Case 1: Radiation Therapy for Locally Advanced NSCLC

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Benjamin P. Levy, MD:Anshu, clearly you play a critical role in stage III patients. How do you approach radiation for stage III dosing? How you discuss this with the patient? How do you manage toxicities? That’s a lot, so I’ll leave it there. But walk us through how you approach these patients.

Anshu K. Jain, MD:Yeah, absolutely, Ben. For stage III patients, the previous thinking was that higher dose results in better outcomes. But the RTOG 0617 study demonstrated that higher wasn’t necessarily better. It established the standard of care in terms of dosing for stage III lung cancer. Really at 60 Gy, look at the NCCN [National Comprehensive Cancer Network] Guidelines. They still give practitioners a range anywhere from 60 Gy to 66 Gy, which really equates to about 6 weeks of daily radiation therapy—Monday through Friday. We’re counseling patients in terms of radiation therapy in the definitive setting and some toxicities they can expect. In stage III, especially with patients with gross mediastinal disease, we really talk to them about esophagitis as being 1 of the major toxicities they may experience during treatment, such as fatigue, of course.

I think in this case, with supraclavicular disease, we would certainly counsel them on the possibility of the brachial plexopathy. Typically, we also discuss radiation pneumonitis as a possible complication of treatment, and certainly in patients with stage IIIB disease. Especially in this case, for example, we’re looking at contralateral mediastinal disease as well as a supraclavicular disease, in which there’s going to be a significant volume of lung that’s going to be treated. We typically try to quantify that in terms of how we predict toxicity by looking at a factor—a parameter caller the V20 [volume of normal lung receiving at least 20 Gy]. Using the V20, we can sometimes predict the risk of pneumonitis in these patients. Certainly in cases where the V20 is going to be on the higher end, we typically try to keep it under about 35%. If it’s going to be on the higher end, we certainly think that they’re going to be at higher risk for pneumonitis. In some cases, that might actually influence the type of concurrent chemotherapy regimen they may choose.

There is some anecdotal evidence to suggest that taxanes may concur, so it might actually increase that risk. We try to look at that information, counsel the patients appropriately, and also have a discussion with medical oncology as well.

Benjamin P. Levy, MD:What percentage of patients, do you think, in your center Ashland Bellefonte Cancer Center in Ashland, Kentucky, can’t get through? You know we have a lot of challenges coaching these patients and getting them through the entire course. They’re getting hammered with chemotherapy and radiation. What percentage can’t make it through? Or are you fairly successful at getting most of these patients through a 6-week to 7-week course of radiation?

Anshu K. Jain, MD:Yeah, you know, it’s a great question, and it’s not an easy treatment by any stretch. Typically, most of our patients are getting through. We do use some of the technologies we have available to us to try to limit the amount of tissue that’s getting radiated. We might use technologies like IMRT [intensity-modulated radiation therapy], which allows us to curb the radiation dose around critical structures, thus reducing the incidence of some toxicities.

We may do something called image guidance, in which we actually take an image of the patient each day during treatment to allow for a more accurate targeting of the tumor. I think that does help get patients through it. Certainly, that has decreased some toxicities. When you look at the subset of patients who had received IMRT versus 3-D conformal radiation therapy in the RTOG 0617 study, they did have less toxicity. So those are some of the technologies we do use.

By carefully evaluating those patients’ nutritional status during treatment, especially with the incidence of esophagitis, you can really stay on top of that, and that really helps patients get through it as well.

Benjamin P. Levy, MD:I’m going to throw 1 curveball at you.

Anshu K. Jain, MD:Yeah.

Benjamin P. Levy, MD:Protons. Are we ready for protons in lung cancer? Is there use for them? I mean, word on the street is that they can cure all patients with anything. Clearly that’s not the case, but are protons coming for us?

Anshu K. Jain, MD:I think protons are going to have a role, but I think it’s going to be primarily in the early-stage setting. When you have these locally advanced cases, there is so much tissue that’s already involved, the benefit of using protons starts to fade away. But there are going to be certain cases, especially if there’s extensive disease adjacent to the heart and other critical structures, that may actually have some impact.

Transcript edited for clarity.