STEREOTACTIC ABLATIVE RADIOTHERAPY FOR ELDERLY PATIENTS WITH NSCLC UNFIT FOR SURGERY

July 14, 2011 (Amsterdam, the Netherlands) — A population-based study has found that the survival of all elderly patients with nonsmall-cell lung cancer (NSCLC) increased significantly after the introduction of stereotactic ablative radiotherapy (SABR), also referred to as stereotactic body radiotherapy.
The study was presented here at the 14th World Conference on Lung Cancer (WCLC) by Suresh Senan, MD, from the VU University Medical Center in Amsterdam, the Netherlands.
Prior to the introduction of SABR, in 2003, many elderly NSCLC patients were considered to be too frail to undergo surgery or conventional radiotherapy, Dr. Senan explained during a press conference. Surgery is the standard of care, but only about 1 in 3 patients older than 75 years of age is deemed fit for surgery, he explained.
The other option at that time — conventional radiotherapy — is not attractive because it involves daily treatment over 6 to 7 weeks and is associated with high recurrence rates. So about 40% of these elderly patients would be left untreated, he said.
"Patients need to be told that there is now another curative option," Dr. Senan said.
Even patients who are fit for surgery should be told about SABR, and the pros and cons of each option should be discussed, he said. Some of these elderly patients are so frail that after surgery they never return home, but instead go into nursing homes, he explained.
"SABR is a simple outpatient treatment, involving 3 to 5 visits, which can keep them alive for longer," he said.
"It is no longer justified to say you are elderly and there is not a good option for you," he emphasized.
Improved Survival
After it was introduced in the Netherlands in 2003, SABR rapidly became the new standard of care for peripheral stage I lung tumors up to about 6 cm, Dr. Senan said.
The study, presented during the presidential session at the meeting, analyzed data from the Netherlands Cancer Registry, and was based on 4605 patients, 75 years or older, diagnosed with stage I NSCLC. It showed that between 2001 and 2009, there was an increase in radiotherapy use, from 31.2% to 37.7% of patients. At the same time, there was a decrease in the number of patients left untreated, from 31.9% to 24.9%.
From 2001 to 2009, the median survival for patients treated with radiation increased by nearly 10 months, from 16.8 months to 26.1 months (hazard ratio [HR], 0.59; P < .0001).
There was no change in survival among the patients who were left untreated, Dr. Senan reported.
There was also a significant improvement in survival in patients who were treated surgically during this time period (35.7 months vs median survival not reached in 2009; HR, 0.73; P < 0001). This is because of improvements in surgical techniques, such as the introduction of video-assisted thoracic surgery, he explained.
Overall, median survival for all elderly NSCLC patients improved during the study period, by around 8 months (from 16.4 to 24.4 months; HR, 0.7; P < .0001). But the greatest improvement in median overall survival was seen in the radiotherapy group, Dr. Senan noted.
Dr. Senan estimated that toward the end of the study period, about 70% of all radiotherapy for NSCLC in the Netherlands was SABR. He suspects that this proportion has increased over the past few years, so that SABR now accounts for 90% or more of all radiotherapy for NSCLC. There are now 11 centers around the country offering SABR, and patients are referred to these centers for treatment, he said.
"We should have confidence that we have enough data to present the options to patients, and not assume that we need to wait for data from clinical trials," Dr. Senan said. "Clinical trials would take a few more years; in the Netherlands, we already have this population study data."
Dr. Senan told Medscape Medical News that "every country has its own culture" when it comes to the uptake of SABR. It was taken up very quickly in the Netherlands, he said, and in Germany and Japan, but in Scandinavia and Australia, there are ongoing trials comparing conventional radiotherapy with SABR.
In the United States, there was enthusiasm for SABR after a small randomized trial found that it was superior to conventional therapy (JAMA. 2010;303:1070-1076). The lead author of that study, Robert Timmerman, MD, professor of radiation oncology at the University of Texas Southwester Medical Center in Dallas, concluded that SABR represents "a remarkable improvement over treatment with standard fractionated radiotherapy for patients with early-stage medically inoperable lung cancer." Although this was a small study (in a total of 59 patients), it was a randomized trial, and was hailed as practice-changing.
This is "one of the most important papers in the past few years" in this field, said Dirk De Ruyscher MD, PhD, professor of respiratory oncology at Maastrict University, the Netherlands. He delivered the State of the Art Lecture on radiotherapy in lung cancer during the meeting, and after reviewing the data on SABR said: "This is something that we should not deny our patients."
"Not treating elderly patients is nihilism," he concluded.
Dr. De Ruyscher and Dr. Senan were both authors on a recent paper outlining recommendations for the planning and delivery of high-dose, high-precision radiotherapy for lung cancer (J Clin Oncol. 2010; 28:5301-5310).
14th World Conference on Lung Cancer (WCLC): Abstract 1252. Presented July 6, 2011.