trials, with inclusion of selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

MEASUREMENT AND RESULTS

The evidence derived from the literature now appears to support routine adjuvant chemotherapy after complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. However, using neoadjuvant therapy followed by surgery for known stage IIIA lung cancer as a routine therapeutic option is not supported by current published randomized trials. Combination chemoradiotherapy, especially delivered concurrently, is still the preferred treatment for prospectively recognized stage IIIA lung cancer with all degrees of mediastinal lymph node involvement. Current and future trials may modify these recommendations.

CONCLUSIONS

Multimodality therapy of some type appears to be preferable in all subsets of stage IIIA patients. However, because of the relative lack of consistent randomized trial data in this subset, the following evidence-based treatment guidelines lack compelling evidence in most scenarios.

The role of radiotherapy in lung cancer: Where is the evidence?

Radiotherapy is one of the main treatment modalities in lung cancer, contributing to both its cure and palliation. Thoracic irradiation has traditionally been considered the mainstay of treatment in inoperable stage III non-small cell lung cancer. However, despite technical developments and the addition of chemotherapy, the curative potential of radiotherapy in this subset of patients is disappointingly poor. The role of radiotherapy as an adjunct to pulmonary resection (preoperative and postoperative) is questionable, but well-designed and executed phase III studies are lacking. An important application of radiotherapy is palliation of tumor-related symptoms in the chest and in metastatic sites, such as bones and brain. In small cell lung cancer, routine applications of radiotherapy include chest radiotherapy in limited disease and prophylactic cranial irradiation in complete responders to chemotherapy, each increasing survival by about 5%.

Chimioradiothérapie exclusive des cancers bronchiques non à petites cellules localement évolués

Chemoradiation is one of the major therapeutic options in thoracic oncology: besides surgery, the best treatment for early-stage tumors, and chemotherapy, not only used in metastatic tumors, but also in a neoadjuvant and adjuvant setting, chemoradiation is the standard strategy for unresectable locally advanced non-small cell lung cancer. Its current modalities include three-dimensional conformal techniques, allowing dose escalation and sequential and concurrent combination with new generation cytotoxic agents to occur. Phase III trials are currently evaluating the benefit from induction and consolidation chemotherapy in this setting. New techniques of radiation may also increase the efficacy and the feasibility of radiation. This constant progress makes chemoradiation one of the most promising combined treatments in thoracic oncology.

Recent developments in the chemotherapeutic options for nonsmall cell lung cancer

Lung cancer is one of the leading causes of cancer deaths in the developed world. It is grossly divided into small cell and nonsmall cell types. Depending on the stage at diagnosis, the principal means of treating nonsmall cell lung cancer are surgery, chemotherapy and/or radiotherapy. However, even when it is diagnosed at an early stage, the progression-free and overall survival rates have been disappointing compared with other cancers. In recent years, there have been a number of developments in the chemotherapeutic options for nonsmall cell lung cancer. The aim of this review is to summarize these developments, in a stage-specific manner, with respect to both standard chemotherapy and also the newer targeted therapies.

Concurrent end-phase boost high-dose radiation therapy for non-small-cell lung cancer with or without cisplatin chemotherapy

The aim of this study was to audit the results of a high-dose, combined-modality prospective protocol for non-small-cell lung cancer in terms of survival, disease-specific survival and toxicity. One hundred and twenty-one patients with non-small-cell lung cancer were treated with a concurrent, end-phase, boost, high-dose radiotherapy protocol with 65 Gy in 35 fractions for more than 5 weeks. Sixty-six patients received radiotherapy alone (group 1), 29 received concurrent chemoradiation (group 2) and 26 received neoadjuvant and concurrent chemotherapy (group 3). Thirty-four patients had stage I disease, six had stage II and 81 had stage III. Overall median survival was 23 months: 75% at 1 year and 23% at 5 years. Median survivals for patients with stage I and stages II and III disease were 43 and 19 months, respectively. For stages II and III patients by groups 1-3, median survivals were 18, 25 and 18 months, respectively, and 2-year survivals were 36, 52 and 38%, respectively. Toxicity was acceptable. Overall, 9% had symptomatic pneumonitis and 7% had grades 3 and 4 oesophagitis. For those who had the mediastinum included in the volume, grade > or = 3 oesophagitis occurred in 0, 11 and 22% (n = 110, P = 0.001), respectively, for treatment groups 1-3. Overall treatment-related mortality was 3%, consisting of two septic deaths, one pneumonitis and possibly one late cardiac event, all occurring in patients who had chemotherapy (7% of 55 patients). Treatment-related mortality declined over the study period. Accelerated radiotherapy was well tolerated, with only moderate increased acute toxicity when combined with concurrent platinum chemotherapy. Toxicity was enhanced by induction chemotherapy. Overall survival outcomes were excellent for this condition. Continued use of this radiotherapy schedule is recommended as the platform for assessment of other chemotherapy schedules.

