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A. Price
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MS12 - Loco-Regional Management of MPM (ID 29)
- Event: WCLC 2013
- Type: Mini Symposia
- Track: Mesothelioma
- Presentations: 1
- Moderators:H. Hoffman, T. Nakano
- Coordinates: 10/29/2013, 14:00 - 15:30, Bayside 103, Level 1
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MS12.3 - Peri-Operative Radiotherapy: Current Data and State of the Art (ID 513)
14:00 - 15:30 | Author(s): A. Price
- Abstract
- Presentation
Abstract
Formal prospective evidence of benefit from cancer treatments for patients with mesothelioma exists only for the small survival increment obtained from combinations of cisplatin and anti-folate agents in those with inoperable disease. Despite this absence of evidence of benefit, and some evidence of detriment, trimodality therapy including neoadjuvant chemotherapy, surgery and adjuvant radiotherapy continues to be regarded as a widespread standard of care in early disease. Only one very small randomised trial has addressed this question[1], and the evidence from that trial suggesting a substantial increase in mortality has been disputed by many believers in trimodality therapy. The surgical literature has recently been extensively reviewed, revealing the paucity of high level evidence for these treatments[2-3]. One Swiss trial investigated the role of radiotherapy in this combination, but closed last year because of poor accrual due to changes in surgical fashion (NCT00334594)[ 4]. The two major surgical approaches to early mesothelioma have been extrapleural pneumonectomy (EPP), first described over 30 years ago, and presented in 16 published reports of which 5 were prospective and only 1 randomised[2]. None of these studies directly compare radiation doses or techniques, and no firm conclusions are possible regarding dose response, or the superiority of techniques as variable as a simple opposed pair with or without electrons to intensity modulated radiotherapy (IMRT) or protons. It seems extremely unlikely that such data will ever exist, and what radiotherapy is used will continue to depend mainly on the expertise, technology and time available locally. There have been publications[5,6], reporting an unexpectedly high morbidity and mortality following IMRT and there may be an argument that simplest is best given the general lack of fatal outcomes with conventional radiotherapy, although dose coverage of certain areas is poor. One report suggested lower local failure with IMRT[7], but this may have related to the higher dose given (50.4 Gy vs 30 Gy) and it was unclear why the slightly higher dose (54 Gy)[ 8] normally used postoperatively was not possible. If IMRT is to be used then treatment times may be shorter with volumetric modulated arc therapy[9]. Whether as a result of the MARS trial, or the disappointing outcomes from prospective trials conducted by the EORTC and in the US[8, 10], surgical fashion has moved in the last few years from EPP to various extents of pleurectomy, where the underlying lung is preserved. This is not a conventional cancer operation involving en bloc resection of tumour with a defined margin, and adjuvant radiotherapy is rendered more difficult, if not impossible, by the residual lung. Attempts to spare the lung at least partially must of necessity involve sparing the pleura overlying the fissures, and significant rates of pneumonitis have been reported, albeit less than in the early reports of IMRT[11]. The doses achievable by these techniques remain relatively low by cancerocidal standards in the context of a disease believed to relatively radioresistant. Cao has also reviewed the 34 publications on pleurectomy, none of which are randomised and very few prospective[3]. Radiotherapy in most series, when it is described at all, seems to be at relatively low dose to the port sites, of questionable benefit since 2 randomised trials have shown no effect from this intervention at the time of diagnosis[12, 13]. The MARS group also plan to look at the benefits of pleurectomy, but radiotherapy is not currently included in the trial outline. Currently this is an area in which virtually no data exist to support decision making. Radiotherapy is likely to remain part of the trimodality recipe for those who continue to believe in EPP, at least until the postulated trial of 670 participants is completed[14], and single centre reports on small numbers of patients with more complex treatment techniques likely to continue. If the next generation of larger trials of radiotherapy looking at port site prophylaxis confirm the lack of utility of this intervention, it is difficult to see that there will be a role for radiotherapy after pleurectomy. Rather than assume such a role, it is to be hoped, but not expected, that randomised trials of the benefits of radiotherapy be instituted. 