Radiochemotherapy as the standard treatment for both elderly and non-elderly fit patients with locally advanced (stage III) nonsmall cell lung cancer

Radiochemotherapy as the standard treatment for both elderly and non-elderly fit patients with locally advanced (stage III) nonsmall cell lung cancer

Lung Cancer 82 (2013) 176–178 Contents lists available at ScienceDirect Lung Cancer journal homepage: www.elsevier.com/locate/lungcan Letters to th...

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Lung Cancer 82 (2013) 176–178

Contents lists available at ScienceDirect

Lung Cancer journal homepage: www.elsevier.com/locate/lungcan

Letters to the Editor Radiochemotherapy as the standard treatment for both elderly and non-elderly fit patients with locally advanced (stage III) nonsmall cell lung cancer Dear Sir, I read with interest recent article by Topkan et al. [1] about successful implementation of aggressive concurrent radiochemotherapy (RT-CHT) in highly selected septuagenarians with stage IIIB non-small-cell lung cancer (NSCLC). The authors should be commended for elegant work which, importantly, is achieved in a large cohort of these patients in a single-institutional setting. They have been offered high dose RT and 1–2 cycles of cisplatin-based CHT to achieve median survival tine (MST) of 17.7 months and a 3-year survival rate of 21.8%. Although longer follow-up may be necessary, good results were achieved in spite of the fact that only 55% of patients received full-dose CHT. However, careful balancing RT metrics and using PET-CT-based planning led to no grade 4–5 toxicity observed during this study. These results add, though indirectly, to the ever growing evidence that advanced age does not negatively influence treatment outcome in NSCLC treated with RT-CHT [2–5]. Our recent analysis in stage III NSCLC on 600 patients treated during three phase III and two phase II studies showed that also in non-elderly age does not influence either survival (overall survival, local progression-free survival, distant metastasis-free survival) [6] or any of the acute or late high-grade (esophageal, bronchopulmonary, haematological, skin, gastric) toxicity [7]. It is now widely accepted belief that chronological age means very little and that comprehensive geriatric evaluation should be incorporated in the general plan and actually guide a clinician in the decision-making process without easily discarding idea to offer aggressive radical treatment in elderly patients. Simply said, presumed difference between patients 75 and 55 years old, respectively may be smaller than one observed when one compares two individuals of e.g. 60 and 40 years old, respectively. Obviously, with careful planning and in properly selected patients, elderly or not, concurrent RT-CHT achieves excellent results and is considered standard treatment option in locally advanced (Stage III) NSCLC as recently reconfirmed by three meta-analyses [8–10]. While authors identify their stringent study criteria as one of the drawbacks of the study, I, however, firmly believe that this is one of the major advantages. It is unreasonable to expect that one clinical study even if prospectively randomizing hundreds of patients would change the fate of the whole scenario in one disease (e.g. stage III NSCLC). What we need as community of thoracic oncologists is more clinical studies such as this one, and, hopefully, more prospective phase II and III studies. Then, we would be able to test many optimization approaches in seemingly different patient population and adapt more or less aggressive

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treatments in setting of e.g. septuagenarians. Authors of this study should view their results as a call for more prospective nature of verification of their research interest and embark on more formal/prospective way of investigating the question of appropriate treatment option in this setting. Sincerely, Conflict of interest statement None declared. References [1] Topkan E, Parlak C, Topuk S, Guler OC, Selek U. Outcomes of aggressive concurrent radiochemotherapy in highly selected septuagenararians with Stage IIIB non-small-cell lung carcinoma: Retrospective analysis of 89 patients. Lung Cancer 2013;81:226–30. [2] Auperin A, Le Pechoux C, Pignon JP, Koning C, Jeremic B, Clamon G, et al. Concomitant radiochemotherapy based on platin compounds in patients with locally advanced non-small cell lung cancer (NSCLC): a meta-analysis of individual data from 1764 patients. Ann Oncol 2006;17:473–83. [3] Socinski MA, Zhang C, Herndon II JE, Dillman RO, Clamon G, Vokes E, et al. Combined modality trials of the Cancer and Leukemia Group B in stage III nonsmall-cell lung cancer: analysis of factors influencing survival and toxicity. Ann Oncol 2004;15:1033–41. [4] Atagi S, Kawahara M, Yokoyama A, Okamoto H, Yamamoto N, Ohe Y, et al. Thoracic radiotherapy with or without daily low-dose carboplatin in elderly patients with non-small-cell lung cancer: a randomised, controlled, phase 3 trial by the Japan Clinical Oncology Group (JCOG0301). Lancet Oncol 2012;13:671–8. [5] Langer C, Hsu C, Curran D. Do elderly patients with locally advanced non-small cell lung cancer benefit from combined modality therapy? A secondary analysis of RTOG 94-10. Int J Radiat Oncol Biol Phys 2001;51:20–1 [abstract]. [6] Jeremic´ B, Miliˇcic´ B, Milisavljevic S. Clinical prognostic factors in patients with locally advanced (stage III) nonsmall cell lung cancer treated with hyperfractionated radiation therapy with and without concurrent chemotherapy: single-institution experience in 600 patients. Cancer 2011;117: 2995–3003. [7] Jeremic B, Milicic B, Milisavljevic S. Toxicity of concurrent hyperfractionated radiation therapy and chemotherapy in locally advanced (stage III) non-small cell lung cancer (NSCLC). Single institution experience in 600 patients. Clin Translat Oncol 2012;14:613–8. [8] Auperin A, Le Pechoux C, Rolland E, Curran WJ, Furuse K, Fournel P, et al. Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small-cell lung cancer. J Clin Oncol 2010;28:2181–90. [9] Liang H-Y, Zhou H, Li H-L, Guan P, Zhou BS. Chemo-radiotherapy for advanced non-small cell lung cancer: concurrent or sequential? It’s no longer the question: a systematic review. Int J Cancer 2010;127:718–28. [10] O’Rourke N, Roqué I, Figuls M, Farré Bernadó N, Macbeth F. Concurrent chemoradiotherapy in non-small cell lung cancer. Cochrane Database Syst Rev 2010;6:CD002140.

Branislav Jeremic Division of Radiation Oncology, Stellenbosch University, The Tygerberg Hospital, Cape Town, South Africa E-mail address: [email protected] 15 July 2013 http://dx.doi.org/10.1016/j.lungcan.2013.07.019