Side Effects of Concurrent Chemoradiotherapy for Advanced NSCLC

Julie Brahmer, MD:Our biggest challenge when talking with a patient about requiring concurrent chemotherapy and radiation is trying to discuss with them that while cure is possible, it’s certainly less likely, since they cannot undergo surgery. Another challenge is trying to get them through chemotherapy and radiation because of the side effects of concurrent treatment.

Most patients have some type of side effect with concurrent chemotherapy and radiation. Fatigue is the biggest side effect that I tell patients to watch out for and to be concerned about, particularly fatigue as cumulative, as time goes by, while they’re doing concurrent chemotherapy and radiation therapy. You can also see a drop in blood count, making you more prone to developing fevers or other infections, and giving chemotherapy and radiation together increases the chance of esophagitis, or pain when swallowing. It can get to the point for some patients, about a third of them, where they have a tough time eating, particularly when they’re given chemotherapy and radiation therapy.

Those patients who come in, either with a lot of weight loss to begin with or are elderly—sometimes we’ll discuss giving sequential chemotherapy followed by radiation therapy or vice versa, radiation therapy followed by chemotherapy. In order to get the best chance of control, giving chemotherapy together with radiation is probably the best.

Certainly, we’ll decide about what type of chemotherapy to give to patients depending on how well they’re feeling. Giving once weekly paclitaxel and carboplatin, at least in my clinic, seems to be better tolerated by patients who are elderly or have some other comorbidities compared with cisplatin and etoposide, where we tend to use that in younger patients who can tolerate the cisplatinum.

Transcript edited for clarity.

Case: A 59-year-old Woman With Locally Advanced NSCLC

• A 59-year-old woman presents after referral from primary care for persistent cough and bloody sputum. She denies shortness of breath, says cough began last fall and she attributes it and the sputum to allergies.
• History:
  • 10-year smoking history, ages 15 to 25
  • Postmenopausal, BMI = 26 kg/m²
  • Basal cell carcinoma on chest and face, had 3 lesions removed 2 years ago
• Evaluation and follow up testing reveal stage IIIB NSCLC:
  • Radiograph shows 2 lesions in left lung (3.1 cm and 5.5 cm)
  • Fiber optic bronchoscopy identifies NSCLC
  • Endobronchial ultrasound reveals ipsilateral mediastinal lymph node involvement
  • WHO performance status 1
  • Histology: nonsquamous
  • Biomarkers
    • EGFRnegative,BRAFnegative,ALK/ROS1negative
    • PD-L1 status: >25%
• Laboratory findings:
  • WBC, renal function, hepatic function within normal ranges
• After multidisciplinary evaluation, the patient was determined not to be a surgical candidate
• She completed a weekly carboplatin/paclitaxel doublet therapy with concomitant radiotherapy (60 Gy)
  • Achieved partial response without progression 3 weeks later
  • Began treatment with durvalumab