Can we optimize chemo-radiation and surgery in locally advanced stage III non-small cell lung cancer based on evidence from randomized clinical trials? A hypothesis-generating study.
OBJECTIVE
Improved local tumor control (LC) improves survival of patients with non-small cell lung cancer (NSCLC). We estimated the capability of surgical and non-surgical options to improve LC further in this disease.


METHODS
Eligible studies were phase III trials reporting 2-year survival data as well as the incidence of LC and/or distant metastases. Effect estimates, as well as the statistical uncertainty of these, were combined in order to estimate the benefit in terms of LC from combining multiple modalities.


RESULTS
It was estimated that the highest rates of LC can be obtained with high-dose concurrent chemo-radiation followed by surgery. In this situation, escalating the pre-operative radiation dose from 45 to 66 Gy, delivered concurrently with chemotherapy, could increase LC from 58% to 76%. Toxicity may also be higher, but could not be estimated. Without surgery, the gain in LC from concurrent chemo-radiation versus sequential, corresponds to a radiation dose increase from 65 to 72 Gy.


CONCLUSIONS
We hypothesize that high-dose concurrent chemo-radiation followed by surgery could be superior to other current treatment approaches for selected patients with stage III NSCLC, provided toxicity would be low. At present, high-dose concurrent chemo-radiation followed by surgery should be considered experimental.
De Ruysscher
Dirk
D
Department of Radiation Oncology, Maastro Clinic, Maastricht University Medical Center, Maastricht, The Netherlands. dirk.deruysscher@maastro.nl
Dehing
Cary
C
Bentzen
Søren M
SM
Houben
Ruud
R
Dekker
André
A
Wanders
Rinus
R
Borger
Jacques
J
Hochstenbag
Monique
M
Boersma
Liesbeth
L
Geskes
Gijs
G
Dingemans
Anne-Marie C
AM
Bootsma
Gerben
G
Lammering
Guido
G
Lambin
Philippe
P
D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000556:secondary / Q000628:therapy*; D017326:Clinical Trials, Phase III as Topic; D003131:Combined Modality Therapy; D018450:Disease Progression; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic