Treatment of inoperable stage III and IV non-small-cell lung cancer: The 'average' radiotherapist's point of view

Stage III non-small-cell lung cancer (NSCLC) presents a major therapeutic p roblem for the radiation oncologist who treats patients outside of clinical trials. It is a heterogeneous disease with great variation of the clinical extent, and the optimal therapeutic decision must be based on various para meters: the most important unfavorable characteristics are represented by a low Karnofsky performance status, weight loss >5%, locally too advanced di sease (e.g. T4, positive pleural effusion), intensive symptomatology, and d istant metastases. The presence of these factors advocates the use of short hypofractionated radiotherapy (RT) schemes of one or two fractions (e.g., 1 x 10 Gy, 2 x 8.5 Gy), which results in fast and effective palliation. Rad ical treatment must be given to patients without the above-mentioned unfavo rable characteristics. Results from randomized clinical trials support the use of high RT doses, preferably hyperfractionated/accelerated. The CHART s chedule could be used in case of squamous-cell histology. Elderly patients could be treated by the standard scheme of 30 x 2 Gy (or equivalent). Chemo therapy reduces the risk of (other than brain) distant metastases and impro ves the median survival time, especially for patients with non-squamous-cel l NSCLC. Platinum-based chemotherapy is usually administered in conjunction with RT as inductive and/or concurrent. Patients of stage IV are probably candidates for chemotherapy in case of good performance status and for a sh ort-term radiotherapy if local symptoms are predominant.