International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationSurvival and Quality of Life After Stereotactic or 3D-Conformal Radiotherapy for Inoperable Early-Stage Lung Cancer
Introduction
Stereotactic ablative radiotherapy (SABR) is emerging as a new standard for medically inoperable patients with early-stage non–small-cell lung cancer (NSCLC) without nodal disease, although its superiority has never been validated with reference to conventionally fractionated three-dimensional conformal radiotherapy (3D-CRT) in a randomized controlled trial 1, 2. High-precision four-dimensional computed tomography (4D-CT) tumor imaging and online position verification considerably reduce and individualize the treated volume while improving targeting precision of SABR compared with classical 3D-CT–based CRT (3). This enables considerable escalation of the fraction dose and reduction of the overall treatment time. As a consequence, excellent local control (LC) rates of more than 80–90% have been reported for SABR 1, 4. Although one Phase II (Radiation Therapy Oncology Group 0618), and two Phase III studies comparing SABR with surgery (NCT00687986; NCT00840749) have been recruiting operable patients with early stage NSCLC, outside of these studies mostly patients unfit for or refusing surgery are presently offered SABR. Recently, a nonrandomized retrospective comparison between SABR and wedge resection has been published showing better LC after SABR, whereas overall survival (OS) was higher after wedge resection (5). In general, patients selected for 3D-CRT, SABR, or limited resection have severely compromised pulmonary function, considerable comorbidity, reduced general condition, and are at advanced age. SABR has been developed in this frail patient population. Among the features rendering this treatment attractive is its patient convenience in terms of noninvasiveness, short treatment duration, and outpatient delivery even for patients with a considerably reduced performance score.
Only one small study that included 39 patients undergoing CyberKnife® treatment for NSCLC has been published reporting on patient-rated health-related quality of life (HRQOL) and pulmonary symptoms after SABR, suggesting stability of HRQOL after SABR (6). A recent analysis in patients undergoing surgery for early-stage NSCLC showed that surgery had substantial temporary impact on HRQOL and some patients experienced HRQOL impairment for a long period (7). An earlier prospective study in patients undergoing 3D-CRT for early-stage NSCLC showed a gradual increase of patient-rated pulmonary symptoms after treatment (8). That study used an identical follow-up regimen for HRQOL as applied at our department and was conducted by one of the coauthors of the present study (J.A.L.), rendering it an ideal cohort to be compared with SABR in the current study.
The objectives of this study were twofold: (1) to investigate posttreatment longitudinal changes of HRQOL among patients treated with SABR and (2) to compare SABR with 3D-CRT regarding OS, disease-specific survival (DSS), LC, and longitudinal changes of HRQOL after either treatment.
This study is the first to investigate posttreatment HRQOL in a large cohort of patients receiving SABR and to compare HRQOL, survival, and LC, after SABR or 3D-CRT administered for early-stage lung tumors.
Section snippets
Selection of the cohorts
Between November 2006 and November 2009, 202 consecutive medically inoperable patients with T1-2N0M0 primary lung tumors were treated with SABR and all were included in this analysis. Patients were discussed in a multidisciplinary team consisting of thoracic surgeons, pulmonologists, anesthesiologists, radiation oncologists, nuclear medicine specialists, radiologists, and pathologists. All patients had technically resectable lesions, but were judged inoperable by specialized thoracic surgeons
Results
The SABR and 3D-CRT cohorts were balanced with the exception of age and WHO performance status, which were both in favor of 3D-CRT (see Discussion) (Table 1). SABR patients underwent a diagnostic fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) scan, whereas between 1994 and 1996, 18F-FDG-PET was unavailable. More lesions were pathologically confirmed in the 3D-CRT group (74% in the 3D-CRT cohort vs. 29% in the SABR cohort; p < .01; see Discussion).
Median follow-up was 13 months.
Discussion
In the last decade, SABR has rapidly been accepted as preferred treatment with curative intent for medically inoperable patients with NSCLC, mainly based on considerably higher LC rates reported for SABR in contrast to previously published two-dimensional RT or 3D-CRT series 1, 4, 19, 20, 21, 22. Although solely based on nonrandomized historical comparisons, LC is felt to be better with SABR at an extent that a randomized trial, though epistemologically preferable, seems unrealistic. Thus,
Acknowledgments
The authors wish to thank M. de Boer, N. A. Bylholt, and A.M. Pot for data entry.
References (27)
- et al.
Stereotactic radiotherapy for stage I lung cancer: Current results and new developments
Cancer/Radiotherapie
(2010) - et al.
Quality of life after stereotactic radiotherapy for stage I non-small-cell lung cancer
Int J Radiat Oncol Biol Phys
(2010) - et al.
Quality of life after curative radiotherapy in stage I non-small-cell lung cancer
Int J Radiat Oncol Biol Phys
(2002) - et al.
Physiologic evaluation of the patient with lung cancer being considered for resectional surgery
Chest
(2007) - et al.
The EORTC QLQ-LC13: A modular supplement to the EORTC Core Quality of Life Questionnaire (QLQ-C30) for use in lung cancer clinical trials. EORTC Study Group on Quality of Life
Eur J Cancer
(1994) - et al.
Optimizing dose prescription in stereotactic body radiotherapy for lung tumours using Monte Carlo dose calculation
Radioth Oncol
(2010) - et al.
A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation
J Chronic Dis
(1987) - et al.
Quality, interpretation and presentation of European Organisation for Research and Treatment of Cancer quality of life questionnaire core 30 data in randomised controlled trials
Eur J Cancer
(2008) - et al.
Hypofractionated stereotactic radiotherapy (HypoFXSRT) for stage I non-small cell lung cancer: Updated results of 257 patients in a Japanese multi-institutional study
J Thorac Oncol
(2007) - et al.
Outcomes of risk-adapted fractionated stereotactic radiotherapy for Stage I non-small-cell lung cancer
Int J Radiat Oncol Biol Phys
(2008)
Has 3-D conformal radiotherapy (3D CRT) improved the local tumour control for stage I non-small cell lung cancer?
Radiother Oncol
Can stereotactic fractionated radiation therapy become the standard of care for early stage non-small cell lung carcinoma
Cancer Treatment Rev
Systemic review of the patterns of failure following stereotactic body radiation therapy in early-stage non-small-cell lung cancer: Clinical implications
Radiother Oncol
Cited by (71)
Optimal Radiation Therapy Fractionation Regimens for Early-Stage Non-Small Cell Lung Cancer
2024, International Journal of Radiation Oncology Biology PhysicsSABR for Early Non-Small Cell Lung Cancer: Changes in Pulmonary Function, Dyspnea, and Quality of Life
2023, International Journal of Radiation Oncology Biology PhysicsQuality of Life After Stereotactic Body Radiation Therapy or Surgery for Early-Stage NSCLC: A Systematic Review
2022, JTO Clinical and Research ReportsOverview of health-related quality of life and toxicity of non-small cell lung cancer patients receiving curative-intent radiotherapy in a real-life setting (the REQUITE study)
2022, Lung CancerCitation Excerpt :Our results show no significant impact of radiotherapy on overall HRQoL and its domains over time for the entire population, except for cognitive functioning, which significantly deteriorates with time. Previous research in ES-NSCLC already showed that radiotherapy in general has no impact on HRQoL, apart from an improved emotional functioning in those receiving SBRT [24,47]. However, a more pronounced decline in physical functioning and increase in dyspnea was reported in patients receiving 3D-CRT compared to SBRT for ES-NSCLC, emphasizing the importance of advanced radiotherapy techniques in that study [47].
Conflict of interest: none.