Radiotherapy in palliative treatment of metastatic NSCLC: not all one and the same

The role of an editorial is to incorporate the results of a new relevant study in the scientific scenario, shedding light on some particular results of the trial which can change the clinical practice. The starting point is the January issue of Journal of Clinical Oncology in which Chen et al. , asserted that when palliative RT is used in patients with metastatic non small cell lung cancer (NSCLC), a substantial proportion of patients receive a greater number of treatments and higher doses  of radiotherapy than supported by current evidence, suggesting an opportunity to improve care delivery. The argument is not new, certainly. On one hand, recent years have shown the publication of many phase III trials, systematic reviews  and guidelines which have confirmed that various shorter schedules of radiotherapy provide good symptomatic relief for bone metastasis and for chest symptoms. On the other hand, national and international practice surveys, as well as several editorials, have pointed out the reluctance of radiation oncologists for short prescriptions.

A Three-Dimensional Conformal Radiation Therapy planning in a left sided lung tumor. High dose distribution cover the disease, sparing the surrounding heath tissue.

A Three-Dimensional Conformal Radiation Therapy planning in a left sided lung tumor. High dose distribution cover the disease, sparing the surrounding heath tissue.

The reluctance to change established patterns of practice is not well studied and there are probably multiple determinants, but as some authors suggest , it may include elements of habit, lack of knowledge of recent clinical data or, in some cases, economic reasons. This editorial aims to restore the dignity of the radiation oncologist’s thought-process, by showing that the thinking captures the nuances of the specific clinical situation, which no other phase III study has done thus far. In recent years, the concept of oligometastatic disease has been introduced. to describe “… a less advanced state of metastatic disease amenable to and potentially curable with local therapy”. In fact, we all have experience of metastatic patients with longer survival than expected. Several studies from surgeons have reported that surgical resection of metastases prolongs survival in selected patients, even if the benefits of resection and appropriate selection criteria in patients who develop metastasis are still poorly defined. Today, the question of whether the oligometastatic state truly exists seems to be outdated. In fact, phatophysiologic mechanisms of oligometastatic disease have also been identified and reported.

Many clinical experiences reached the conclusion that chemotherapy remains the standard of care for patients with metastatic disease, but patients presenting
 with a limited number and extent of metastatic disease
 may benefit from localized therapy, such as radiotherapy. Obviously, technologic advances in radiotherapy have resulted in a greater comfort level in treating patients with oligometastatic disease because of lower treatment-related toxicity. Referring back to the Chen et al. report, it seems to be a shared view that short course radiotherapy is a safe and effective tool for palliating lung cancer symptoms and it is appropriate for selected poor-prognosis patients. However, it is important to note that the suggestion of improved long-term survival for favourable-risk patients treated with higher radiation doses illustrates the critical need to appropriately classify metastatic NSCLC patients. The challenge for the next decade will be to select those patients who may benefit from more aggressive treatment in a more appropriate manner.

Sara Ramella, Rinaldi Carla Germana, Rolando Maria D’Angelillo
Division of Radiation Oncology, Campus Bio-Medico University
Rome, Italy

 

Publication

Radiotherapy in palliative treatment of metastatic NSCLC: not all one and the same.
Ramella S, D’Angelillo RM.
Ann Palliat Med. 2013 Apr

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