Managing CRT-Related Adverse Events in NSCLC

Mark A. Socinski, MD:The management of adverse effects as a result of chemoradiation really is best handled by first educating the patient in terms of what the adverse effects are. I counsel patients that basically the primary adverse effect that we have to deal with is esophagitis. I describe it to patients as a sunburn of the esophagus. One of the challenges of radiation is a radiation oncologist wants to use radiation to destroy the cancer, but you realize that radiation beams are high energy beams going through the body, and they aren’t specifically just hitting the cancer, they will also hit normal tissue such as esophagus, heart, spinal cord, lung. And the art of radiation oncology really is focused around, how can I deliver the lethal dose to the cancer but avoid treating too much of the normal tissue? It’s really overtreatment of normal tissue that causes toxicity.

The organ that is most difficult to miss sometimes is the esophagus. And so esophageal symptoms are very common. Esophagitis is the number 1 adverse effect that we have to deal with. I say to patients, it’s like a sunburn of your esophagus, and when you swallow, it hurts. And most humans don’t like to do things that hurt. So they don’t get in calories and they don’t get in hydration. I tell them that for the first 2 weeks of radiation—if the normal course of radiation is 6 weeks—you’re going to do fine. You tend not to see much esophageal symptoms in the first 2 weeks, and I say to them, around 2 weeks you’re going to start noticing that there’s something different about your swallowing. It may initially feel like a knot, it may be painful, but you need to tell us about this because then we start supportive care.

We use pain relief, local soothants. Sometimes we use antifungal agents. I think reflux from the stomach can exacerbate it so we use H2 [histamine 2] blockers to prevent the acid reflux. And, if it hurts to swallow, you need pain medication so you can swallow. The other issue is if you’re not keeping yourself hydrated, guess what? You’re coming to radiation every day, and in my case these patients are coming to get chemotherapy once a week. Tell us that you’re not getting the fluids and we can give you intravenous hydration to make sure that you don’t get dehydrated.

So the management is educating the patients and expecting the toxicity and being ready to manage it prospectively. It’s OK. Patients can get through grade 1 esophagitis. The clinician wants to make sure they don’t have grade 3 or 4 esophagitis because then the patient has to get a treatment break, and that’s bad. We want to make sure that we do everything that we can to get patients from point A, being the first day of radiation, to point B, the last day of radiation. That’s a 6-week period roughly. We want to make sure that they never miss a day of radiation. And the most common cause for missing radiation is esophageal toxicity. So be prospective and manage it carefully.

There’s myelosuppression. You’re giving chemotherapy, that has to be managed. The most common event is anemia. Patients may need blood transfusions. Fatigue is a problem. Radiation does have that kind of nonspecific fatigue as does chemotherapy. This is tough treatment for some patients. It is important to have a team, starting with the medical radiation oncologist but also the oncology nurse, the medical assistants, and the radiation technologists. I say to patients, all your job is, is to get through this 6 weeks of radiation.

You need to be a cheerleader. As I said, educate them. You need to say to them, “No matter how bad you feel, you need to come in for your radiation. You come in, tell us how you’re feeling, and we’ll do whatever it takes to make you better. Our job is to get you through this.” There’s very good evidence that if patients get through the planned treatment on time versus having breaks because of toxicity, those patients who get through treatment have better long-term survival. So I think it centers around education and prospective management, and being 1 week ahead of any of the problems that you’re going to have.

Transcript edited for clarity.

Case: A 52-Year-Old Male With Stage IIIA NSCLC

Initial presentation

• A 52-year-old man presented with a 15-lb weight loss and worsening dyspnea
• PMH: HTN
• SH: Computer programmer; Smoked a pack/day for 30 years; Quit smoking 2 years ago; Married with 4 kids
• PE: Unremarkable

Clinical workup

• Imaging:
  • Initial CT showed a 5-cm left upper lobe mass with aortopulmonary window and left paratracheal adenopathy measuring up to 2.5 cm
  • Subsequent PET scan showed activity in the left upper lobe mass and all nodal areas
  • No extrathoracic disease was identified
  • MRI showed no brain metastases
• Mediastinal sampling: EBUS was performed and documented squamous carcinoma in the left paratracheal lymph nodes
• Staging: T2N2M0
• ECOG PS 1
• Multidisciplinary tumor board deemed his tumor unresectable due to multistation N2 disease

Treatment

• Concurrent cisplatin/etoposide with external-beam radiotherapy
• Repeat CT 4 weeks after completion of concurrent chemoradiotherapy showed a PR with no new sites of disease