Clinical Investigation
Local Control and Survival Following Concomitant Chemoradiotherapy in Inoperable Stage I Non-Small-Cell Lung Cancer

https://doi.org/10.1016/j.ijrobp.2008.10.067Get rights and content

Purpose

Concomitant chemoradiotherapy (CRT) increases survival rates compared with radical radiotherapy alone (RT) in Stage III non-small-cell lung cancer (NSCLC), as a result of improved local control. The effect of CRT on local control in Stage I NSCLC is less well documented. We retrospectively reviewed local control and survival following CRT or RT for inoperable Stage I NSCLC patients.

Methods and materials

Eligible patients had histologically/cytologically proved inoperable Stage I NSCLC and had undergone complete staging investigations including an F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) scan. Radiotherapy was planned as (1) 60 Gy in 30 fractions over 6 weeks with or without concomitant chemotherapy or (2) 50–55 Gy in 20 fractions without chemotherapy.

Results

Between 2000 and 2005, 73 patients met the eligibility criteria and were treated as follows: CRT (60 Gy)—39; RT (60 Gy)—23; RT (50–55 Gy)—11. The median follow-up time for all patients was 18 months (range, 1–81 months). Survival analysis was based on intent to treat. Local progression-free survival (PFS) at 2 years was 66% with CRT and 55% with RT. The 2-year distant PFS was 60% following CRT and 63% after RT. The 2-year PFS rates were 57% and 50%, respectively. The 2-year survival rate for patients treated with CRT was 57% and 33% in patients receiving RT.

Conclusions

Despite the use of CRT and routine staging with FDG-PET, both local and distant recurrences remain important causes of treatment failure in patients with inoperable stage I NSCLC.

Introduction

Surgery is usually considered the treatment of choice for early stage non-small-cell lung cancer (NSCLC). For medically inoperable patients or those who decline surgery, radical radiotherapy (RT) is generally accepted as the standard of care. Results with radiotherapy alone in Stage I and II NSCLC are disappointing with local failure rates varying between 6% to 70% and 2-year overall survival rates between 33% to 72% (1).

To improve these outcomes, different strategies have been explored such as the combined use of chemotherapy and radiotherapy. In Stage III NSCLC, the addition of chemotherapy to radiation therapy increases survival rates compared with RT alone, as a result of improved local control 2, 3. Limited data suggest that concomitant chemoradiotherapy (CRT) might improve survival in Stage I NSCLC. A meta-analysis from the Non-small Cell Lung Cancer Collaborative Group reported a 13% reduction in the risk of death in patients receiving sequential chemotherapy and radiotherapy compared to RT alone (4). This benefit was present regardless of disease stage. A subgroup analysis of an Australian Phase III trial of radiation with or without chemotherapy in inoperable NSCLC has shown an advantage of combined treatment compared to radiation alone for Stage I and II disease 5, 6.

On the basis of this experience, we adopted CRT as the standard of care for patients with medically inoperable Stage I NSCLC provided that the patient is judged fit for chemotherapy. The aim of this study was to review retrospectively disease control and survival in patients with Stage I NSCLC patients who were treated with CRT or RT between 2000 and 2005.

Section snippets

Methods and Materials

Patients planned to be treated with radical radiotherapy for NSCLC between January 2000 and December 2005 were identified in the Peter MacCallum Cancer Centre (Peter Mac) radiotherapy database. This review was restricted to those patients with Union Internationale Contre le Cancer (UICC) clinical Stage I histologically or cytologically proven NSCLC who were treated with or without concomitant chemotherapy. All patients had a complete clinical examination, a computed tomography (CT) of the chest

Results

Results with respect to the four endpoints are presented by treatment group in Table 2. The 2-year OS rate for patients treated with CRT was 57% (95% confidence interval [CI], 41%–72%) and 33% (95% CI, 18%–51%) in patients receiving RT (Fig. 1).

The local PFS at 2 years was 66% (95% CI, 49%–81%) with CRT and 55% (95% CI, 28%–79%) with RT (Fig. 2). One patient in the RT group underwent salvage surgery following local progression. This patient developed both distant progression (5 months) and

Discussion

This study provides useful benchmark information on survival and disease control in patients with inoperable Stage I NSCLC who were staged and treated using contemporary techniques. Despite the use of FDG-PET staging and concomitant chemotherapy, both local and distant progression were important causes of treatment failure. An effect on survival or local control of the addition of chemotherapy to RT could not be demonstrated. This was expected given the limited number of events in each group

References (19)

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The abstract for this article was selected for poster viewing at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

Conflict of interest: none.

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