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Decision Analysis for Prophylactic Cranial Irradiation for Patients With Small-Cell Lung Cancer

J. Jack Lee, B. Nebiyou Bekele, Xian Zhou, Scott B. Cantor, Ritsuko Komaki, Jin Soo Lee

From the Department of Biostatistics & Applied Mathematics, and Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX; and Research Institute and Hospital, National Cancer Center Korea, Gyeonggi-do, Republic of Korea

Address reprint requests to J. Jack Lee, PhD, Department of Biostatistics & Applied Mathematics, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 447, Houston, TX 77030-4009; e-mail: jjlee{at}mdanderson.org

PURPOSE: Prophylactic cranial irradiation (PCI) has been shown to provide survival benefit in patients with limited disease small-cell lung cancer (LD-SCLC) who have achieved complete response. However, PCI may also produce long-term neurotoxicity (NT). The benefits and risks of PCI in LD-SCLC are evaluated.

METHODS: We developed a decision-analytic model to compare quality-adjusted life expectancy (QALE) in a cohort of SCLC patients who do or do not receive PCI by varying survival rates and the frequency and severity of PCI-related NT. Sensitivity analyses were applied to examine the robustness of the optimal decision.

RESULTS: At current published survival rates (26% 5-year survival rate with PCI and 22% without PCI) and a low NT rate, PCI offered a benefit over no PCI (QALE = 4.31 and 3.70 for mild NT severity; QALE = 4.09 and 3.70 for substantial NT severity, respectively). With a moderate NT rate, PCI was still preferred. If the PCI survival rate increased to 40%, PCI outperformed no PCI with a mild NT severity. However, no PCI was preferred over PCI (QALE = 5.72 v 5.47) with substantial NT severity. Two-way sensitivity analyses showed that PCI was preferred for low NT rates, mild NT severity, and low long-term survival rates. Otherwise, no PCI was preferred.

CONCLUSION: The current data suggest PCI offers better QALE than no PCI in LD-SCLC patients who have achieved complete response. As the survival rate for SCLC patients continues to improve, NT rate and NT severity must be controlled to maintain a favorable benefit-risk ratio for recommending PCI.

Supported in part by the National Cancer Institute Grants No. CA16672 and CA91844, and the Department of Defense Grants No. DAMD17-01-1-0689, DAMD17-02-1-0706, and W81XWH-04-1-0142.

J.J.L. and B.N.B. contributed equally to the work.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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