Long term follow up and analysis of long term survivors in patients treated with paclitaxel-based concurrent chemo/radiation therapy for locally advanced non-small cell lung cancer

PURPOSE

For patients with locally advanced non-small cell lung cancer (LANSCLC), concurrent chemotherapy/radiation therapy (RT) has become the standard of care. Three multi-institutional phase II studies with paclitaxel-based chemotherapeutic regimen given concurrently with RT for patients with LANSCLC were performed from March of 1994 to May of 1997. We sought to determine mature data from this database of patients, as well as to perform analysis of a cohort of patients who have achieved long term survival (LTS) when treated with this regimen.

PATIENTS AND METHODS

Database of these patients was analyzed retrospectively upon longer follow up, with median follow up for the three studies being 498 days (range 11-2905 days, average 780 days). Weight loss limitation for the three studies was liberal: weight loss <10% and <15% 3 months preceding diagnosis (LUN-27 and LUN-63, respectively), and no weight loss limitation for LUN-56.

RESULTS

The 4-year overall survival (OS) for the three trials was 16.3%, and 2-year progression free survival (PFS) was 25.7%. Statistical analysis of the long term survivors (OS > 4 years) was performed, and performance status (PS) was found to be a significant factor predictive of LTS. PS of 0 compared to 1 yielded a 2.5-fold increased likelihood of LTS (p = .04). There was also a trend (p = .067) for responders (complete or partial response) to yield a five-fold likelihood of LTS compared to non-responders (stable or progressive disease).

CONCLUSION

Our results support the efficacy of combined modality therapy (CMT) for patients with LANSCLC even despite our more liberal weight loss eligibility criteria. Furthermore, our analysis indicates that LTS is more likely to be achievable in patients with PS = 0 compared to 1 when treated with CMT for LANSCLC.

Response to combined modality therapy correlates with survival in locally advanced non–small-cell lung cancer

PURPOSE

Although concurrent chemoradiotherapy can now achieve demonstrated long-term survival in patients with locally advanced non-small-cell lung cancer (LANSCLC), it is difficult to predict which patients will benefit most from this therapeutic approach. Studies have suggested that local control, and the response to therapy, may be linked to improved survival; however, detailed analysis of the impact of tumor response to chemoradiotherapy on survival has not been thoroughly reported. Therefore, we sought to determine the impact of the response rate on survival for patients who were treated with combined modality therapy for LANSCLC.

METHODS AND MATERIALS

We reviewed the data from 116 patients enrolled between 1994 and 1997 in three trials investigating paclitaxel-based concurrent chemoradiotherapy for LANSCLC. Tumor size measurements were assessed immediately before and 2 months after completion of combined modality therapy to determine the response and to calculate the percentage of decrease in tumor size.

RESULTS

Patients with a response (complete or partial) had an improved 4-year overall survival rate compared with patients with no response (stable or progressive disease; 21.1% vs. 3.3%, p <0.0001) in the 109 assessable patients. Progression-free survival also improved significantly with response. An analysis of the percentage of decrease in tumor size vs. survival was performed (n = 74) using Cox proportion model analysis. After combined modality therapy, a 20%, 40%, 60%, 80%, and 100% decrease in tumor size conferred a 39%, 63%, 78%, 86%, and 92% reduction in risk of death compared with a 0% decrease in tumor size (p <0.0001).

