Effectiveness of accelerated radiotherapy for patients with inoperable non-small cell lung cancer (NSCLC) and borderline prognostic factors without distant metastasis: A retrospective review

Purpose: The standard treatment for patients with unresectable or medically inoperable non-small cell lung cancer (NSCLC) and good prognostic factors (e.g., weight loss [WL] less than or equal to 5% and Karnofsky performance status [KPS] greater than or equal to 70) is induction chemotherapy followe d by definitive radiotherapy to the primary site at 1.8-2.0 Gy per fraction with a total dose of 60-63 Gy to the target volume. Patients with poor pro gnostic factors usually receive radiotherapy alone, but the fractionation s chedule and total dose have not been standardized. To attempt to optimize i rradiation doses and schedule, we compared the effectiveness of accelerated radiotherapy (ACRT) alone to 35 Gy at 3 Gy per fraction with standard radi ation therapy (STRT) of 60-66 Gy at 2 Gy per fraction in regard to tumor re sponse, local control, distant metastasis, toxicity, and survival. Methods and Materials: Fifty-five patients treated with radiation for NSCLC at The University of Texas M. D. Anderson Cancer Center between 1990 and 1 994 were identified. All 55 patients had node-positive, and no distant meta stasis (Nf, M0) of NSCLC. Two cohorts were identified. One cohort (26 patie nts) had borderline poor prognostic factors (KPS less than 70 but higher th an 50, and/or WL of more than 5%) and was treated with radiotherapy alone t o 45 Gy over 3 weeks at 3 Gy/fraction (ACRT). The second cohort (29 patient s) had significantly better prognostic factors (KPS greater than or equal t o 70 and WL less than or equal to 5%) and was treated to 60-66 Gy over 6 to 6(1)/(2) weeks at 2 Gy per fraction (STRT) during the same period. Results: In the first cohort treated by ACRT, the distribution of patients by AJCC stage was IIB 8%, IIIA 19%, and IIIB 73%. Sixty-two percent had KPS <70, and 76% had a WL of >5%. The maximum response rate as determined by c hest X-rag was 60% among 45 of 55 patients who were evaluable for response: combined complete responses (20%) and partial responses (40%). Overall sur vival in these patients was 13% at 2 and 5 years, with a locoregional contr ol rate of 42% and a freedom from distant metastasis rate of 54%. The ACRT cohort treated with 3 Gy per fraction had significantly lower KPS scores (p = 0.003) and greater WL (p = 0.063) than the cohort STRT treated with 2 Gy per fraction. However, treatment results and toxicity were not significant ly different between the two cohorts in spite of significantly better progn ostic factors in the STRT cohort. Conclusions: Despite having worse prognostic factors, the cohort treated wi th radiotherapy alone to 45 Gy at 3 Gy per fraction over 3 weeks (ACRT) had response rates, locoregional control, and overall survival comparable to t hose in the cohort treated by a total dose of 60-66 GS at 2 Gy per fraction over 6 to 6(1)/(2) weeks (STRT). Given that accelerated treatment schedule s decrease treatment time and cost less, these may, in the current health c are environment, be important factors for health care providers to consider in treating patients who have locally advanced NSCLC and borderline poor p rognostic factors. (C) 1999 Elsevier Science Inc.