The American Society for Radiation Oncology (ASTRO) recently announced a new guideline for the use of radiotherapy in the most common type of lung cancer — non-small cell lung cancer (NSCLC). The guideline is entitled “Definitive and adjuvant radiotherapy in locally advanced non-small cell lung cancer: An American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline” and its executive summary was recently published in the journal Practical Radiation Oncology (PRO) under the title “Adjuvant radiation therapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline.”
The goal is to provide orientation in terms of current treatment options and future research to both physicians and patients, especially on the use of adjuvant external beam radiation therapy in locally advanced NSCLC. The guideline was developed based on a review of 74 medical studies published between January 1966 and March 2013, and a consensus-based expert opinion from 14 leading lung cancer oncologists in the United States and Canada.
“Radiation therapy is a central component of treatment protocols for patients with locally advanced non-small cell lung cancer, with five-year survival rates of approximately 26 percent” said a co-chair of the guideline expert panel Dr. George Rodrigues in a news release. “This guideline summarizes more than 35 years of clinical trial evidence to provide the best evidence-based guidance on radiation therapy to improve outcomes for this challenging patient population.”
Five Key Questions are described in the guideline concerning the role of definitive and adjuvant radiation therapy for curative-intent treatment of locally advanced NSCLC. Besides the 74 studies mentioned, 27 clinical practice guidelines studies were also included due to their relevance to one or more of the Key Questions.
The first Key Question concerns the optimal external beam radiation therapy dose fractionation for NSCLC treatment without chemotherapy. Radiation therapy alone has been shown to improve overall patient survival and the recommended dose is a minimum of 60 Gray. The second is identical to the first one but includes the use of chemotherapy, where the guideline suggests that patients treated with concomitant chemotherapy, should receive 60 Gray (2 Gray once a day for six weeks) of radiation therapy.
The third Key Question refers to the optimal timing of external beam radiation therapy regarding systemic chemotherapy. The guideline suggests that ideally, radiation therapy and chemotherapy should be initiated at the same time, if patients cannot tolerate this regimen then sequential chemotherapy is recommended followed by radical radiation therapy.
The fourth Key Question assesses the use of adjuvant post-operative radiation therapy in advanced NSCLC. The guideline recommends that individuals with primary and/or nodal disease should be given post-operative radiation therapy in order to improve local control; however, it has not been proven that this measure increases overall survival.
Last, the fifth Key Question refers to situations when neoadjuvant radiation therapy or chemoradiation prior to surgery are indicated for NSCLC treatment. According to the guideline, there is no evidence supporting the routine use of either one in the pre-operative management of NSCLC.