A Review of Chemotherapy and Radiotherapy Near the End of Life in Individuals with Metastatic Non-small Cell Lung Cancer (original) (raw)
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Use of Palliative Radiotherapy Among Patients With Metastatic Non–Small-Cell Lung Cancer
International Journal of Radiation Oncology*Biology*Physics, 2007
Purpose: Radiotherapy (RT) is known to effectively palliate many symptoms of patients with metastatic nonsmall-cell lung cancer (NSCLC). Anecdotally, RT is believed to be commonly used in this setting, but limited population-based data are available. The objective of this study was to examine the utilization patterns of palliative RT among elderly patients with Stage IV NSCLC and, in particular, to identify factors associated with its use. Methods and Materials: A retrospective population-based cohort study was performed using linked Surveillance, Epidemiology and End Results (SEER)-Medicare data to identify 11,084 Medicare beneficiaries aged $65 years who presented with Stage IV NSCLC in the 11 SEER regions between 1991 and 1996. The primary outcome was receipt of RT. Logistic regression analysis was used to identify factors associated with receipt of RT. Results: A total of 58% of these patients received RT, with its use decreasing over time (p = 0.01). Increasing age was negatively associated with receipt of treatment (p <0.001), as was increasing comorbidities (p <0.001). Factors positively associated with the receipt of RT included income (p = 0.001), hospitalization (p <0.001), and treatment with chemotherapy (p <0.001). Although the use varied across the SEER regions (p = 0.001), gender, race/ethnicity, and distance to the nearest RT facility were not associated with treatment. Conclusions: Elderly patients with metastatic NSCLC frequently receive palliative RT, but its use varies, especially with age and receipt of chemotherapy. Additional research is needed to determine whether this variability reflects good quality care. Ó 2007 Elsevier Inc.
Processes of Discontinuing Chemotherapy for Metastatic Non-Small-Cell Lung Cancer at the End of Life
Journal of oncology practice / American Society of Clinical Oncology, 2015
Administration of chemotherapy close to death is widely recognized as poor-quality care. Prior research has focused on predictors and outcomes of chemotherapy administration at the end of life. This study describes processes of chemotherapy discontinuation and examines their relationships with timing before death, hospice referral, and hospital death. We reviewed health records of a prospective cohort of 151 patients with newly diagnosed metastatic non-small-cell lung cancer who participated in a trial of early palliative care. Chemotherapy treatments during final regimen were qualitatively analyzed to identify categories of discontinuation processes. We then quantitatively compared predictors and outcomes of the process categories. A total of 144 patients died, with 81 and 48 receiving intravenous (IV) and oral chemotherapies as their final regimen, respectively. Five processes were identified for IV chemotherapy: definitive decisions (19.7%), deferred decisions or breaks (22.2%), ...
Journal of cancer research and clinical oncology, 2003
We investigated the influence of potential pre-treatment clinical prognostic factors in stage IV non-small cell lung cancer (NSCLC). A total of 285 patients were enrolled in two consecutive prospective randomised studies which compared (study 1) carboplatin and prolonged oral etoposide (group 1; n=58) with the same etoposide alone (group 2; n=59), and (study 2) carboplatin and prolonged oral etoposide (group 1; n=84) with the same carboplatin and high-dose intravenous etoposide (group 2; n=84). The median survival time for all 285 patients was 7 months, while 1- and 2-year survival rates were 29% and 8%, respectively. Age did not impact on outcome ( P=0.21), while female patients did significantly better than male patients ( P<0.0001). Patients with KPS 80-100 did significantly better than those with KPS 50-70 ( P<0.0001), as did patients with less pronounced weight loss ( P<0.0001) and those with only one metastatic site when compared to those having at least two metastati...
Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 2015
To optimize palliation in incurable locally advanced non-small cell lung cancer (NSCLC), the International Atomic Energy Agency conducted a prospective randomized study (NCT00864331) comparing protracted palliative radiotherapy (RT) course with chemotherapy (CHT) followed by short-course palliative RT. Treatment-naive patients with histologically confirmed NSCLC, stage IIIA/IIIB, received either 39Gy in 13 fractions as RT alone (arm A, n=31) or 2-3 platinum-based CHT cycles followed by 10Gy in a single fraction or 16Gy in 2 fractions separated by one week (arm B, n=34). Primary outcome was overall survival. Treatment groups were balanced with respect to various variables. Median survival for all 65 patients was 8months, while median survival was 7.1 and 8.1months for the two arms, respectively (log-rank p=0.4 by study arm, and p=0.6 by Cox regression and stratified by country and sub-stage). One and three year survival rates for the two arms were 29%, and 9% and 41%, and 6%, respect...
