title: Intensity modulated radiotherapy for stage III non-small cell lung cancer in the United States: predictors of use and association with toxicities.
abstract: BACKGROUND
  Intensity modulated radiotherapy for stage III lung cancer has become commonplace in the United States in the absence of randomized controlled trials. We used a large, population-based database to determine which factors led to increased utilization of IMRT and to evaluate associations of IMRT with toxicities.
  
  
  METHODS
  The Surveillance, Epidemiology, and End Results (SEER)-Medicare records identified 3986 individuals aged 66 years or older diagnosed with stage III lung cancer between 2001 and 2007 and treated with IMRT or 3D conformal radiotherapy. Predictors of IMRT use were determined using logistic regression. Associations of IMRT use with diagnosis codes for radiation-related toxicities were evaluated with multivariate proportional hazards regression and propensity-score matching.
  
  
  RESULTS
  Among the 3986 patients studied, the median age was 75 years, 54.1% were male, and 62% had IIIA disease. Two hundred and fifty seven (6.5%) patients received IMRT, with use increasing from 0.5% in 2001 to 14.7% in 2007 (P < 0.001). Key predictors of IMRT delivery included increasing year of diagnosis and treatment in a freestanding center (odds ratio, 2.10; 95% confidence interval [CI], 1.59-2.77, P < 0.001); tumor size, stage, and number of radiotherapy fractions delivered were not associated with IMRT use. IMRT use was not associated with a higher burden of lung or esophagus toxicities when compared to 3DCRT.
  
  
  CONCLUSIONS
  These findings suggest that practice environment strongly influenced adoption of IMRT for lung cancer. Patient and tumor factors were not significant predictors of IMRT use. Esophagus and lung toxicity rates were similar between IMRT and 3DCRT.
authors.affiliation: Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States. Electronic address: smshirvani@mdanderson.org.
authors.forename: Shervin M
authors.initials: SM
authors.lastname: Shirvani
authors.forename: Jing
authors.initials: J
authors.lastname: Jiang
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Gomez
authors.forename: Joe Y
authors.initials: JY
authors.lastname: Chang
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Buchholz
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Smith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology* / Q000532:radiotherapy*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology* / Q000532:radiotherapy*; D008297:Male; D009367:Neoplasm Staging; D011379:Prognosis; D016016:Proportional Hazards Models; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects; D018426:SEER Program; D016896:Treatment Outcome; D014481:United States
keywords: Comparative effectiveness; IMRT; Non-small cell lung cancer; Radiation technique; Technology utilization
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