CONCLUSION

The response by conventional response criteria correlated strongly with improved overall survival and progression-free survival and an increasing percentage of decrease in tumor size resulted in a reduction in the risk of death. Additional investigation of the degree of response as a factor predictive of improved therapeutic efficacy, translating into improved survival, is warranted.

Neoadjuvant therapy: an emerging concept in oncology

Neoadjuvant therapy, an adjunctive therapy given before the main therapy, has become an integral part of modem multidisciplinary cancer management. Organized by the primary organ involved by cancer, this review summarizes the outcomes of neoadjuvant therapy for common malignant solid tumors, based on large, randomized, controlled trials. In locally advanced rectal, laryngeal, and breast cancer, neoadjuvant therapy enables organ preservation; however, it does not improve overall survival when compared with definitive treatment followed by adjuvant therapy. In locally advanced bladder and cervical cancer, patients who undergo neoadjuvant therapy before radical surgery appear to have better survival than those receiving definitive therapy alone; however, it is unclear if the neoadjuvant approach will be superior to definitive therapy followed by adjuvant therapy. To date, the survival benefits of neoadjuvant therapy for resectable non-small cell lung, esophageal, gastric, and prostate cancer remains under investigation.

Integrating concurrent navelbine and cisplatin to hyperfractionated radiotherapy in locally advanced non-small cell lung cancer patients treated with induction and consolidation chemotherapy: feasibility and activity results

OBJECTIVES

The purpose of this study was to determine the effectiveness and toxicity of a new combination schedule based on concurrent navelbine, cisplatin and hyperfractionated radiotherapy in patients with locally advanced NSCLC treated with platinum and gemcitabine induction and consolidation chemotherapy.

MATERIALS AND METHODS

The 37 patients with pathological confirmed advanced NSCLC (non-surgical stages IIIA and IIIB) were included in the study. All of them were assessable for survival and 32 for response. The treatment schedule consisted of cisplatin (100 mg/m2) or carboplatin (400 mg/m2) on day 1 with gemcitabine (1000 mg/m2) on days 1, 8 and 15. Treatment was given every 28 days for two courses, followed by concurrent administration of accelerated modified hyperfractionated radiotherapy, with concomitant boost, with a total dose of 61.64 Gy administered for 5 weeks, with cisplatin and navelbine, for two courses, finally followed by two courses of the same initial chemotherapy.

RESULTS

Four patients achieved complete response (12.5%) and 14 (44%) partial response, for an overall objective response rate of 56.5%. After a minimum follow-up duration of 35.5 months, median progression free survival was 12.2 months. The median survival was 15.4 months with actuarial 1-, 2- and 3-year survival of 67, 21 and 15%, respectively. The main toxicity was hematological. There was esophagitis (grades III and IV) in 30% of the patients and there were two treatment-related deaths.

CONCLUSION

Combined treatment with concurrent radiotherapy and chemotherapy in non-surgical NSCLC is an acceptable treatment modality. However, the toxicity was not negligible.

A phase III randomised study comparing two different dose-intensity regimens as induction chemotherapy followed by thoracic irradiation in patients with advanced locoregional non-small-cell lung cancer

PURPOSE

The aim of this study was to determine the role of chemotherapy dose intensity in patients with initially unresectable non-metastatic non-small-cell lung cancer (NSCLC), with survival as primary end point, by testing two different regimens as induction chemotherapy followed by thoracic irradiation.

PATIENTS AND METHODS

Patients had pathologically proven NSCLC, an initially unresectable non-metastatic tumour without homolateral malignant pleural effusion, no prior history of malignancy and had received no prior therapy. Treatment was randomised for chemotherapy between three courses of MIP (mitomycin C 6 mg/m2; ifosfamide 3 g/m2; cisplatin 50 mg/m2) or SuperMIP (mitomycin C 6 mg/m2; ifosfamide 4.5 g/m2; cisplatin 60 mg/m2, carboplatine 200 mg/m2), followed by chest irradiation (60 Gy; five times per week, for 6 weeks). If the tumour became resectable after chemotherapy, surgery was performed, followed by mediastinal irradiation.

