An analysis of data from 46,803 patients with stage IV non–small cell lung cancer (NSCLC) who received palliative chest radiation therapy found that 49% received radiotherapy for longer than 15 fractions, and 28% received more than 25 fractions. This treatment pattern “is inconsistent with the results of published phase III studies,” Matthew Koshy, MD, of the University of Chicago, and colleagues pointed out in the Journal of the National Cancer Institute. In addition, approximately 19% of the patients received concurrent chemoradiation, “a practice that is not only unsupported by the evidence, but one that places the patient at increased risk of toxicity without an established palliative or survival advantage,” the investigators stated.
“This demonstrates that a substantial number of patients requiring palliative thoracic radiotherapy are overtreated, and further work is necessary to ensure these patients are treated according to evidenced-based guidelines,” the authors concluded.
Strongest Predictive Factors
The study participants were identified using the National Cancer Database from 2004 to 2012. The median age of the patients was 67 years, and the median primary tumor size was 5 cm.
“The strongest independent predictors of long-course radiation therapy were private insurance (odds ratio [OR] = 1.40 vs uninsured, 95% confidence interval [CI] = 1.28–1.53) and treatment in community cancer programs (OR = 1.49, 95% CI = 1.38–1.58) compared with academic research programs,” the authors reported. The strongest predictive factors for chemoradiotherapy were private insurance (OR = 1.38, 95% CI = 1.23–1.54) compared with uninsured patients and treatment in community cancer programs (OR = 1.44, 95% CI = 1.33–1.56) compared with academic programs.
“This study found that in patients who underwent palliative thoracic radiotherapy, a ‘reverse disparity’ exists in that the group of patients who usually receive care consistent with evidence-based guidelines (ie, white and insured patients) were overtreated with longer courses of radiotherapy and concurrent chemoradiotherapy. These intensive treatments are associated with higher risks of morbidity—esophagitis, in particular—without a meaningful clinical gain, and thus further investigation into this pattern is important.”
Patients treated more recently, from 2009–2012 vs from 2004–2008, were less likely to be treated with more than 15 fractions of radiation therapy and slightly less likely to be treated with concurrent chemoradiotherapy. The reduction in long-course radiation “suggests that population-level progress can be made and that clinical practice guidelines can change practice patterns,” the authors observed. “Furthermore, early involvement with palliative care specialists can meaningfully improve outcomes and adherence to evidence-based treatment choices in the noncurative setting.” ■
Koshy M, et al: J Natl Cancer Inst. September 30, 2015 (early release online).