The effect of radiotherapy on the survival of non-small cell lung cancer patients

WITHDRAWN: Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable)

The authors are unable to update this review. A new team is being sought to update it.

The editorial group responsible for this previously published document have withdrawn it from publication.

Characteristics of patients with lung cancer in the city of Manaus, Brazil

OBJECTIVE

To analyze the characteristics of patients with lung cancer.

METHODS

A retrospective descriptive study of patients receiving a histopathological diagnosis of lung cancer between 1995 and 2002 in the city of Manaus, Brazil. Data were collected from the medical archives of three hospitals. Statistical analyses were carried out, and survival curves were generated by means of an actuarial estimator.

RESULTS

Of the 352 patients selected, 262 (74.4%) were male and 90 (25.6%) were female. The mean age was 62 years. The following histological types were identified: squamous cell carcinoma, 62.8%; adenocarcinoma, 24.7%; small cell carcinoma, 9.1%; and large cell carcinoma, 3.4%. The most common stages were stages IIIB and IV, in 45% and 21.5%, respectively. Of the total sample, 73.4% were submitted to treatment. Of these, 51.4% underwent radiotherapy; 16.6%, surgery; 15.8%, chemotherapy; and 16.2%, radiotherapy in association with chemotherapy. Cumulative survival rates were low: three-year survival was 6.5%, and five-year survival was 3.5%.

CONCLUSIONS

In this group of patients with lung cancer, survival rates were considerably lower than those reported in the literature. This might be attributable to the limited access to the specialized health care system and the advanced stage of the disease at diagnosis.

Comparison of CT and positron emission tomography/CT coregistered images in planning radical radiotherapy in patients with non-small-cell lung cancer

Imaging with F-18 fluorodeoxyglucose positron emission tomography (PET) significantly improves lung cancer staging, especially when PET and CT information are combined. We describe a method for obtaining CT and PET images at separate acquisitions, which allows coregistration and incorporation of PET information into the radiotherapy (RT) planning process for non-small-cell lung cancer. The influence of PET information on RT planning was analysed for 10 consecutive patients. Computed tomography and PET images were acquired with the patient in an immobilization device, in the treatment position. Using specially written software, PET and CT data were coregistered using fiducial markers and imported into our RT planning system (Cadplan version 6). Treatment plans were prepared with and without access to PET/CT coregistered images and then compared. PET influenced the treatment plan in all cases. In three cases, geographic misses (gross tumour outside planning target volume) would have occurred had PET not been used. In a further three cases, better planning target volume marginal coverage was achieved with PET. In four patients, three with atelectasis, there were significant reductions in V20 (percentage of the total lung volume receiving 20 Gy or more). Use of coregistered PET/CT images significantly altered treatment plans in a majority of cases. This method could be used in routine practice at centres without access to a combined PET/CT scanner .

Comparison of inverse-planned three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for non–small-cell lung cancer

PURPOSE

Lungs are the major dose-limiting organ during radiotherapy (RT) for non-small-cell lung cancer owing to the development of pneumonitis. This study compared intensity-modulated RT (IMRT) with three-dimensional conformal RT (3D-CRT) in reducing the dose to the lungs.

METHODS

Ten patients with localized non-small-cell lung cancer underwent computed tomography (CT). The planning target volume (PTV) was defined and the organs at risk were outlined. An inverse-planning program, AutoPlan, was used to design the beam angle-optimized six-field noncoplanar 3D-CRT plans. Each 3D-CRT plan was compared with a series of five IMRT plans per patient. The IMRT plans were created using a commercial algorithm and consisted of a series of three, five, seven, and nine equidistant coplanar field arrangements and one six-field noncoplanar plan. The planning objectives were to minimize the lung dose while maintaining the dose to the PTV. The percentage of lung volume receiving >20 Gy (V20) and the percentage of the PTV covered by the 90% isodose (PTV90) were the primary endpoints. The PTV90/V20 ratio was used as the parameter accounting for both the reduction in lung volume treated and the PTV coverage.

RESULTS

All IMRT plans, except for the three-field coplanar plans, improved the PTV90/V20 ratio significantly compared with the optimized 3D-CRT plan. Nine coplanar IMRT beams were significantly better than five or seven coplanar IMRT beams, with an improved PTV90/V20 ratio.

