What is the best practice radiotherapy approach in patients with stage II inoperable NSCLC?
As in stage I NSCLC, surgery is the standard of care for patients with stage II NSCLC. In patients who are not fit for surgery, radiotherapy may be a curative option.
Stage II disease constitutes a small proportion of all patients with NSCLC, therefore, it is unusual to find studies restricted to this population of patients. In the CHART study, 7% of patients had stage II disease; in the CHARTWEL study, it was 6%. A randomised phase 3 trial of conventional radiotherapy (55 Gy in 20 fractions) with and without concomitant gemcitabine in patients with stage I and II NSCLC was closed early because of slow accrual. There were no differences in survival between arms but significantly more adverse events in patients randomised to gemcitabine. Because of the paucity of evidence for inoperable node positive stage II disease, it seems reasonable to use the recommendation guidelines for node positive stage III disease, to which the reader is directed, (refer radiotherapy stage III inoperable).
Evidence summary and recommendations
Patients with inoperable stage II disease could be offered radiotherapy with curative intent with or without concomitant chemotherapy.
- Saunders M, Dische S, Barrett A, Harvey A, Griffiths G, Palmar M. Continuous, hyperfractionated, accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: mature data from the randomised multicentre trial. CHART Steering committee. Radiother Oncol 1999 Aug;52(2):137-48 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10577699].
- Baumann M, Herrmann T, Koch R, Matthiessen W, Appold S, Wahlers B, et al. Final results of the randomized phase III CHARTWEL-trial (ARO 97-1) comparing hyperfractionated-accelerated versus conventionally fractionated radiotherapy in non-small cell lung cancer (NSCLC). Radiother Oncol 2011 Jul;100(1):76-85 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21757247].
- Price A, Yellowlees A, Keerie C, Russell S, Faivre-Finn C, Gilligan D, et al. Radical radiotherapy with or without gemcitabine in patients with early stage medically inoperable non-small cell lung cancer. Lung Cancer 2012 Sep;77(3):532-6 [Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22672970].