RESULTS

A total of 351 patients were eligible: 176 in the MIP arm and 175 in the SuperMIP arm, with 43% and 51% stages IIIA and IIIB, respectively. There was a significantly higher objective response rate with SuperMIP (46%) compared with MIP (35%) (P=0.03) [95% confidence interval (CI) for the difference between the response rates, 1% to 22%]. After induction chemotherapy, surgery was performed in 54 (15%) patients (27 per arm) and chest irradiation in 203 (57%) patients (102 in the MIP arm and 101 in the SuperMIP). In terms of survival, there was no statistically significant difference between the two study arms (P=0.16), with median survival times of, for MIP and SuperMIP, respectively, 12.5 (95% CI 10.1-14.9) and 11.2 (95% CI 9.7-12.8) months. Haematological toxicity and dosage reductions were higher with SuperMIP, which was nevertheless associated with a significantly increased absolute dose intensity.

CONCLUSIONS

High dose-intensity induction chemotherapy does not improve survival in initially unresectable non metastatic NSCLC.

[Sequential chemo-radiation in non-small cell lung cancer: a retrospective study of 100 patients]

Combined chemotherapy and radiotherapy has shown to be the correct treatment of unresectable non-small cell lung cancer, after many years of poor survival figures with standard radiotherapy alone. It has also been demonstrated that the benefit of chemotherapy is mainly achieved if cisplatin-based schedules are used. The authors present a retrospective study of 100 cases of stage III non-small cell lung cancer treated with a sequential approach of chemotherapy and radiotherapy and evaluate median and overall survival, local progression-free survival and distant progression-free survival. The results of our series are quite similar to those published in literature.

The treatment of unresectable, locally advanced non-small-cell lung cancer: a radiation therapy perspective with an emphasis on the trials of the Radiation Therapy Oncology Group

Radiation therapy used as a single modality in the treatment of locally advanced non-small-cell lung cancer is potentially curative, but long-term survival rates are disappointing due to both locoregional and distant failures. The trials of the Radiation Therapy Oncology Group (RTOG) have been instrumental in defining the optimal management of this disease. The conclusions and questions posed by the RTOG are discussed in this review. The conclusions of this review include the following: chemotherapy combined with radiation therapy improves survival in patients with good performance, with increased toxicity; concurrent chemoradiation is superior to sequential chemoradiation. Questions remain regarding the value of the addition of induction or consolidation chemotherapy to concurrent chemoradiation, the value of three-dimensional conformal radiation therapy, the role of altered fractionation regimens in combination with chemotherapy, the optimal chemotherapeutic regimen, and the role of novel biologic agents.

A systematic overview of radiation therapy effects in non-small cell lung cancer

A systematic review of radiation therapy trials in several tumour types was performed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for evaluation of the scientific literature are described separately (Acta Oncol 2003; 42: 357-365). This synthesis of the literature on radiation therapy for non-small cell lung cancer (NSCLC) is based on data from 4 meta-analyses and 31 randomized trials. Moreover, data from 12 prospective studies, 12 retrospective studies and 6 other articles were used. In total, 65 scientific articles are included, involving 18 310 patients. The results were compared with those of a similar overview from 1996 including 28 172 patients. The conclusions reached can be summarized as follows: Extensive clinical experience indicates that radiotherapy for medically inoperable patients or patients refusing surgery with NSCLC stage I/II prolongs survival, 15 -20% of these patients reaching long-term (5-year) survival. However, no randomized trials have addressed this issue. There is strong evidence that postoperative radiotherapy in radically resected stage I/II NSCLC does not prolong survival compared with observation alone. There is some evidence that continuous hyperfractionated accelerated radiotherapy (CHART) is associated with increased survival compared to conventional radiotherapy in locally advanced NSCLC and also in medically unfit patients with stage I/II NSCLC. However, the benefit is limited to squamous cell histology. There is strong evidence that combined modality treatment with platinum-based chemotherapy and radiotherapy, either neoadjuvant or concomitant, is superior to radiotherapy alone in terms of survival in locally advanced unresectable NSCLC and should be the standard of care in patients with good performance status. There is some evidence that concomitant chemo-radiotherapy is associated with increased survival compared with sequential chemo-radiotherapy, albeit at the price of increased toxicity Comment: Combined chemo-radiotherapy of primary non-resectable stage III NSCLC followed by surgery in responders lacks evidence from prospective randomized trials and cannot be recommended for routine use. There is strong evidence that radiotherapy can palliate symptoms associated with the intrathoracic tumour burden. There is some evidence that two large fractions may be as effective as conventional schedules consisting of 10-13 smaller fractions in terms of palliation of symptoms. There is some evidence that endobronchial brachytherapy for palliation of symptoms associated with endobronchial tumours is not superior to external beam radiotherapy.