CONCLUSION

The results of our study have shown that IMRT can reduce the dose to the lungs compared with 3D-CRT by improving the conformity of the plan.

Thresholding in PET images of static and moving targets

Continued therapeutic gain in the treatment of non-small-cell lung cancer (NSCLC) will depend upon our ability to escalate the dose to the primary tumour while minimizing normal tissue toxicity. Both these objectives are facilitated by the accurate definition of a target volume that is as small as possible. To this end, both tumour immobilizations via deep inspiratory breath-hold, along with positron emission tomography (PET), have emerged as two promising approaches. Though PET is an excellent means of defining the general location of a tumour focus, its ability to define exactly the geometric extent of such a focus strongly depends upon selection of an appropriate image threshold. However, in clinical practice, the image threshold is typically not chosen according to consistent, well-established criteria. This study explores the relationship between image threshold and the resultant PET-defined volume using a series of F-18 radiotracer-filled hollow spheres of known internal volumes, both static and under oscillatory motion. The effects of both image threshold and tumour motion on the resultant PET image are examined. Imaging data are further collected from a series of simulated gated PET acquisitions in order to test the feasibility of a patient-controlled gating mechanism during deep inspiratory breath-hold. This study illustrates quantitatively considerable variability in resultant PET-defined tumour volumes depending upon numerous factors, including image threshold, size of the lesion, the presence of tumour motion and the scanning protocol. In this regard, when using PET in treatment planning for NSCLC, the radiation oncologist must select the image threshold very carefully to avoid either under-dosing the tumour or overdosing normal tissues.

Estimating the benefit and cost of radiotherapy for lung cancer

Purpose: To estimate the benefit and cost of using radiotherapy (RT) in the initial management of lung cancer in the general population.

Methods: We identified indications for RT in the initial management of small cell and non–small cell lung cancer through a review of the literature. The proportion of patients with each specific indication for treatment was determined using epidemiological observations from cancer registry data and from the literature. We estimated the benefit gained from RT use for each indication in the model using values published in the literature. We estimated the cost of RT for each indication using published Canadian data. The total benefit and cost was calculated for all indications combined. Results are reported in 2001 Canadian dollars.

Results: The mean benefit was 7 months of survival for each lung cancer patient treated with curative intent and 3 months of symptom control for each patient treated with palliative intent. The average cost was $9,881 per life year gained and $13,938 per year of symptom control gained. Sensitivity analysis revealed values between $7,905 and $19,762 per year of survival gain and between $10,368 and $27,875 per year of symptom control gained.

Conclusions: Using RT in the initial management of lung cancer can provide considerable gains in survival and symptom control. The cost of RT for the initial management of lung cancer is inexpensive compared with a common cut off of $50,000 per life year gained.

Lung cancer 5: state of the art radiotherapy for lung cancer

Radiotherapy has a key role in curative and palliative treatments of patients with lung cancer. Important advances are described in the technique of treatment delivery and its integration with chemotherapy.

Portal imaging to assess set-up errors, tumor motion and tumor shrinkage during conformal radiotherapy of non-small cell lung cancer

PURPOSE

To investigate patient set-up, tumor movement and shrinkage during 3D conformal radiotherapy for non-small cell lung cancer.

MATERIALS AND METHODS

In 97 patients, electronic portal images (EPIs) were acquired and corrected for set-up using an off-line correction protocol based on a shrinking action level. For 25 selected patients, the orthogonal EPIs (taken at random points in the breathing cycle) throughout the 6-7 week course of treatment were assessed to establish the tumor position in each image using both an overlay and a delineation technique. The range of movement in each direction was calculated. The position of the tumor in the digitally reconstructed radiograph (DRR) was compared to the average position of the lesion in the EPIs. In addition, tumor shrinkage was assessed.