Journal of Clinical Oncology, 2012
Purpose Prior research shows that introducing palliative care soon after diagnosis for patients with metastatic non–small-cell lung cancer (NSCLC) is associated with improvements in quality of life, mood, and survival. We sought to investigate whether early palliative care also affects the frequency and timing of chemotherapy use and hospice care for these patients. Patients and Methods This secondary analysis is based on a randomized controlled trial of 151 patients with newly diagnosed metastatic NSCLC presenting to an outpatient clinic at a tertiary cancer center from June 2006 to July 2009. Participants received either early palliative care integrated with standard oncology care or standard oncology care alone. By 18-month follow-up, 133 participants (88.1%) had died. Outcome measures included: first, number and types of chemotherapy regimens, and second, frequency and timing of chemotherapy administration and hospice referral. Results The overall number of chemotherapy regimens...
Journal of the National Cancer Institute, 2015
Background: High-level evidence has established well-recognized standard treatment regimens for patients undergoing palliative chest radiotherapy (RT) for stage IV non-small cell lung cancer (NSCLC), including treating with fewer than 15 fractions of RT, and not delivering concurrent chemoradiation (CRT) because of its increased toxicity and limited efficacy in the palliative setting. Methods: The study included patients in the National Cancer Database from 2004 to 2012 with stage IV lung cancer who received palliative chest radiation therapy. Logistic regression was performed to determine predictors of standard vs nonstandard regimens (>15 fractions or CRT). All statistical tests were two-sided. Results: There were 46 803 patients in the analysis and 49% received radiotherapy for longer than 15 fractions, and 28% received greater than 25 fractions. Approximately 19% received CRT. The strongest independent predictors of long-course RT were private insurance (odds ratio [OR] = 1.40 vs uninsured, 95% confidence interval [CI] = 1.28 to 1.53) and treatment in community cancer programs (OR = 1.49, 95% CI = 1.38 to 1.58) compared with academic research programs. The strongest factors that predicted for concurrent chemoradiotherapy were private insurance (OR = 1.38 95% CI = 1.23 to 1.54) compared with uninsured patients and treatment in community cancer programs (OR = 1.44, 95% CI = 1.33 to 1.56) compared with academic programs. Conclusions: Approximately half of all patients with metastatic lung cancer received a higher number of radiation fractions than recommended. Patients with private insurance and treated in community cancer centers were more likely to receive longer courses of RT or CRT. This demonstrates that a substantial number of patients requiring palliative thoracic radiotherapy are overtreated and further work is necessary to ensure these patients are treated according to evidencedbased guidelines.