Induction chemotherapy followed by radical local therapy for locally advanced non-small cell lung cancer

Many patients who receive a diagnosis of non-small cell lung cancer (NSCLC) have locally advanced disease at initial presentation. Historically, these patients were treated with primary thoracic radiation therapy and had poor long-term survival rates, secondary to both progression of local disease and development of distant metastases. With the goal of improving clinical outcomes, multiple concepts of combined-modality therapy for locally advanced NSCLC have been investigated. The rationale for using chemotherapy in the induction regimen is to eliminate subclinical metastatic disease while improving local control. The optimal treatment of locally advanced NSCLC continues to evolve, but combined-modality therapy has led to improved survival rates compared to treatment with radiation alone and has become the new standard of care. This report reviews the major trials that have investigated various combinations of surgery, radiation therapy, and chemotherapy in the treatment of locally advanced NSCLC.

Preliminary results of radiotherapy with or without weekly paclitaxel in locally advanced non-small cell lung cancer

PURPOSE

In this study our objective was to evaluate the therapeutic significance of concurrent paclitaxel and radiotherapy compared with radiotherapy alone.

PATIENTS AND METHODS

Patients with stage III A/B NSCLC were randomly assigned to receive either radiotherapy alone (group 2) or concurrent weekly paclitaxel with radiotherapy (group 1) in GMMA. Radiotherapy was given as a split-course schedule with the total dose of 56 Gy. Paclitaxel, 60 mg/m(2), was administered only to group 1 on the first day of each radiotherapy week. To assess differences between values, P values were calculated with the chi(2) test. A Mann Whitney U-test was used to assess significant differences between the two values. Actuarial survival curves were calculated by the Kaplan-Meier method.

RESULTS

There were 25 patients who underwent chemoradiotherapy and 26 who underwent radiotherapy only. Median follow-up was 14 months. The overall response rate was 92% and 70% for groups 1 and 2, respectively ( P= 0.003). Median survival was 15.2 months for group 1, and 12.0 months for group 2 ( P= 0.027).

CONCLUSION

Based on this response and the toxicity profile, outpatient split-course radiotherapy and weekly paclitaxel seems to be feasible and safe.

Treatment of stage IIIA non-small cell lung cancer

Stage IIIA non-small cell lung cancer represents a relatively heterogeneous group of patients with metastatic disease to the ipsilateral mediastinal (N2) lymph nodes and also includes T3N1 patients. Presentations of disease range from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky multistation nodal disease. Controversy abounds as to the optimal treatment of the various stage IIIA subsets, which is fueled by a lack of meaningful, large randomized trials. Multimodality therapy of some type appears to be preferable in stage IIIA patients.

Combined chemotherapy and radiotherapy in inoperable non-small cell lung cancer

Despite its low efficacy, radiotherapy has traditionally been considered the mainstay of treatment in inoperable stage III NSCLC. One of the attempts to improve the outcome is combining radiation with chemotherapy. This strategy is expected to increase the cure rate not only by improved locoregional tumor control but also by elimination of micrometastases outside the radiotherapy field. Chemotherapy and radiation may be applied in sequence or concurrently. The results of randomized studies testing these two strategies have been inconsistent, however a series of recent trials and the metaanalysis demonstrated a survival benefit of chemoradiation over radiotherapy alone. Recently, concurrent chemotherapy and radiation was found to be superior to sequential application but toxicity of the former is higher. The value of new agents (taxanes, vinorelbine, gemcitabine and topoisomerase inhibitors) in combined modality therapy of NSCLC seems to be promising, but warrants further clinical evaluation.

