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A. Swaminath
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MINI 04 - Clinical Care of Lung Cancer (ID 102)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Advanced Diseases - NSCLC
- Presentations: 1
- Moderators:L. Gaspar, V. Westeel
- Coordinates: 9/07/2015, 16:45 - 18:15, Mile High Ballroom 2c-3c
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MINI04.14 - Comparative Survival in Patients with Brain Metastases from Non-Small Cell Lung Cancer Treated before and after Implementation of Radiosurgery (ID 2862)
16:45 - 18:15 | Author(s): A. Swaminath
- Abstract
- Presentation
Background:
Survival after a diagnosis of brain metastases (BM) in non-small cell lung cancer (NSCLC) is generally considered poor. We previously reported median survival of approximately 4 months in a cohort of patients treated with whole brain radiotherapy (WBRT), the standard of care in many centres. Since that time, we implemented a program of stereotactic radiosurgery (SRS), based on randomized trials and large prospective series, supporting WBRT + SRS or SRS alone in selected patients. The current study examined survival and prognostic factors in a consecutive cohort of NSCLC BM patients after the introduction of an SRS program.
Methods:
A retrospective review of 167 NSCLC patients referred with BM to a tertiary cancer centre from 2010-2012 (NEW cohort) was undertaken. These data were compared to a prior cohort of 91 patients treated between 2005 and 2007 (OLD cohort). Summary statistics were used to describe the patient characteristics as well as outcomes. The Kaplan-Meier method was used to calculate time-to-event outcomes for overall survival (OS), from the time of BM diagnosis. Cox proportional hazards regression was used to investigate factors prognostic for outcomes. An optimal model was constructed using forward stepwise selection, and tests were two-sided with a p-value <0.05 deemed statistically significant.
Results:
Overall survival from diagnosis of BM (median 4.3 months NEW vs 3.9 months OLD p=0.74) was not significantly different between cohorts. A univariate analysis of the NEW cohort demonstrated significant differences in OS between treatment groups (SRS, WBRT + SRS, WBRT or no treatment), in terms of female gender (p=0.034), lack of neurological symptoms (p=0.001), number of BM (p<0.001), GPA (p=0.001), and ECOG status at BM (p=0.009). Treatment regimen with SRS or WBRT + SRS was significant as a prognostic factor for OS as well (p<0.001). Results were similar if one excluded the no treatment group. As some factors were not collected in the OLD cohort, a separate model was constructed including only data available from both cohorts. After adjusting for factors included in the optimal model, cohort was not statistically significant for OS (hazard ratio=1.03, 95% CI 0.90-1.59; p =0.88). There was a trend towards improved OS in the NEW vs OLD cohorts in patients <50 years of age (median 11.8 vs 7.5 months, p=0.39) and 50-59 years of age (median 7.8 vs 3.7 months, p=0.052); this trend reversed to favour the OLD vs NEW cohort in patients >70 (4.3 vs 2.8 months, p=0.01). This was coincident with increased uptake of chemotherapy (p<0.001) and better ECOG status (p=0.007) in younger age groups in the NEW versus OLD cohort.
Conclusion:
There has been no improvement in survival of NSCLC patients with BM, following the implementation of SRS. Selected patients (younger age, female gender, good fitness, fewer brain metastases) appear to demonstrate improved OS with SRS. However, this may also reflect a better natural history of the disease, or a greater tendency to offer them systemic therapy, in addition to receipt of SRS.
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MINI 07 - ChemoRT and Translational Science (ID 110)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 1
- Moderators:D. Raben, B. Kavanagh
- Coordinates: 9/07/2015, 16:45 - 18:15, 201+203
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MINI07.02 - Chemoradiotherapy versus Radiotherapy Alone in Elderly Patients with Stage III Non-Small Cell Lung Cancer: A Systematic Review (ID 3163)
16:45 - 18:15 | Author(s): A. Swaminath
- Abstract
- Presentation
Background:
Approximately 30% of non-small cell lung cancer (NSCLC) patients present with locally advanced (stage III) disease, and half are elderly (age ≥70). Young, fit patients with stage III NSCLC have improved survival with the use of combined chemotherapy and radiation therapy (CRT) over radiation therapy (RT) alone – HR 0.74 in a 2010 Cochrane systematic review. Elderly patients have more comorbid illnesses and suffer greater treatment toxicity, thus it is unclear whether they benefit more from CRT over RT. The objective of this systematic review is to explore the evidence base for using CRT in elderly patients with stage III NSCLC.
Methods:
We performed a systematic review including trials identified in MEDLINE, EMBASE and CENTRAL databases from inception to March 8, 2015, plus relevant conference proceedings since 2000. We included randomized controlled trials (RCTs) of elderly patients (≥70 years old) with stage III NSCLC or elderly subgroups from individual patient meta-analyses comparing CRT versus RT alone. We excluded studies that treated patients with palliative intent, included surgical patients, or in which both arms received chemotherapy. We did not restrict language. Two reviewers independently extracted summary outcome data. Risk of bias was assessed using the Cochrane Risk of Bias tool. We used a random effects model and inverse variance method to pool time-to-event outcomes. We calculated Peto Odds Ratios (POR) using RevMan 5.3 to pool dichotomous outcomes with a zero cell and otherwise calculated Risk Ratios (RR).