Oncology & hematology review, 2010
Lung cancer is the leading cause of cancer deaths, having caused an estimated 1.18 million deaths worldwide in 2002. 1 In the US alone, lung cancer resulted in an estimated 159,300 deaths in 2009. 2 Most deaths are from non-small-cell lung cancer (NSCLC), which accounts for more than 80% of lung cancers diagnosed in the US. Sadly, most patients present with advanced, inoperable disease. While stage IV patients remain incurable, there is now potentially curative therapy that can be offered to most patients with stage III NSCLC. 3 Radiotherapy Becomes Standard Treatment for Unresectable Non-small-cell Lung Cancer Over 40 years ago, Wolf et al. established the role of RT in the treatment of lung cancer. Their randomized phase III trial compared radiotherapy (RT) versus placebo for clinically inoperable lung cancer (including both small-cell and NSCLC). RT was delivered with 200-250kV X-rays and included the delivery of 40-50Gy in 1.5-2.0Gy daily fractions. The median survival of patients given RT was 142 days compared with 112 days for those who received the placebo (p=0.05). 4 A phase III Radiation Therapy Oncology Group (RTOG) trial evaluated the effect of dose on outcome by randomly assigning patients to receive 40Gy in 20 daily fractions, 50Gy in 25 daily fractions, or 60Gy in 30 daily fractions. The local failure rates determined with serial chest X-rays were 48% with 40Gy, 38% with 50Gy, and 27% with 60Gy. Although the differences in survival were not significant, this study defined the standard RT dose as 60Gy in 30 daily fractions. 5 This dose fractionation pattern remained the standard of care for decades. Conventional RT alone resulted in a median survival of 10 months and a five-year survival of 5%. Until the 1990s, the standard treatment for locally advanced inoperable lung cancer was RT alone. 5 Combined Radiotherapy (RT) plus Chemotherapy Supplants RT Alone as Standard Therapy In order to improve the outcome of treatment, chemotherapy was added to RT. Phase III trials demonstrated a survival advantage following the addition of chemotherapy to RT for NSCLC. 6,7 The Cancer and Leukemia Group B reported that induction chemotherapy (cisplatin plus vinblastine) followed by conventional RT (60Gy/30 fractions) resulted in significantly better survival than conventional RT alone. 6 The median and five-year survivals were 13.7 months and 17% for the combined therapy versus 9.6 months and 6% for RT alone (p=0.012). 6 Additional phase III trials confirmed that cisplatin-based chemotherapy plus RT produced better survival rates than RT alone. 7-10 Subsequent phase III trials established that concurrent chemotherapy plus RT resulted in significantly better survival than sequential therapy. 11,12 Modern trials of concurrent chemotherapy plus RT have reported five-year survival rates of up to 29%. 13 Local Failures Remain a Significant Problem Local control rates based on radiographic studies appear substantially better than those based on pathological findings. Le Chevalier et al.
Metastatic non-small cell lung cancer: a benchmark for quality end-of-life cancer care?
The Medical Journal of Australia, 2015
Objectives: To investigate the quality of end-of-life care for patients with metastatic non-small cell lung cancer (NSCLC). Design and participants: Retrospective cohort study of patients from first hospitalisation for metastatic disease until death, using hospital, emergency department and death registration data from Victoria, Australia, between 1 July 2003 and 30 June 2010. Main outcome measures: Emergency department and hospital use; aggressiveness of care including intensive care and chemotherapy in last 30 days; palliative and supportive care provision; and place of death. Results: Metastatic NSCLC patients underwent limited aggressive treatment such as intensive care (5%) and chemotherapy (< 1%) at the end of life; however, high numbers died in acute hospitals (42%) and 61% had a length of stay of greater than 14 days in the last month of life. Although 62% were referred to palliative care services, this occurred late in the illness. In a logistic regression model adjusted for year of metastasis, age, sex, metastatic site and survival, the odds ratio (OR) of dying in an acute hospital bed compared with death at home or in a hospice unit decreased with receipt of palliative care (OR, 0.25; 95% CI, 0.21-0.30) and multimodality supportive care (OR, 0.65; 95% CI, 0.56-0.75). Conclusion: Because early palliative care for patients with metastatic NSCLC is recommended, we propose that this group be considered a benchmark of quality end-of-life care. Future work is required to determine appropriate quality-of-care targets in this and other cancer patient cohorts, with particular focus on the timeliness of palliative care engagement. (VEMD). http://www.health.vic.gov. au/hdss/vemd/index.htm (accessed Mar 2012).
BJR|Open
Objective: To analyse patterns of treatment with curative intent commonly used in elderly patients with locally advanced non-small-cell lung carcinoma (NSCLC) and predictive factors of overall survival in routine clinical practice. Methods: This multicentre prospective study included consecutive patients aged ≥65 years old diagnosed with NSCLC between February 2014 and January 2018. Inclusion criteria: age ≥65 years, stage IIIA/IIIB NSCLC. Treatment decisions were taken by a multidisciplinary committee. Kaplan-Meier curves and log-rank test were used to identify which clinical/treatment-associated variables, or pre-treatment quality of life (QOL) considering EORTC QLQ-C30 (and LC13 module) were predictive of overall survival. Results: A total of 139 patients were recruited. Median follow-up was 9.9 months (1.18-57.36 months) with a median survival of 14 months (range 11-17 months). In the group>75-year-old patients, the committee recommended chemotherapy and sequential radiothera...