As reported in the Journal of Clinical Oncology by Andrea Bezjak, MD, of Princess Margaret Cancer Center, Toronto, and colleagues,1 ASCO has recently endorsed the American Society for Radiation Oncology (ASTRO) evidence-based guideline on external-beam radiotherapy for patients with locally advanced non–small cell lung cancer (NSCLC).2,3 The ASTRO guideline recommendations were considered by ASCO experts to be clear, thorough, and based on the most relevant scientific evidence. An ASCO endorsement panel endorsed the guideline and added qualifying statements. The endorsement panel was co-chaired by Dr. Bezjak and Christopher G. Azzoli, MD, of Massachusetts General Hospital, Boston.
The primary ASTRO guideline question is: What is the role of external-beam radiotherapy in the management of locally advanced NSCLC? The target population for the guideline consists of patients with stage II or III locally advanced NSCLC whose disease is unresectable and patients with stage II or III disease who are eligible for surgery.
Key Recommendations
ASCO’s key recommendations extracted from the ASTRO guideline are summarized here, with ASCO qualifying language shown in italics.
- For curative-intent treatment of locally advanced NSCLC, concurrent chemoradiation is recommended because it improves local control and overall survival compared with sequential chemotherapy followed by radiation or radiation therapy alone.
- The standard dose fractionation of radiation with concurrent chemotherapy is 60 Gy given in fractions of 2 Gy once per day over 6 weeks. Dose escalation beyond 60 Gy with conventional fractionation has not been demonstrated to be of benefit.
- There is no role for the routine use of induction chemotherapy before chemoradiotherapy.
- There is no role for the routine use of consolidation chemotherapy after chemoradiotherapy. Current data fail to support the routine use of consolidation chemotherapy after chemoradiotherapy, but this remains an option for patients who did not receive full systemic chemotherapy doses during radiotherapy.
- The ideal concurrent chemotherapy regimen has not been determined. The two most common regimens are cisplatin/etoposide and carboplatin/paclitaxel.
- For patients who cannot tolerate concurrent chemoradiotherapy, sequential chemotherapy followed by radical (definitive) radiation is recommended because it improves overall survival when compared with radiotherapy alone.
- Radiotherapy alone may be used for patients ineligible for combined-modality treatment; it may offer better tolerability but poorer survival.
- Postoperative radiotherapy may be recommended for patients with complete resection of N2 disease to improve local control, but it should be delivered sequentially after adjuvant chemotherapy.
- Postoperative radiotherapy is recommended for patients with incomplete resection (microscopic or gross positive margin or gross residual disease), to be given either concurrently or sequentially with chemotherapy.
- Patients with resectable stage III NSCLC should be managed by a multidisciplinary team that uses best surgical judgment. The best candidates for preoperative chemoradiotherapy have preoperatively planned lobectomy (as opposed to pneumonectomy), no weight loss, are female, and have only one involved nodal station. ■
Disclosure: Drs. Bezjak and Azzoli reported no potential conflicts of interest.
References
1. Bezjak A, Temin S, Franklin G, et al: Definitive and adjuvant radiotherapy in locally advanced non-small-cell lung cancer: American Society of Clinical Oncology clinical practice guideline endorsement of the American Society for Radiation Oncology evidence-based clinical practice guideline. J Clin Oncol. May 5, 2015 (early release online).
2. Rodrigues G, Choy H, Bradley J, et al: Definitive radiotherapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline. Pract Radiat Oncol 5:141-148, 2015.
3. Rodrigues G, Choy H, Bradley J, et al: Adjuvant radiotherapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline. Pract Radiat Oncol 5:149-155, 2015.
For More Information
More information on ASCO’s endorsement of the ASTRO clinical practice guideline for radiotherapy in locally advanced NSCLC is available from ASCO at www.asco.org/endorsements/NSCLCradiotherapy. Information for patients about NSCLC is available at www.cancer.net/cancer-types/lung-cancer.
The ASTRO guideline is available at http://www.practicalradonc.org/article/S1879-8500(15)00082-X/fulltext and http://www.practicalradonc.org/article/%20S1879-8500(15)00083-1/fulltext.
