New Guidelines Aim to Improve Quality of Life For Patients With Advanced Lung Cancer

Some patients with incurable non-small cell lung cancer (NSCLC) should receive chemotherapy concurrent with palliative thoracic radiation therapy, according to an updated guideline released by the American Society for Radiation Oncology (ASTRO).

The change comes after the review of studies published from March 2010 through July 2016.

“The data summarized in the guideline update suggest that for highly selected patients receiving palliative-intent therapy for stage 3 non-small cell lung cancer, adding chemotherapy to thoracic radiation or, conversely, adding thoracic radiation to chemotherapy, offers modestly improved survival times and may afford more durable palliation of symptoms related to thoracic disease burden compared to what is achieved through either chemotherapy alone or radiation alone,” Benjamin Moeller, M.D., Ph.D., chair of the guideline task force and a radiation oncologist at the Levine Cancer Institute in Charlotte, North Carolina, said in an interview with CURE.

More than half of patients with NSCLC receive a diagnosis of locally advanced (stage 3) or metastatic (stage 4) disease, according to ASTRO. These patients are often concerned with quality of life and relieving pain or side effects, which can be accomplished through palliative radiation therapy. Symptoms may include chest pain, cough, labored or obstructed breathing and coughing up blood.

“Acute esophagitis, or temporary pain on swallowing, is normally the most bothersome side effect for patients treated with palliative thoracic radiation,” he said. “It typically responds well to conservative management but, particularly for patients who begin treatment already frail, it can result in hospitalization.”

The new recommendation from ASTRO advises to use the addition of concurrent chemotherapy along with palliative thoracic radiation therapy only for highly selected patients with stage 3 NSCLC, including those who are deemed incurable by their treating physicians, are candidates for chemotherapy, have an Eastern Cooperative Oncology Group, more commonly known as ECOG, performance status between zero and two and have a life expectancy of at least three months.

“Both randomized controlled trials prompting this guideline update studied ‘incurable’ stage 3 non-small cell lung cancer, but used non-overlapping criteria for defining this otherwise undefined patient subset,” Moeller said. “Therefore, without prospective data to guide which patients with stage 3 non-small cell lung cancer should be considered curable, the guidelines’ authors left it to the treating physicians to define curability.”

The newly updated guideline modifies one published in 2011, which stated that there was no added benefit of concurrent chemoradiation in the palliation of lung cancer symptoms. However, two randomized controlled trials have since been published that suggest concurrent chemotherapy offers clinically meaningful benefits to patients receiving palliative thoracic radiation, Moeller explained.

Since there is not a standard of care for patients being treated with palliative intent, this guideline offers practitioners a level of confidence in the guidance and allows them to discuss concurrent chemoradiotherapy as an option in the palliative management of incurable stage 3 NSCLC.

The other key questions addressed by the original ASTRO palliative lung guideline were not revised in this update, as there was insufficient new data to support altering the guidance on dose of palliative thoracic external beam radiation or the role of endobronchial brachytherapy.

“Palliative thoracic radiation and palliative chemotherapy can improve both quantity and quality of life, but they also both come with side effects,” Moeller said. “Patients need to ask questions of their health care team about the goals and anticipated side effects of the palliative care they are being offered and speak up if these do not align with their wishes.”