ASTRO updates lung radiation guideline for non-small cell lung cancer patients

The American Society for Radiation Oncology (ASTRO) released an update to its clinical guideline for the use of palliative-intent radiation therapy for patients with incurable non-small cell lung cancer (NSCLC).  

According to an April 4 ASTRO release, the guideline now recommends the addition of concurrent chemotherapy to radiation therapy for patients with incurable stage III NSCLC and those who tolerate chemotherapy and have a life expectancy beyond three months. Since 2011, the guideline had stated that there was no added benefit of concurrent chemoradiation in the palliation of lung cancer symptoms, according to the release.   

"The primary question we faced with this [guideline] revision was whether providers can enhance the impact of moderate, palliative doses of radiation by introducing additional therapy," said Benjamin Moeller, MD, PhD, chair of the guideline task force and a radiation oncologist at the Levine Cancer Institute in Charlotte, N.C., in a prepared statement. "Patients in this setting typically receive two to three weeks of daily radiation, during which they might expect to have one to two weeks of clinically significant, treatment-related side effects—most commonly inflammation of the esophagus. Following treatment, however, these patients experience a more robust and durable stabilization of their quality of life, including less pain and fewer symptoms." 

Below are key recommendations regarding eligibility for concurrent chemoradiation and delivery/dosing from the updated 2018 full-text guideline, as stated by ASTRO:  

  • Patients who are likely to benefit more from concurrent chemotherapy and radiation therapy than from either modality alone include those with (1) stage III NSCLC disease, who are (2) not eligible for curative-intent therapy but are (3) candidates for chemotherapy, (4) have an ECOG Performance Status between zero and two and (5) have a life expectancy of at least three months. 

  • For all other patients with incurable NSCLC, including those with stage IV disease, the evidence remains insufficient to support concurrent thoracic chemoradiation; combined treatment is not recommended outside of clinical trials and multi-institutional registries. 

  • For radiation therapy, a moderately hypofractionated approach with external beam radiation therapy is recommended ("moderate" = daily radiation doses of 280 to 300 Centigray (cGy) per fraction to a total dose of 3000 or 4200 cGy). Higher radiation doses may not be tolerable for palliative-intent patients and lower doses may not confer a quality-of-life benefit. Best practice also includes minimizing unnecessary radiation dose to the esophagus. 

"The original recommendations for radiation dosing and the role of brachytherapy in this setting were not addressed or revised in the current update, because new evidence has not directly addressed these issues," according to the press release. "Additionally, as with the original guideline, the update does not address the question of curative versus palliative treatment for NSCLC; rather, its scope includes optimal treatment with thoracic radiation and chemotherapy in patients for whom the decision has been made to treat palliatively."