Lung cancer--where are we today? Current advances in staging and nonsurgical treatment

Lung cancer remains the commonest cause of cancer death in both men and women in the developed world, although mortality rates for men are dropping. Spiral computed tomography (CT) of the chest in middle-aged, smoking subjects may identify two to four times more lung cancers than a chest X-ray, with more than 70% of tumors being Stage I. The incidence of benign nodules is high, making interpretation difficult. Randomized controlled trials are required to determine whether spiral CT detects lung cancer early enough to improve mortality. Preoperative staging has relied on CT scans, but positron emission tomography scanning has greater sensitivity, specificity, and accuracy than CT and is recommended as the final confirmatory investigation when the CT shows resectable disease. In locally advanced non-small cell lung cancer, there is a small advantage for the addition of chemotherapy to radiotherapy, but no advantage for postoperative radiotherapy. Chemotherapy gives no benefit when given as neoadjuvant or adjuvant treatment around surgery. In advanced disease, newer cytotoxic agents confer a small survival advantage over older combinations, but the advantage in median survival over best supportive care remains a few months with modest improvements in quality of life. Survival with small cell lung cancer has shown little increase over the last 15 years despite multiple attempts to manipulate the timing, dose intensity of chemotherapy, and the potential of radiotherapy. Novel therapies are urgently needed for all cell types of lung cancer.

Chemoradiotherapy of non-small cell lung cancer

The efficacy of radiotherapy in locally advanced unresectable non-small cell lung cancer is low. This method does not provide effective eradication of bulky disease in the thorax, neither does it prevent uncontrolled systemic disease. The addition of chemotherapy to radiation results in increased cure rate by both improving tumor control in the thorax and by eliminating or delaying the emergence of metastatic disease. The two most frequently tested strategies of combining chemotherapy and radiation include primary chemotherapy followed by radiation and concurrent application of both methods. This review provides the rationale for this strategy and presents the results of major Phase III studies. Discussed are advantages of chemoradiation, its limitations in clinical practice and prospects for the future.

Dose-escalation study of weekly irinotecan and daily carboplatin with concurrent thoracic radiotherapy for unresectable stage III non-small cell lung cancer

Dose-escalation study was performed to evaluate the maximum tolerated dose, recommended dose and toxicity profile of weekly irinotecan with daily carboplatin and concurrent thoracic radiotherapy in patients with locally advanced non-small-cell lung cancer. Thirty-one previously untreated patients with unresectable stage III non-small-cell lung cancer were enrolled in this study. Patients received weekly irinotecan plus carboplatin (20 mg x m(-2) daily for 5 days a week) for 4 weeks and thoracic radiotherapy (60 Gy in 30 fractions). The irinotecan dose was escalated from 30 mg x m(-2) in increments of 10 mg x m(-2). Four irinotecan dose levels were given and 30 patients were assessable. Their median age was 62 years (range: 52-72 years), 28 had a performance status of 0-1 and two had a performance status of 2, 12 had stage IIIA disease and 18 had IIIB disease. There were 19 squamous cell carcinomas, 10 adenocarcinomas, and one large cell carcinoma. The dose-limiting toxicities were pneumonitis, esophagitis, thrombocytopenia and neutropenia. The maximum tolerated dose of irinotecan was 60 mg x m(-2), with two patients developing grade 4 pulmonary toxicity and one patient died of pneumonitis (grade 5). The recommended dose of irinotecan was 50 mg x m(-2). Other grade 3 or 4 toxicities were nausea and vomiting. Three patients achieved complete remission and 15 had partial remission, for an objective response rate of 60.0%. The median survival time was 14.9 months, and the 1- and 2-year survival rates were 51.6% and 34.2%, respectively. The study concluded that the major toxicity of this regimen was pneumonitis. This therapy may be active against unresectable non-small-cell lung cancer and a phase II study is warranted.