RESULTS

The mean overall set-up errors after correction were 0, 0.6 and 0.2 mm in the x (left-right), y (cranial-caudal) and z (anterior-posterior) directions, respectively. After correction, the standard deviations (SDs) of systematic errors were 1.4, 1.5 and 1.3 mm and the SDs of random errors were 2.9, 3.1 and 2.0 mm in the x-, y- and z-directions, respectively. Without correction, 41% of patients had a set-up error of more than 5 mm vector length, but with the set-up correction protocol this percentage was reduced to 1%. The mean amplitude of tumor motion was 7.3 (SD 2.7), 12.5 (SD 7.3) and 9.4 mm (SD 5.2) in the x-, y- and z-directions, respectively. Tumor motion was greatest in the y-direction and in particular for lower lobe tumors. In 40% of the patients, the projected area of the tumor regressed by more than 20% during treatment in at least one projection. In 16 patients it was possible to define the position of the center of the tumor in the DRR. There was a mean difference of 6 mm vector length between the tumor position in the DRR and the average position in the portal images.

CONCLUSIONS

The application of the correction protocol resulted in a significant improvement in the set-up accuracy. There was wide variation in the observed tumor motion with more movement of lower lobe lesions. Tumor shrinkage was observed. The position of the tumor on the planning CT scan did not always coincide with the average position as measured during treatment.

Factors influencing the use of thoracic radiotherapy in lung cancer--an analysis of the 1995 Scottish lung cancer audit

AIMS

To determine the frequency of delivery of thoracic radiotherapy (TRT) to patients with lung cancer in Scotland in 1995, and identify patient, disease and process variables affecting the probability of receiving TRT.

METHODS

Retrospective case note audit of all patients with lung cancer diagnosed in Scotland in 1995.

RESULTS

1118 (30.8%) of 3,855 patients diagnosed with lung cancer in Scotland in 1995 for whom the medical records could be traced received TRT. In those who did not have small cell lung cancer, multivariate analysis indicated that diagnosis by a lung cancer specialist, clinical extent of disease and microscopic verification of cancer (all P<0.0001) and age (P=0.0005) were associated with an increased chance of receiving TRT. There was also a wide variation between different Health Boards (HB) of residence in the proportion of patients receiving TRT (P<0.0001). There was no association between the presence of local symptoms (cough, chest pain or haemoptysis) and the delivery of TRT. Of 351 patients with limited stage small cell lung cancer, 51 (14.5%) received chemotherapy and TRT, and 19 (5.4%) chemotherapy and cranial irradiation.

CONCLUSIONS

TRT was delivered to fewer than one-third of patients with lung cancer in Scotland in 1995. This is lower than reported in other international audits. The chance of receiving TRT seemed to be associated with service issues rather than clinical need.

Dose, volume, and tumor control prediction in primary radiotherapy of non-small-cell lung cancer

BACKGROUND

To evaluate the influence of total dose and tumor volume on local control and survival in primary radiotherapy of non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

We retrospectively analyzed the clinical course and CT-derived pre- and post-therapeutic tumor volume data of 135 patients with NSCLC undergoing primary radiotherapy at our department between 1989 and 1996. Among these, a total of 192 spatially separated tumor volumes (135 primary tumors, 1 additional intrapulmonary tumor, and 56 involved lymph nodes) were available for analysis. In all patients, treatment was planned using CT-based three-dimensional treatment planning. The dose to each tumor volume was derived from the individual dose plans. Mean total dose was 59.9 Gy (range: 30-80 Gy). All but 3 patients were followed until death. For local control analysis, each tumor was analyzed separately, and its remission status was determined in serial follow-up CT scans. A total of 784 CT scans were analyzed. Actuarial local control analysis was performed for the 192 separated tumor volumes, and survival analysis was performed for the 135 patients. Tumor control probability was calculated using a Poisson statistical model.

RESULTS

Overall 1- and 2-year local control rate was 50% and 37%, respectively. The 2-year local control rate for tumors <50 ccm, 50-200 ccm, and >200 ccm was 51%, 22%, and 10%, respectively (p = 0.02). The 2-year local control rate for dose levels < or = 60 Gy and >60 Gy was 28% and 43% (p < 0.001). For the subgroup of 147 tumors smaller than 100 ccm, the local control rate increased up to 70% (1 year) and 51% (2 years) with doses of more than 60 Gy. For tumors larger than 100 ccm, no dose effect was seen. Only 2 of 45 tumors >100 ccm were controlled more than 2 years. Multivariate analysis revealed tumor volume, total dose, histopathologic type, and grading as significant and independent prognostic factors for local control. The number of delay days by split course (if used) and application of chemotherapy was not found to influence local control. Overall 1- and 2-year survival rate was 42% and 13%. Total radiation dose, chemotherapy, and T and N stage---but not tumor volume---were found to be independent and significant prognostic factors for survival in multivariate analysis.

