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157 Radical radiotherapy for NSCLC in the very elderly: Can failure to tolerate treatment be predicted?
Poster abstracts, 11th Annual British Thoracic Oncology Group Conference, 2013: Radiotherapy Results: 36 patients identified. NSCLC Patient selection Pathological confirmation PET/CT staged RFTS; FEV1 TF Smoking Cessation advised (where applicable) Patient treatment Paradigm Stage I/II Offer CHART If not available; 55 Gy/20 or 64 66 Gy/32 33# Consider SBR if N0 and tumour 4 cm, 2 cm from main airways, PS0 2 Stage III Consider chemoradiotherapy (CRT)
Reference
Target compliance
Audit results
LUCADA NICE NICE
75% 100% 100%
NICE
100%
81% 100% 100% 100% 71%
NICE
100%
UK SBR Consortium Guidelines
100%
NICE
100%
If not suitable for CRT consider CHART Treatment Delivery Immobilisation Device Compensation for respiratory motion considered
NICE
100%
On Target RCR On Target RCR
100% 100%
Treatment Verification with orthogonal images Corrected Gaps
On Target RCR RCR
100% 100%
objective scoring system such as ACE-27 should be considered. It has been shown that performance status is not predictive for survival following treatment but may predict tolerance of radiotherapy. Within this patient population caution must be exercised in selecting and consenting patients for radical radiotherapy with consideration paid to co-morbidities and stage of disease, accepting this information can only help guide decisions. Table 1. Group characteristics
0% 100% 67%
92% 25% not fit enough for CRT, 19% not for chemotherapy, 31% field too big 0% 100% 100% 4D CT 15% Fluoroscopy 6% Standard Margins 79% 100% (MV imaging) 75%
CHART is not available at our centre, SBR is only accessed by referral to other UK centres. Of those offered SBR only 50% accepted; the others did not want to travel. Concurrent chemoradiation (CRT) was considered in all but one stage III patients (where the preferred treatment was chemotherapy followed by surgery), but delivered in only 25%. 4D-CT was being introduced in this period. Conclusions: Advanced radiotherapy treatments (SBR and CRT) were considered for most patients. Local implementation of SBR may increase patient acceptance. Technological improvements are being seen. We want to compare our results with other cohorts. 157 Radical radiotherapy for NSCLC in the very elderly: Can failure to tolerate treatment be predicted? S. Chaudhury *, A.J. McPartlin, R. Swindell, N. Bayman, P. Burt, A. Chittalia, J. Coote, C. Faivre-Finn, M. Harris, H. Lander, L. Lee, H. Sheikh, L. Pemberton. Christie NHS Foundation Trust, UK Introduction: Very elderly patients, over 80yo, make up an increasing proportion of newly diagnosed NSCLC cases being considered for radical radiotherapy. Typically this group have higher co-morbidity levels than a younger cohort which impact on ability to tolerate radical treatment. A weighted validated scoring system such as Adult Comorbidity Evaluation 27 (ACE-27) can objectively quantify co-morbidity at pre-treatment assessment. This study compared very elderly patients who successfully completed therapy with those whose treatment was stopped early, looking for differences at baseline. Methods: Between 2007 2011, 138 consecutive patients (>80 yo) who completed radical treatment and 19 patients (>75 yo) whose treatment stopped early were identified. All received treatment for NSCLC and were prescribed 55 Gy in 20 once-daily fractions, the UK’s most common radical lung regime. Electronic notes were reviewed to obtain staging, demographic, performance status (PS) and ACE-27 data. Results: The two groups were broadly well matched (Table 1). Those failing to complete treatment had worse performance status and more co-morbidities. The most common pre-existing condition in those not completing treatment was COPD, present in 9 patients (47%). Conclusion: Identifying prior to therapy which very elderly patients may struggle with treatment is challenging. In this study those failing to finish treatment had worse performance status at initial review and had more co-morbidity. There was also a relatively increased proportion of incomplete treatments in stage III disease. Accurately assessing patients’ co-existing conditions using an
S53
Age Gender Stage I II III Average PS Average ACE-27
Completing treatment (n = 138)
Incomplete treatment (n = 19)
83.9 Male 59%