Building a better therapy for stage IIIA non-small cell lung cancer

What do clinicians know about stage IIIA lung cancer? They know accurate staging is critical and requires wide application of mediastinoscopy. They know that surgery and radiation alone each can cure a small subset of patients, and complete resection is of the utmost importance in surgically treated patients. They know that chemotherapy can increase the number of patients cured when combined with definitive radiation, and concurrent chemoradiotherapy seems superior to sequential. Neoadjuvant chemotherapy also seems to cure more patients than surgery alone, but more data are necessary. Trimodality therapy remains a promising but unproved approach in patients with stage IIIA disease. With the exciting new molecularly targeted agents, trials examining quad-modality therapy are just around the corner.

Combined modality treatment with chemotherapy and radiation in locally advanced non-small cell lung cancer

This article reviews combined chemotherapy and radiation in locally advanced inoperable non-small cell lung cancer. Presented are rationale for the use of this strategy, methods of combining drugs and radiation and results of major phase III trials.

Combined chemotherapy and radiation in locally advanced non-small-cell lung cancer

The efficacy of radiotherapy in locally advanced non-small-cell lung cancer is limited. One attempt to improve survival uses a combination of radiation and chemotherapy. These two modalities can be applied in sequence or concurrently, but results from phase III trials of combined therapy versus radiation alone have been inconsistent. Early studies were mostly negative, but more recent trials using platinum-based regimens have shown some survival benefit for combined treatments. The positive impact of chemotherapy has also been shown in a meta-analysis. In recent studies, concurrent chemotherapy and radiation appears better than sequential application. However, the benefit of the combined approach is modest and should be balanced against increased early and late toxicity. The role of new agents such as taxanes, vinorelbine, gemcitabine, and topoisomerase inhibitors in combined modality therapy of non-small-cell lung cancer warrants further clinical investigation.

Combined modality therapy in NSCLC

Combined modality treatment has 'come out of age' and increasingly represents standard of care for a rapidly growing number of patients in locally advanced stages of NSCLC. Modern progress of treatment techniques as well as possibilities for supportive interventions will lead to lesser treatment toxicities, better patient's compliance to treatment protocols and combinations of different modalities with a more efficient outcome. This number will further increase, as more and more centres in Europe are setting up the logistics of multidisciplinary treatment groups for patients with lung cancer. Standard of care for most disease stages is currently under investigation in large randomised phase-III trials. Further research in the forthcoming years has to address questions of treatment individualisation (risks, prognosis, need for local control in the individual patient, biological evaluation of tumour aggressiveness, DNA-fingerprinting of tumours, evaluation of MRD-status, treatment in the community). New drugs or treatment principles with different mechanisms of action such as antiangiogenesis factors, signal-transduction inhibitors, immunotherapy, antisense-oligonucleotides or gene(replacement) therapy may stimulate further clinical research. This may eventually define 'new modalities of treatment' thus leading to modern 'second-generation combined-modality protocols' including some of the new principles.

Modulation of radiation-induced cytokine elevation associated with esophagitis and esophageal stricture by manganese superoxide dismutase-plasmid/liposome (SOD2-PL) gene therapy

Radiation of the esophagus of C3H/HeNsd mice with 35 or 37 Gy of 6 MV X rays induces significantly increased RNA transcription for interleukin 1 (Il1), tumor necrosis factor alpha (Tnf), interferon gamma inducing factor (Ifngr), and interferon gamma (Ifng). These elevations are associated with DNA damage that is detectable by a comet assay of explanted esophageal cells, apoptosis of the esophageal basal lining layer cells in situ, and micro-ulceration leading to dehydration and death. The histopathology and time sequence of events are comparable to the esophagitis in humans that is associated with chemoradiotherapy of non-small cell lung carcinoma (NSCLC). Intraesophageal injection of clinical-grade manganese superoxide dismutase-plasmid/liposome (SOD2-PL) 24 h prior to irradiation produced an increase in SOD2 biochemical activity in explanted esophagus. An equivalent therapeutic plasmid weight of 10 microgram ALP plasmid in the same 500 microliter of liposomes, correlated to around 52-60% of alkaline phosphatase-positive cells in the squamous layer of the esophagus at 24 h. Administration of SOD2-PL prior to irradiation mediated a significant decrease in induction of cytokine mRNA by radiation and decreased apoptosis of squamous lining cells, micro-ulceration, and esophagitis. Groups of mice receiving 35 or 37 Gy esophageal irradiation by a technique protecting the lungs and treating only the central mediastinal area were followed to assess the long-term effects of radiation. SOD2-PL-treated irradiated mice demonstrated a significant decrease in esophageal wall thickness at day 100 compared to irradiated controls. Mice with orthotopic thoracic tumors composed of 32D-v-abl cells that received intraesophageal SOD2-PL treatment showed transgenic mRNA in the esophagus at 24 h, but no detectable human SOD2 transgene mRNA in explanted tumors by nested RT-PCR. These data provide support for translation of this strategy of SOD2-PL gene therapy to studies leading to a clinical trial in fractionated irradiation to decrease the acute and chronic side effects of radiation-induced damage to the esophagus.

