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Palliative Thoracic Radiotherapy for Lung Cancer: A Systematic Review

Alysa Fairchild, Kristin Harris, Elizabeth Barnes, Rebecca Wong, Stephen Lutz, Andrea Bezjak, Patrick Cheung, Edward Chow

From the Cross Cancer Institute, Edmonton, Alberta; Odette Cancer Centre, Sunnybrook Health Sciences Centre; Princess Margaret Hospital, Toronto, Ontario, Canada; and the Blanchard Valley Regional Cancer Centre, Findlay, OH

Corresponding author: Alysa Fairchild, MD, FRCPC, Department of Radiation Oncology, Cross Cancer Institute, 11560 University Avenue, Edmonton, AB T6G 1Z2 Canada; e-mail: alysafai{at}cancerboard.ab.ca

Purpose The optimal dose of radiotherapy (RT) to palliate symptomatic advanced lung cancer is unclear. We systematically reviewed randomized controlled trials (RCTs) of palliative thoracic RT.

Methods RCTs comparing two or more dose fractionation schedules were reviewed using the random-effects model of a freely available information management system. The relative risk and 95% CI for each outcome were presented in Forrest plots. Exploratory analysis comparing dose schedules after conversion to the time-adjusted biologically equivalent dose (BED) was performed to investigate for a dose-response relationship.

Results A total of 13 RCTs involving 3,473 randomly assigned patients were identified. Outcomes included symptom palliation, overall survival, toxicity, and reirradiation rate. For symptom control in assessable patients, lower-dose (LD) RT was comparable with higher-dose (HD), except for the total symptom score (TSS): 65.4% of LD and 77.1% of HD patients had improved TSS (P = .003). Greater likelihood of symptom improvement was seen with schedules of 35 Gy₁₀ versus lower BED. At 1 year after HD and LD RT, 26.5% versus 21.7% of patients were alive, respectively (P = .002). Sensitivity analysis suggests this survival improvement was seen with 35 Gy₁₀ BED schedules compared with LDs. Physician-assessed dysphagia was significantly greater in the HD arm (20.5% v 14.9%; P = .01), and the likelihood of reirradiation was 1.2-fold higher after LD RT.

Conclusion No significant differences were observed for specific symptom-control end points, although improvement in survival favored HD RT. Consideration of palliative thoracic RT of at least 35 Gy₁₀ BED may therefore be warranted, but must be weighed against increased toxicity and greater time investment.

Presented in part at the 49th Annual Meeting of the American Society for Therapeutic Radiology and Oncology, October 28–November 1, 2007, Los Angeles, CA.

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

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