Stage IIIA NSCLC Treatment
In some cases, endobronchial laser therapy and/or brachytherapy has been used to alleviate proximal obstructing lesions.
- A systematic review identified six randomized trials of high-dose rate brachytherapy (HDREB) alone or with external-beam radiation therapy (EBRT) or laser therapy.
- Better overall symptom palliation and fewer retreatments were required in previously untreated patients using EBRT alone.[Level of evidence: 1iiC]
- Although EBRT is frequently prescribed for symptom palliation, there is no consensus about when the fractionation scheme should be used.
- For EBRT, different multifraction regimens appear to provide similar symptom relief;[23,24,25,26,27,28] however, single-fraction radiation therapy may be insufficient for symptom relief compared with hypofractionated or standard regimens, as seen in the NCIC Clinical Trials' Group trial NCT00003685.[Level of evidence: 1iiC]
- Evidence of a modest increase in survival in patients with better PS given high-dose EBRT is available.[23,24][Level of evidence: 1iiA]
- HDREB provided palliation of symptomatic patients with recurrent endobronchial obstruction previously treated by EBRT, when it was technically feasible.
The addition of sequential and concurrent chemotherapy to radiation therapy has been evaluated in prospective randomized trials and meta-analyses. Overall, concurrent treatment may provide the greatest benefit in survival with increase in toxic effects.
Concomitant platinum-based radiation chemotherapy may improve survival of patients with locally advanced NSCLC. However, the available data are insufficient to accurately define the size of such a potential treatment benefit and the optimal schedule of chemotherapy.
- A meta-analysis of patient data from 11 randomized clinical trials showed the following:
- Cisplatin-based combinations plus radiation therapy resulted in a 10% reduction in the risk of death compared with radiation therapy alone.[Level of evidence: 1iiA]
- A meta-analysis of 13 trials (based on 2,214 evaluable patients) showed the following:
- The addition of concurrent chemotherapy to radical radiation therapy reduced the risk of death at 2 years (relative risk [RR] = 0.93; 95% CI, 0.88-0.98; P = .01).
- For the 11 trials with platinum-based chemotherapy, RR was 0.93 (95% CI, 0.87-0.99; P = .02).
- A meta-analysis of individual data from 1,764 patients was based on nine trials and showed the following:
- The HR of death among patients treated with radiation therapy and chemotherapy compared with radiation therapy alone was 0.89 (95% CI, 0.81-0.98; P = .02), corresponding to an absolute benefit of chemotherapy of 4% at 2 years.
- The combination of platinum with etoposide seemed more effective than platinum alone.
Concurrent versus sequential chemoradiation therapy
The results from two randomized trials (including RTOG-9410) and a meta-analysis indicate that concurrent chemotherapy and radiation therapy may provide greater survival benefit, albeit with more toxic effects, than sequential chemotherapy and radiation therapy.[32,33,34][Level of evidence: 1iiA]