The physical parameters and molecular events associated with radiation-induced lung toxicity

Radiation therapy (RT) is frequently used to treat patients with tumors in and around the thorax. Clinical radiation pneumonitis is a common side effect, occurring in 5% to 20% of patients. Efforts to identify patients at risk for pneumonitis have focused on physical factors, such as dose and volume. Recently, the underlying molecular biological mechanisms behind RT-induced lung injury have come under study. Improved knowledge of the molecular events associated with RT-induced lung injury may translate into a better ability to individualized therapy. This review discusses our current understanding of the physical and molecular factors contributing to RT-induced pulmonary injury.

Locally advanced, unresectable non-small cell lung cancer: new treatment strategies

Approximately 40% of non-small cell lung cancer (NSCLC) patients present with locally advanced, unresectable lesions. Treatment with thoracic radiotherapy yields survivals averaging just 9 to 10 months, and long-term survival at 5 years is poor. Recent studies indicate that chemotherapy followed by thoracic radiotherapy improves 5-year survival by three- to fourfold. Nevertheless, most patients do ultimately die of the underlying disease. New strategies designed to enhance local tumor control-use of radiation-sensitizing drugs, three-dimensional treatment planning techniques, or altered radiation fractionation schedules-may further improve survival outcome. In addition, newer cisplatin-based regimens containing either paclitaxel or vinorelbine improve survival over that achieved with older vinca alkaloid or podophyllotoxin combination regimens. Accordingly, the newer drug regimens combined with radiotherapy can be expected to further improve survival in this subset of NSCLC patients. Prospective studies are underway to test this conjecture.

Final results of phase III trial in regionally advanced unresectable non-small cell lung cancer: Radiation Therapy Oncology Group, Eastern Cooperative Oncology Group, and Southwest Oncology Group

STUDY OBJECTIVES

The purpose of this phase III clinical trial was to test whether chemotherapy followed by radiation therapy resulted in superior survival to either hyperfractionated radiation or standard radiation in surgically unresectable non-small cell lung cancer.

DESIGN

Patients were prospectively randomized to 2 months of cisplatin, vinblastine chemotherapy followed by 60 Gy of radiation at 2.0 Gy per fraction or 1.2 Gy per fraction radiation delivered twice daily to a total dose of 69.6 Gy, or 2.0 Gy per fraction of radiation once daily to 60 Gy. Patients were enrolled from January 1989 through January 1992, and followed for a potential minimum period of 5 years.

SETTING

This trial was an intergroup National Cancer Institute-funded trial within the Radiation Therapy Oncology Group, the Eastern Cooperative Oncology Group, and the Southwest Oncology Group.

PATIENTS

Patients with surgically unresectable non-small cell lung cancer, clinical stage II, IIIA, and IIIB, were required to have a Karnofsky Performance Status of > or = 70 and a weight loss of < 5% for 3 months before study entry. Four hundred ninety patients were registered on trial, of which 458 patients were eligible.

CONCLUSION

Overall survival was statistically superior for the patients receiving chemotherapy and radiation vs the other two arms of the study. The twice-daily radiation therapy arm, although better, was not statistically superior in survival for those patients receiving standard radiation. Median survival for standard radiation was 11.4 months; for chemotherapy and irradiation, 13.2 months; and for hyperfractionated irradiation, 12 months. The respective 5-year survivals were 5% for standard radiation therapy, 8% for chemotherapy followed by radiation therapy, and 6% for hyperfractionated irradiation.