Results:
We screened 2951 citations identifying 68 articles for full text evaluation, 16 of which have not been accessible yet. Four reports of three studies met inclusion criteria (n = 407 elderly patients). All trials were evaluated as having a high risk of bias due primarily to lack of blinding. Overall survival in elderly patients was superior in those treated with CRT compared to RT (HR 0.66, 95%CI 0.53 to 0.82, I[2] 0%, p 0.0009). Progression-free survival was also improved with CRT (HR 0.67, 95%CI 0.53 to 0.85, I[2] 0%, p 0.001). Toxicity assessments were available in two studies with 119 patients receiving CRT and 121 RT. Treatment-related death occurred in 6 (5%) with CRT and 5 (4%) with RT (RR 1.22, 95%CI 0.38 to 3.88) and grade ≥3 pneumonitis was seen in 6 patients in each group, (RR 1.01, 95%CI 0.34 to 3.06) – neither was significantly different between treatments. Neutropenia – 57% v 2% (POR 14.38, 95%CI 8.26 to 25.04) and thrombocytopenia – 30% v 3% (RR 7.62, 95%CI 2.09 to 27.79) were more common with CRT. Febrile neutropenia occurred in 3 (2.5%) patients with CRT and zero patients with RT, but this did not meet significance (POR 7.54, 95%CI 0.78 to 72.82). No studies included patient-reported quality of life.
Conclusion:
CRT in elderly patients with stage III NSCLC results in improved survival as compared to RT alone, at the expense of increased treatment-related hematologic toxicity. Quality of life assessment should be included in any future trial design. CRT can be considered for fit patients ≥70 years of age with stage III NSCLC.
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MINI 18 - Radiation Topics in Localized NSCLC (ID 139)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
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MINI18.07 - Early Results of a Quality Assurance Program in a Randomized Trial of Stereotactic Body Radiotherapy for Stage I Medically Inoperable Lung Cancer (ID 2887)
16:45 - 18:15 | Author(s): A. Swaminath
- Abstract
- Presentation
Background:
A large Canadian multicentre randomized trial (LUSTRE) has recently opened to determine if stereotactic body radiotherapy (SBRT) to 48 Gy in 4 fractions (peripheral) or 60 Gy in 8 fractions (central) improves outcomes compared to conventionally hypofractionated radiotherapy (CRT) to 60 Gy in 15 fractions in early stage non-small cell lung cancer. Given the rapid diffusion of lung SBRT technology across Canada, a unique radiotherapy quality assurance (RTQA) program was devised to minimize variations in practice. This study describes the RTQA experience to date.
Methods:
Centres participating in LUSTRE are required to satisfy three RTQA requirements prior to being accredited: (a) Respond to a survey describing treatment equipment, planning system details and image guidance parameters in order to confirm that their centre is compliant with protocol guidelines; (b) Assess SBRT delivery accuracy using a thoracic phantom produced by IROC (Imaging and Radiation Oncology Core); and (c) Successfully complete four treatment plans from the developed trial planning guide using SBRT and CRT for one centrally and one peripherally located cancer.
Results:
Currently 13 centres are undergoing RTQA: (a) Surveys have been completed in 8 centres, 2 require revision, and 3 are incomplete. (b) Phantom testing has been completed in 9 centres, 2 are incomplete, 1 has results pending, and 1 is being resubmitted. Although 6/13 centres were identified as having active SBRT programs (>3 patients/month), only 2/6 had completed the IROC phantom prior to study accreditation (most having in-house end-to-end tests). (c) 8/13 centres have successfully submitted their test cases. All 8 submitting centres passed on SBRT/CRT distributions and conformality indices. However, 5/8 centres required resubmission for contouring revisions. In one case, the GTV/ITV was incorrectly contoured. In another case, it was contoured on the incorrect dataset. In the remainder, normal organs (lungs, bronchi, esophagus) had contouring errors, particularly the bronchial tree; contours excluded the major bronchi, and in 2 cases, normal lung parenchyma was included. Some centres did not follow standardized nomenclature for targets and normal organs, as they were likely new to this naming convention. Some issues were related to misinterpretation of the planning guide, prompting the trial group to work with centres to ensure a seamless future workflow.
Conclusion:
Preliminary results show that most well-established lung SBRT centres rely on their own in-house standards, while others are using LUSTRE RTQA to implement new SBRT programs. Our experience shows that when centres participate in an independent review, alterations are recommended that can improve their own existing QA processes, and contribute to standardized practice nationwide. Such an RTQA process can be a model worth considering in future radiotherapy randomized trials, and also when instituting new radiotherapy technologies into existing clinical programs.
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