1. Treasure T et al, Lancet Oncol. 2011 Aug;12(8):763-72. 2. Cao CQ et al, J Thorac Oncol. 2010 Oct;5(10):1692-703. 3. Cao CQ et al, Lung Cancer. 2013 Jun 12. doi:pii: S0169-5002(13)00212-2. 4. http://clinicaltrials.gov/show/NCT00334594 5. Allen AM et al., Int J Radiat Oncol Biol Phys. 2006 Jul 1;65(3):640-5. 6. Patel PR et al., Int J Radiat Oncol Biol Phys. 2012 May 1;83(1):362-8. 7. Buduhan G et al., Ann Thorac Surg. 2009 Sep;88(3):870-5. 8. Van Schil PE et al., Eur Respir J. 2010 Dec;36(6):1362-9. 9. Scorsetti M et al., Int J Radiat Oncol Biol Phys. 2010 Jul 1;77(3):942-9. 10. Krug, LM et al., J Clin Oncol. 2009 Jun 20;27(18):3007-13. 11. Rosenzweig KE et al., Int J Radiat Oncol Biol Phys. 2012 Jul 15;83(4):1278-83. 12. Bydder S et al., Br J Cancer. 2004 Jul 5;91(1):9-10. 13. O’Rourke N et al., Radiother Oncol. 2007 Jul;84(1):18-22. 14. Weder W et al, Lancet Oncol. 2011 Nov;12(12):1093-4.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O24 - Cancer Control and Epidemiology III (ID 134)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Prevention & Epidemiology
- Presentations: 1
- Moderators:N. Van Zandwijk, P. Yang
- Coordinates: 10/29/2013, 16:15 - 17:45, Bayside 103, Level 1
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O24.02 - Lung cancer in South East Scotland, are we still making progress? (ID 1320)
16:15 - 17:45 | Author(s): A. Price
- Abstract
- Presentation
Background
South-East Scotland Cancer Network (SCAN) serves 1.4 million people using unified protocols collecting prospective data. We published population-based data from 1995 and 2002 (J Thorac Oncol. 2008;3(5):491-8) demonstrating increased cancer treatment and improved overall survival. This review investigates whether this has been sustained.Methods
Patients were identified from Scottish Cancer Registry (SCR), SCAN audit and Edinburgh Cancer Centre databases to extract tumour characteristics, initial management (usually ≤6 months of diagnosis) and overall survival (OS). Missing data was sought from patients’ health records. Multivariate analysis (MVA) examined sex, age(<60,60-69,70-79,80+), deprivation, Healthboard of residence, performance status (PS), pathology and stage (localised, regional, metastatic) affecting use of any treatment, potentially curative treatment (PCT) defined as surgery (S) or potentially curative radiotherapy (PC-RT - ≥50Gy for NSCLC or ≥40Gy+chemo for SCLC) using Cox’s proportional hazards model to obtain factors affecting survival.Results
1117 patients were identified in the audit. 51.5% were men, median age 72 (range 31-98) years. 47.3% were from the two most deprived quintiles. 49.5% had WHO PS 0-1, 23.5% WHO2, 24.2% WHO3-4. 58.5% NSCLC (23.5% Stage I-II, 25.7% III, 48.8% IV), 13% SCLC (37.9% stage I-III, 61.4 stage IV) and 28.5% radiology-only diagnosis (24.5% Stage I-II, 19.5% III, 52.8% IV). 59.9% received some form of treatment; 28.4% with PCT ((126 S+/-chemo(C) = 19% of NSCLC), 190 PC-RT +/- C), and 31.5% palliatively. 467 (41.8%) received any RT, 268 (24%) any C. MVA showed age >70, PS≥2, metastatic disease, ‘not-SCLC’, but not sex, deprivation or Healthboard, were associated (all p<0.01) with lower treatment delivery, and only age > 80, PS≥2, radiology-only diagnosis and non-localised disease (all p<0.01) with reduced PCT. Median survival was 5.03 months (95%CI 4.3-5.8) with 46.8% alive at 6 months, 32.0% 12 and 17.7% 24 months following diagnosis. Male sex, PS≥2 and non-localised disease were associated with increased HR for death (all p<0.01). Comparison with the 2002 cohort (n= 971, Dumfries excluded from both cohorts) showed similar age and pathology profile, but increased women, residents from most deprived quintile and metastatic disease. Uni-variate analysis showed a similar proportion received treatment (62.3% 2002 v. 59.9% 2010 p=0.14) but more received PCT (23.6% v. 28.2% p=0.02) principally through increased use of PC-RT (13.1% v. 17.1% p=0.01). On MVA (without PS) the use of any treatment reduced (OR 0.73 (0.59-0.92) however, use of PCT increased (OR 1.84 (1.37-2.47) due to more PC-RT (1.57 (1.18-2.08)), but not surgery. Median (5.16 v. 4.90 months p=0.65), 1 year (29.0% (31.9-26.1) v. 31.4% (34.3-28.5) and 2 year (14.9% (17.3-12.5) v. 17.4% (19.8-15.0) survival were unchanged.Conclusion
In the last 8 years in SCAN, there has been an increase in the number of women with lung cancer along with a worsening deprivation profile and increased identification of stage IV disease, possibly through improved staging. There has been an increase in potentially curative, but reduction in all therapy delivered without any apparent impact on survival. This analysis demonstrates the challenges of improving population-based outcomes in a disease where most present with advanced disease and are often unfit for treatment .Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
