Radiochemotherapy and fractionation in locally advanced non-small-cell lung cancer

Abstract

Lung cancer (LC) is the leading cause of cancer-related mortality around the world. The more common non-small-cell LC (NSCLC) constitutes 85 % of all LC. Tobacco abuse is the well-established cause of NSCLC which directly relates with more than 85 % cases. Locally advanced NSCLC (LA-NSCLC), namely, stage IIIA/B, is diagnosed in a highly heterogeneous group of patients with significantly differing clinical outcomes. Based on the results of two landmark phase III randomized controlled trials, the standard of care for unresectable LA-NSCLC is definitive conventionally fractionated 60–66 Gy concurrent chemoradiotherapy with utilizing platinum-based doublets in order to offer these patients the highest chance for prolonged disease-free and overall survival. Hyperfractionated radiotherapy may provide a further 3 % survival gain at long term, but in cost of increased acute toxicity rates. However, even with such an aggressive approach, the outcome of these patients still remains poor with median OS of only 15.3–21.7 months, impacting the need for novel treatment strategies. Optimal management of elderly LA-NSCLC patients is a subject of debate, but available data suggests that chronological age should not shape the treatment options of carefully selected elderly patients with LA-NSCLC who have a good performance status, minor/no weight loss, and no comorbidity; instead, like younger patients, they should be offered radical C-CRT as the standard of care. Likewise, although further confirmatory studies are needed to establish both the efficacy and tolerability of thoracic reirradiation, available results suggest that reirradiation can achieve satisfactory tumor control and survival rates for local recurrences of NSCLC provided that attention is paid to the possible hazards. In this respect novel TRT technologies such as IMRT may serve beneficial by permitting dose escalation with no excess risk of toxicity.