CONCLUSION

Tumor volume is an important predictor of local control in NSCLC. We found a clear dose effect for local control and survival in NSCLC. Long-term local control for a significant proportion of patients seems possible for small tumors only (<100 ccm, i.e., maximum diameter 6 cm) with doses of 70 Gy and more. Tumors of > or = 100 ccm are unlikely to be controlled long term by conventional doses up to 70 Gy. These results support dose escalation in patients with NSCLC.

Long-term survival in patients with non-small cell lung cancer treated with palliative radiotherapy

The aim of palliative thoracic radiotherapy in patients with advanced non-small cell lung cancer (NSCLC) is to alleviate symptoms. This study was designed to determine whether any patients achieved long-term survival after this treatment. In Edinburgh, between 1974 and 1993, 4531 patients were treated with palliative radiotherapy for NSCLC, receiving ten fractions or fewer. We reviewed the case notes of the long-term survivors. Sixty-one (1.3%; 95% confidence interval (CI) 1.0-1.6) patients survived for more than 5 years; 43 (70%) had histological confirmation of cancer; 28 (46%) had stage Stage I or II, 28 (46%) Stage III and one Stage IV disease; 53 (87%) patients were treated with doses of 30-35 Gy in ten daily fractions, seven (12%) received 20 Gy in five daily fractions and one received a 10 Gy single fraction. Forty-two (69%) patients had a radiological complete response, 16 (26%) a partial response and the remainder stable disease. Clinically significant radiation pneumonitis occurred in one (2%) patient, radiation myelopathy in two (3%) and multiple rib fractures in one (2%). There did not appear to be an association between long-term survival and a radiosensitive phenotype. On univariate analysis, long-term survival was more frequent in patients receiving ten-fraction regimens than in those who underwent a shorter course of radiotherapy (chi 2 = 19.5, P < 0.001). Thirty-four (0.8%; 95% CI 0.6-1.0) patients were disease free at death or at last review (median 10 years; range 5-17). We conclude that palliative thoracic radiotherapy produces long-term survival in 1.3% and personal cure in up to 1% of patients with advanced NSCLC.

Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review

OBJECTIVES

To determine the effectiveness of radical radiotherapy in medically inoperable stage I/II non-small cell lung cancer (NSCLC) and the extent of treatment related morbidity.

METHODS

Randomised trials were sought by electronically searching the Cochrane Clinical Trials Register, and both randomised and non-randomised trials were sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching. The studies included were those of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose of >40 Gy in 20 fractions over 4 weeks or its radiobiological equivalent.

RESULTS

Two randomised and 35 non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria, leaving one randomised and 26 non-randomised studies for analysis. In the randomised trial 2 year survival was higher following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) than following 60 Gy in 30 fractions over 6 weeks (24%). An estimated 2003 patients were included in the 26 non-randomised studies; overall survival was 22-72% at 2 years, 17-55% at 3 years, and 0-42% at 5 years. Following treatment, 11-43% of patients died from causes other than cancer. Cancer specific survival was 54-93% at 2 years, 22-56% at 3 years, and 13-39% at 5 years. Complete response rates were 33-61% and local failure rates were 6-70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses although the reasons for prescribing higher doses were not clearly stated. The outcome was worse in those with prior weight loss or poor performance status. Assessment of treatment related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.

CONCLUSIONS

No randomised trials compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.

Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review

OBJECTIVES

To determine the effectiveness of radical radiotherapy in medically inoperable stage I/II non-small cell lung cancer (NSCLC) and the extent of treatment related morbidity.

METHODS

Randomised trials were sought by electronically searching the Cochrane Clinical Trials Register, and both randomised and non-randomised trials were sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching. The studies included were those of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose of >40 Gy in 20 fractions over 4 weeks or its radiobiological equivalent.

