From the Guidelines
Radiotherapy is a crucial treatment modality in non-small cell lung cancer (NSCLC), particularly in stage III disease, where concurrent chemoradiotherapy or sequential chemotherapy and radiation therapy are recommended over radiation alone. The indications for radiotherapy in NSCLC vary across different stages and clinical scenarios.
Key Indications for Radiotherapy in NSCLC
- Early-stage (I-II) inoperable NSCLC: stereotactic body radiation therapy (SBRT) is the standard approach, delivering 48-60 Gy in 3-5 fractions with excellent local control rates 1.
- Locally advanced (stage III) disease: concurrent chemoradiotherapy with 60-66 Gy over 6-7 weeks alongside platinum-based chemotherapy is the standard of care, followed by durvalumab maintenance for eligible patients 1.
- Stage IV disease: radiotherapy serves palliative purposes to control symptoms from primary tumors or metastases, typically delivering 30 Gy in 10 fractions or 20 Gy in 5 fractions 1.
- Postoperative radiotherapy: used in cases with positive margins or nodal involvement, delivering 50-60 Gy over 5-6 weeks 1.
Rationale for Radiotherapy in NSCLC
The rationale for radiotherapy in NSCLC is its ability to deliver targeted cell death to tumor tissue while sparing surrounding normal structures. Modern techniques like intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT) have significantly improved the therapeutic ratio by reducing toxicity to surrounding organs 1.
Evidence-Based Recommendations
According to the ASCO guideline, patients with stage III NSCLC who are not candidates for concurrent chemoradiation but are candidates for chemotherapy should be offered sequential chemotherapy and radiation therapy over radiation alone, as it has been shown to improve overall survival (OS) and progression-free survival (PFS) compared to radiation alone 1. This is supported by a recent meta-analysis and systematic review, which included 13 randomized control trials and found that patients receiving some form of chemotherapy with radiation had a higher OS and PFS compared to patients receiving radiation alone 1.
From the Research
Indications of Radiotherapy in Non-Small Cell Lung Cancer
- Radiotherapy is a treatment option for non-small cell lung cancer (NSCLC), particularly for medically inoperable patients with early-stage disease 2, 3, 4.
- Stereotactic body radiation therapy (SBRT) is a type of radiotherapy that delivers high doses of radiation to the tumor with high precision, and is considered the standard of care for inoperable early-stage NSCLC 2, 3, 4.
- SBRT has been shown to achieve superior local control and survival compared to conventionally fractionated radiation therapy 2, 4.
- The indications for radiotherapy in NSCLC include:
- Medically inoperable patients with early-stage disease 2, 3, 4.
- Patients with comorbidities that prohibit them from undergoing a major surgical procedure 5.
- Patients with locally advanced NSCLC who are not candidates for surgical resection 5.
- Patients with limited metastatic disease who may benefit from the combination of SBRT and systemic therapy 5.
- The goal of radiotherapy in NSCLC is to achieve local control of the tumor, while minimizing toxicity and improving survival 2, 3, 4.