81.2 Male 63%
20% 47% 33% 1.46 1.5
22% 39% 39% 1.66 1.8
158 The role of primary chemotherapy prior to continuous hyperfractionated accelerated radiotherapy (CHART) in the treatment of non-small cell lung carcinoma at Nottingham University Hospital C.E. Knox *, K.L. Foweraker, S.A. Morgan. Nottingham University Hospitals NHS Trust, UK Background: Continuous hyperfractionated accelerated radiotherapy (CHART) improves outcome in localised unresectable nonsmall cell lung carcinoma compared to conventional radiotherapy. Chemotherapy also improves survival but little data is available about combining chemotherapy with CHART. This retrospective single centre study assesses the outcome with chemotherapy given before CHART. Methods: 348 consecutive unselected patients treated with CHART at Nottingham University Hospitals between 2003 and 2009 were analysed for morbidity and survival, including 96 patients who received primary chemotherapy. Results: Tumour stage ranged between IA and IV; tumour size between 1.0 cm and 10 cm; squamous histology in 65%. Patients who had primary chemotherapy (96, 70% male) had significantly larger tumours (4.43 cm vs. 3.54 cm) and were significantly younger than the CHART alone group (252, 66% male). Median survival and progression-free survival for stage III (78 patients) were 19.9 and 13.3 months; 16.5 and 11.0 months for the CHART alone group (74 patients) (nsd). Adjusted for TNM stage, performance status, gender and tumour size using multivariate Cox regression analysis the adjusted hazard ratio for survival and progressionfree survival of stage III patients after chemotherapy was 0.81 (p = 0.29) and 0.62 (p = 0.05) respectively. Grade 3/4 oesophagitis was more common after chemotherapy (6.8% versus 2.7%, p = 0.10) but there was no difference in pneumonitis, and no grade 5 toxicity. Conclusion: In this non-randomised series chemotherapy was selectively offered to patients with more advanced tumours, yet there was a 3.32 month improvement in survival in stage III disease after initial chemotherapy. Adjusted for potential confounders, the chemotherapy group had a 19% improvement in survival and a 28% improvement in progression-free survival although grade 3/4 oesophagitis was twice as frequent. Despite concerns of enhanced toxicity, and of potential tumour cell recruitment or selection of radioresistant cells from chemotherapy prior to CHART, it remains a valid treatment option and leads to improved progression-free survival.
Reference
Target compliance
Audit results
LUCADA NICE NICE
75% 100% 100%
NICE
100%
81% 100% 100% 100% 71%
NICE
100%
UK SBR Consortium Guidelines
100%
NICE
100%
If not suitable for CRT consider CHART Treatment Delivery Immobilisation Device Compensation for respiratory motion considered
NICE
100%
On Target RCR On Target RCR
100% 100%
Treatment Verification with orthogonal images Corrected Gaps
On Target RCR RCR
100% 100%
objective scoring system such as ACE-27 should be considered. It has been shown that performance status is not predictive for survival following treatment but may predict tolerance of radiotherapy. Within this patient population caution must be exercised in selecting and consenting patients for radical radiotherapy with consideration paid to co-morbidities and stage of disease, accepting this information can only help guide decisions. Table 1. Group characteristics
0% 100% 67%
92% 25% not fit enough for CRT, 19% not for chemotherapy, 31% field too big 0% 100% 100% 4D CT 15% Fluoroscopy 6% Standard Margins 79% 100% (MV imaging) 75%
CHART is not available at our centre, SBR is only accessed by referral to other UK centres. Of those offered SBR only 50% accepted; the others did not want to travel. Concurrent chemoradiation (CRT) was considered in all but one stage III patients (where the preferred treatment was chemotherapy followed by surgery), but delivered in only 25%. 4D-CT was being introduced in this period. Conclusions: Advanced radiotherapy treatments (SBR and CRT) were considered for most patients. Local implementation of SBR may increase patient acceptance. Technological improvements are being seen. We want to compare our results with other cohorts. 