RESULTS

Two randomised and 35 non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria, leaving one randomised and 26 non-randomised studies for analysis. In the randomised trial 2 year survival was higher following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) than following 60 Gy in 30 fractions over 6 weeks (24%). An estimated 2003 patients were included in the 26 non-randomised studies; overall survival was 22–72% at 2 years, 17–55% at 3 years, and 0–42% at 5 years. Following treatment, 11–43% of patients died from causes other than cancer. Cancer specific survival was 54–93% at 2 years, 22–56% at 3 years, and 13–39% at 5 years. Complete response rates were 33–61% and local failure rates were 6–70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses although the reasons for prescribing higher doses were not clearly stated. The outcome was worse in those with prior weight loss or poor performance status. Assessment of treatment related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.

CONCLUSIONS

No randomised trials compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.

Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable)

BACKGROUND

In general, surgery is believed to offer the best prospects for cure for early stage non-small cell lung cancer (NSCLC). In spite of the intention to consider all patients with stage I-II disease for surgery, there are those who, although technically operable, either refuse surgery or are considered inoperable because of insufficient respiratory reserve, cardiovascular disease or general frailty. This group may therefore be considered "medically inoperable". Some respiratory physicians refer these patients for radical radiotherapy whilst others believe that radiotherapy has little to offer and adopt a watch policy, referring patients for palliative radiotherapy only when they become symptomatic. Although there is little evidence from randomised trials to support the use of radical radiotherapy for stage I/II NSCLC, it is the perception of most clinical oncologists (radiotherapists) that patients should receive radical, as opposed to palliative, treatment (COIN 1999).

OBJECTIVES

To determine the effectiveness and the morbidity of radical radiotherapy for medically inoperable NSCLC.

SEARCH STRATEGY

Randomised trials were sought by electronic searching the Cochrane Clinical Trials Register and both randomised and non-randomised trials sought by searching Medline and Excerpta Medica (Embase). Further studies were identified from references cited in those papers already identified by electronic searching.

SELECTION CRITERIA

Studies of patients of any age with stage I/II NSCLC receiving radiotherapy at a dose greater than 40Gy in 20 fractions over four weeks or its radiobiological equivalent.

DATA COLLECTION AND ANALYSIS

Two randomised and thirty-five non-randomised studies were identified. One randomised and nine non-randomised studies did not meet the selection criteria and were not included in the review.

MAIN RESULTS

In the randomised trial comparing two radiotherapy schedules, two-year survival was superior following continuous hyperfractionated accelerated radiotherapy (CHART; 37%) compared to 60Gy in 30 fractions over six weeks (24%). There were 26 non-randomised retrospective studies including an estimated 2003 patients, in which overall survival results varied between 33-72% at two years, 17-55% at three years and 0-42% at five years. The proportion of deaths not due to cancer was 11-43%. Cancer-specific survival was between 54-93% at two years, 22-56% at three years and 13-39% at five years. Complete response rates were 33-61% and local failure rates between 6-70%. Distant metastases developed in approximately 25% of patients. Better response rates and survival were seen in those with smaller tumours and in those receiving higher doses though the reasons for prescribing higher doses were not clearly stated. Worse outcome was seen in those with prior weight loss or poor performance status. Assessment of treatment-related morbidity and effects on quality of life and symptom control were inconclusive because of the lack of prospective evaluation and paucity of data.

REVIEWER'S CONCLUSIONS

There were no randomised trials that compared a policy of immediate radical radiotherapy with palliative radiotherapy given when patients develop symptoms. In the absence of such trials, radical radiotherapy appears to result in a better survival than might be expected had treatment not been given. A substantial, though variable, proportion of patients died during follow-up from causes other than cancer. The optimal radiation dose and treatment technique (particularly with respect to mediastinal irradiation) remain uncertain.

The cost-effectiveness and cost-utility of high-dose palliative radiotherapy for advanced non-small-cell lung cancer

PURPOSE

To compute cost-effectiveness/cost-utility (CE/CU) ratios, from the treatment clinic and societal perspectives, for high-dose palliative radiotherapy treatment (RT) for advanced non-small-cell lung cancer (NSCLC) against best supportive care (BSC) as comparator, and thereby demonstrate a method for computing CE/CU ratios when randomized clinical trial (RCT) data cannot be generated.

