ESTRO 37: Elderly Patients With NSCLC May Be Less Likely to Benefit From Concurrent Chemoradiotherapy
An analysis of elderly patients with non–small cell lung cancer (NSCLC) treated in a phase II trial of radiotherapy combined with chemotherapy has shown that they were less likely to benefit than younger patients if the two treatments were given at the same time. These findings were presented at the European Society for Radiotherapy & Oncology (ESTRO) 37 Conference (Abstract PV0039).
Previous research has shown that for NSCLC patients with locally advanced disease, radiotherapy given simultaneously with chemotherapy (concurrent chemoradiotherapy) gives the best chance of survival, compared to giving chemotherapy followed by radiotherapy (sequential chemoradiotherapy). However, it is a more intensive treatment and can lead to more numerous and severe side effects. Until now, it was unknown whether concurrent chemoradiotherapy also improved survival in patients aged 75 or older, and how they would tolerate the treatment.
Study Methods
The trial investigated intensity-modulated radiation therapy (IMRT)—a form of radiotherapy that precisely targets the cancer and adapts the beam’s shape to that of the tumor, avoiding or reducing exposure of nearby healthy tissues—combined with chemotherapy. The radiation dose was personalized to each patient, so that the maximum possible total dose was delivered to the tumor, while sparing nearby organs that could be harmed by radiation. This is known as the isotoxic principle, and the researchers wanted to see if it was possible to give higher tumor doses without increasing the risk of side effects, and if it improved survival.
A total of 300 patients took part in the trial at the MAASTRO Clinic (Maastricht, The Netherlands) between May 2009 and April 2012, of whom 76 (25.3%) were aged 75 or older. The patients received IMRT alone, concurrent chemoradiotherapy, or sequential chemoradiotherapy. The researchers reviewed the patients’ overall survival in October 2017.
Findings
Judith van Loon, MD, PhD, a radiation oncologist at the MAASTRO Clinic, said, “We found that elderly patients who were treated with concurrent chemoradiotherapy had a worse survival than younger patients. They also did worse than the elderly patients treated with sequential chemoradiotherapy or radiotherapy alone. Furthermore, it was not possible to increase the dose to the tumor without increasing the chance of side effects.”
Among patients aged 75 or older, 32% received concurrent chemoradiotherapy, 29% sequential chemoradiotherapy, and 39% radiotherapy alone. The total dose of radiation that could be delivered in the concurrent chemoradiotherapy group was an average of 66.2 Gy. In the sequential chemoradiotherapy group, it was an average of 66.7 Gy.
Overall survival was significantly worse in the elderly patients receiving concurrent chemoradiotherapy, even though the majority of them (96%) were assessed at the beginning of the study as having a World Health Organization (WHO) performance score of 1 or less—meaning they were fully active and able to carry on normal life.
Compared with younger patients, the average overall survival was 15.5 vs 19.8 months, and after 5 years, 13.2% elderly patients were alive compared to 24.1% of younger patients. While overall survival was worse for the elderly patients treated with concurrent chemoradiotherapy, the survival was similar to younger patients among the elderly who were treated with sequential chemoradiotherapy or radiotherapy alone. Overall, there was no difference in adverse effects between elderly and younger patients.
“These results indicate that the standard treatment for [patient with] lung cancer may not result in the best outcomes for elderly patients,” said Dr. van Loon. “Most importantly, they show that selecting elderly patients for concurrent chemoradiotherapy on the basis of their performance score is not sufficient. Physicians need to take care when deciding whether or not to administer concurrent chemoradiotherapy outside the conditions of a study.”
“These findings underscore the need for prospective studies that incorporate geriatric assessment in this understudied group of elderly cancer patients, as this enables us to identify predictive factors for treatment outcome. Also, we should look not only at the chance of cure but also quality of life and patient-reported outcome measures. This can help physicians to select the best treatment for individual patients”, she continued.
“A multicenter trial is currently investigating the value of a geriatric assessment in elderly patients with locally advanced lung cancer. Within this trial, patients that are assessed as fit enough to be treated with chemoradiotherapy are randomly assigned to concurrent or sequential chemoradiotherapy. Results from this trial are expected in 2022,” Dr. van Loon concluded.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