157 Radical radiotherapy for NSCLC in the very elderly: Can failure to tolerate treatment be predicted? S. Chaudhury *, A.J. McPartlin, R. Swindell, N. Bayman, P. Burt, A. Chittalia, J. Coote, C. Faivre-Finn, M. Harris, H. Lander, L. Lee, H. Sheikh, L. Pemberton. Christie NHS Foundation Trust, UK Introduction: Very elderly patients, over 80yo, make up an increasing proportion of newly diagnosed NSCLC cases being considered for radical radiotherapy. Typically this group have higher co-morbidity levels than a younger cohort which impact on ability to tolerate radical treatment. A weighted validated scoring system such as Adult Comorbidity Evaluation 27 (ACE-27) can objectively quantify co-morbidity at pre-treatment assessment. This study compared very elderly patients who successfully completed therapy with those whose treatment was stopped early, looking for differences at baseline. Methods: Between 2007 2011, 138 consecutive patients (>80 yo) who completed radical treatment and 19 patients (>75 yo) whose treatment stopped early were identified. All received treatment for NSCLC and were prescribed 55 Gy in 20 once-daily fractions, the UK’s most common radical lung regime. Electronic notes were reviewed to obtain staging, demographic, performance status (PS) and ACE-27 data. Results: The two groups were broadly well matched (Table 1). Those failing to complete treatment had worse performance status and more co-morbidities. The most common pre-existing condition in those not completing treatment was COPD, present in 9 patients (47%). Conclusion: Identifying prior to therapy which very elderly patients may struggle with treatment is challenging. In this study those failing to finish treatment had worse performance status at initial review and had more co-morbidity. There was also a relatively increased proportion of incomplete treatments in stage III disease. Accurately assessing patients’ co-existing conditions using an
S53
Age Gender Stage I II III Average PS Average ACE-27
Completing treatment (n = 138)
Incomplete treatment (n = 19)
83.9 Male 59%
81.2 Male 63%
20% 47% 33% 1.46 1.5
22% 39% 39% 1.66 1.8
158 The role of primary chemotherapy prior to continuous hyperfractionated accelerated radiotherapy (CHART) in the treatment of non-small cell lung carcinoma at Nottingham University Hospital C.E. Knox *, K.L. Foweraker, S.A. Morgan. Nottingham University Hospitals NHS Trust, UK Background: Continuous hyperfractionated accelerated radiotherapy (CHART) improves outcome in localised unresectable nonsmall cell lung carcinoma compared to conventional radiotherapy. Chemotherapy also improves survival but little data is available about combining chemotherapy with CHART. This retrospective single centre study assesses the outcome with chemotherapy given before CHART. Methods: 348 consecutive unselected patients treated with CHART at Nottingham University Hospitals between 2003 and 2009 were analysed for morbidity and survival, including 96 patients who received primary chemotherapy. Results: Tumour stage ranged between IA and IV; tumour size between 1.0 cm and 10 cm; squamous histology in 65%. Patients who had primary chemotherapy (96, 70% male) had significantly larger tumours (4.43 cm vs. 3.54 cm) and were significantly younger than the CHART alone group (252, 66% male). Median survival and progression-free survival for stage III (78 patients) were 19.9 and 13.3 months; 16.5 and 11.0 months for the CHART alone group (74 patients) (nsd). Adjusted for TNM stage, performance status, gender and tumour size using multivariate Cox regression analysis the adjusted hazard ratio for survival and progressionfree survival of stage III patients after chemotherapy was 0.81 (p = 0.29) and 0.62 (p = 0.05) respectively. Grade 3/4 oesophagitis was more common after chemotherapy (6.8% versus 2.7%, p = 0.10) but there was no difference in pneumonitis, and no grade 5 toxicity. Conclusion: In this non-randomised series chemotherapy was selectively offered to patients with more advanced tumours, yet there was a 3.32 month improvement in survival in stage III disease after initial chemotherapy. Adjusted for potential confounders, the chemotherapy group had a 19% improvement in survival and a 28% improvement in progression-free survival although grade 3/4 oesophagitis was twice as frequent. Despite concerns of enhanced toxicity, and of potential tumour cell recruitment or selection of radioresistant cells from chemotherapy prior to CHART, it remains a valid treatment option and leads to improved progression-free survival.