METHODS AND MATERIALS

Unit cost estimates based on an earlier reported 1989-90 analysis of treatment costs at the Vancouver Island Cancer Centre, Victoria, British Columbia, Canada, are updated to 1997-1998 and then used to compute the incremental cost of an average dose of high-dose palliative RT. The incremental number of life days and quality-adjusted life days (QALDs) attributable to treatment are from earlier reported regression analyses of the survival and quality-of-life data from patients who enrolled prospectively in a lung cancer management cost-effectiveness study at the clinic over a 2-year period from 1990 to 1992.

RESULTS

The baseline CE and CU ratios are $9245 Cdn per life year (LY) and $12,836 per quality-adjusted life year (QALY), respectively, from the clinic perspective; and $12,253/LY and $17,012/QALY, respectively, from the societal perspective. Multivariate sensitivity analysis for the CE ratio produces a range of $5513-28,270/LY from the clinic perspective, and $7307-37,465/LY from the societal perspective. Similar calculations for the CU ratio produce a range of $7205-37, 134/QALY from the clinic perspective, and $9550-49,213/QALY from the societal perspective.

CONCLUSION

The cost effectiveness and cost utility of high-dose palliative RT for advanced NSCLC compares favorably with the cost effectiveness of other forms of treatment for NSCLC, of treatments of other forms of cancer, and of many other commonly used medical interventions; and lies within the US $50, 000/QALY benchmark often cited for cost-effective care.

Response of global quality of life to high-dose palliative radiotherapy for non-small-cell lung cancer

PURPOSE

To estimate the impact of high-dose palliative radiotherapy treatment (RT) for inoperable non-small cell lung cancer (NSCLC) on the patient's quality of life (QoL) over the remaining survival period, and to compute the number of quality adjusted life days (QALDs) gained.

METHODS AND MATERIALS

The QoL of an NSCLC patient is modelled as a function of the days left to live, the days since the start of treatment, a patient specific intercept, and a random error term. Least squares regression analysis is used to fit this model to 376 monthly QoL observations supplied by 42 prospectively enrolled high-dose palliative RT patients with NSCLC. Prediction analysis, based on the regression results and on previously published estimates of the survival response to high-dose palliative RT, is used to compute QALDs gained as a result of treatment.

RESULTS

QoL improves steadily over the first 86 days after the start of treatment. This improvement then dissipates to 0 over the subsequent 140 days. Median survival after entry (266 days) yields 158.5 QALDs, of which 56.9 can be attributed treatment: 12.6 as a result of a higher daily QoL and 44.3 as a result of longer survival.

CONCLUSION

Patients with inoperable NSCLC who received high-dose palliative RT, and survived the median 266 days after entry into the study, can attribute about one-third of their 158.5 QALDs to the QoL and survival responses to treatment.

[Combined radiochemotherapy of non-small-cell bronchial carcinoma with taxol]

BACKGROUND

In the last few years platin-based radiochemotherapy has become standard treatment for patients with advanced, surgically unresectable non-small-cell lung cancer (NSCLC). More recently new chemotherapeutic agents have shown superior activity. Among them paclitaxel (Taxol) is one of the most extensively investigated.

RADIOTHERAPY

Despite of promising initial results, locally uncontrolled tumor and distant metastases continue to be the most serious problem of this disease. Improvement of local control can be achieved by escalating radiation dose, by shortening of treatment time with accelerated fractionation or by additional use of radiosensitizing agents. Concerning local control a tumor volume-dose relationship has been described. Three-dimensional conformal treatment planning eventually with intensity modulated fields, combined with biological TCP/NTCP calculation models allows risk-adapted escalation and intensification of irradiation.

TAXOL

A radiosensitizing effect of Taxol by means of G2/M block has been reported. However, radiobiological data are contradictory and suggest a radiosensitizing effect even without cell-cycle arrest. For simultaneous paclitaxel and 60 Gy normally fractionated radiotherapy several prospective dose escalation studies have confirmed a maximum weekly Taxol dose of 60 mg/m2. Changes in paclitaxel application (e.g. daily, twice weekly or biweekly) or in radiotherapy fractionation require a corresponding adaption of Taxol dose. Dose limiting toxicity of this simultaneous treatment is esophagitis. With respect to the high rate of distant metastases sequential application of combined chemotherapeutic regimens (e.g. Taxol 200 mg/m2/Carboplat AUC 6) is generally recommended.