Presentation on theme: "The rationale for concurrent chemotherapy and radiotherapy in small cell lung cancer Dr Hannah Lord Ninewells Dundee 17th Sept 2010."— Presentation transcript:
The rationale for concurrent chemotherapy and radiotherapy in small cell lung cancer Dr Hannah Lord Ninewells Dundee 17th Sept 2010
Small Cell 20% of all lung cancer Associated with smoking Rapid doubling time Falling incidence in many parts of UK, not in Scotland A systemic disease, even when staged as “localised.” As such, systemic treatment is vital.
The History In 1969, 5 year survival: 1% with surgery 4% with radiotherapy In 1970s, advent of platinum based chemotherapy. Led to 4-5 fold improvement in response rates
Small Cell With chemo, excellent responses, but early and frequent relapse. Need to build on the improvement.
XRT XRT already well known as effective. XRT potentiates the effect of chemotherapy XRT has non over-lapping toxicities with chemotherapy XRT has different mode of action and may deal with potentially chemoresistant disease
Evidence For XRT 13 randomised controlled trials have investigated the role of XRT Pignon (1) 1992 meta-analysis (and Warde (2) 1993) 2103 patients with LD 433 had ED 1.Pignon JP et al, N Engl J Med 1992; 327: December 3, 1992December 3, Warde P et al “Does thoracic irradiation improve survival and local control in limited stage small cell carcinoma of the lung?” JCO 1992;10:
3 year survival improved from 8.9% to 14.3% (5% improvement) HR = 0.86 = 14% reduced risk of death No difference if LD / ED or timing of XRT
Role of XRT Value of XRT proven. Principles of radiotherapy are to give the treatment in as short a time as possible for maximum effectiveness Minimise re-growth of tumour, which is known to have a rapid doubling time
XRT Concurrent treatment: i) To reduce overall treatment time (repopulation of tumour) ii) To allow 2 modalities to potentiate one another ii) ? to improve outcomes
How to determine timing of XRT? Randomised controlled trials 8 looking at timing of XRT 3 positive 5 negative
Trial 1: NCIC study (3) 1993 Randomised controlled trial in Canada 308 pts XRT commencing at cycle 2 (week 3) vs. cycle 6 (week 15) 40Gy in 15 fractions given 3. N Murray et al Importance of timing for thoracic irradiation in the combined modality treatment of limited-stage small-cell lung cancer. JCO Vol , 1993 The National Cancer Institute of Canada Clinical Trials Group
NCIC Results Early XRTLate XRTp Value PFS OS ( median) year survival 30%22% year survival 26%11%0.008
Trial 2: Jeremic (4) Yugoslavian study patients 4 x Carbo Etop and 4 x Cis Etop (carbo with XRT) 54Gy in 1.5Gy / fraction given bd XRT weeks 1-4 (early) or weeks 6-9 (late) EarlyLateP value Median survival (months) year survival (%) Jeremic et al “ Initial versus delayed accelerated hyperfractionated radiation therapy and concurrent chemotherapy in limited small-cell lung cancer: a randomized study” JCO Vol 15, , 1997
Trials 3: Takada (5) Japanese study patients 4 x EP with 45Gy in 1.5Gy fractions given bd XRT started d2 cycle 1 vs. after cycle 4 ( sequential rather than late) 5. Takada M, Fukuoka M, Kawahara M, et al: Phase III study of concurrent versus sequential thoracic radiotherapy in combination with cisplatin and etoposide for limited-stage small-cell lung cancer: Results of the Japan Clinical Oncology Group Study J Clin Oncol 20: , 2002
Results ConcurrentSequential Median survival (months) year survival (%) year survival (%) year survival (%) P= not significant due to small sample size
Costs of XRT Increased haematolgical toxicity Similar oesophagitis ( 9% vs 4%) 1% incraese in treatment related deaths Well tolerated overall
Negative trials 1: Perry (6) US Study patients: chemo, vs. chemo + early XRT, vs. chemo + late XRT Results: XRT group as a whole did better that chemo alone group But no benefit from early vs delayed XRT 6. Perry MC et al Chemotherapy with or without radiation therapy in limited small cell lung carcinoma of the lung NEJM 1987;316:
Negative trials 2: Spiro A London based trial (7) published 2005, replicated the NCIC study. 3 cycles of CAV followed by 3 cycles of EP XRT with first course of EP (4th cycle of chemo) vs. XRT with last course (6 th ) of chemo Failed to demonstrate a survival advantage from early XRT with chemo. 7. Spiro SG et al JCO Vol 24 No : pp Early Compared With Late Radiotherapy in Combined Modality Treatment for Limited Disease Small-Cell Lung Cancer: A London Lung Cancer Group Multicenter Randomized Clinical Trial and Meta-AnalysisEarly Compared With Late Radiotherapy in Combined Modality Treatment for Limited Disease Small-Cell Lung Cancer: A London Lung Cancer Group Multicenter Randomized Clinical Trial and Meta-Analysis
Negative trials 3-5 Work et al, James et al, Gregor et al, all negative. No advantage shown to early XRT
What do we do? A meta-analysis!
Meta-analysis 2004 (6) Looked at 7 studies (Spiro not published at that time ) 1524 patients 6. B. Fried et al Systematic Review Evaluating the Timing of Thoracic Radiation Therapy in Combined Modality Therapy for Limited-Stage Small-Cell Lung Cancer JCO Vol 22, No 23, 2004: pp American Society of Clinical Oncology.DOI: /JCO American Society of Clinical Oncology.DOI: /JCO OutcomeIn favour of early XRT 2 year survival Relative risk 1.17 (CI = ) 3 year survival Relative risk 1.13 (CI = ) (not significant)
Meta-analysis Summary A small but significant improvement in 2-year OS for ERT versus LRT Similar to the benefit of adding RT to chemotherapy, or to addition or prophylactic cranial irradiation.
Cautions: Studies using platinum-based chemotherapy had 2 year OS RRs of 1.30 (95% CI, 1.10 to 1.53; P 0.002) favouring early XRT. 3 year OS RRs of 1.35 (95% CI, 1.07 to 1.70; P 0.01) BUT: Studies using once-daily fractionation showed no difference in 2- and 3-year OS for early vs. late XRT. Studies using non-platinum-based chemotherapy regimens had non-significant differences in OS.
Cochrane Review OS at 2 and 5 years: not significantly different for early vs late XRT. However, if removed 1 trail, which did not use platinum, survival advantage at 5 years for early vs. late OR = 0.64 p=0.02 If XRT was given within < 30 days: 5 year survival was even better OR=0.56 p = 0.02
So…… Radiotherapy adds to chemotherapy without doubt Early appears to be superior to late, but this is more evident when given with platinum based chemo, and if given in hyperfractionated manner (i.e. bd) Short overall treatment time is best
Future Are you convinced? Or confused? bd fractionation ? Do we move to this? CONVERT study ongoing to clarify this question in UK and Europe Dose escalation – no proof that higher doses lead to better outcomes ( although common in N America - get paid / fraction)