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Impact of Intensity-Modulated Radiation Therapy Technique for Locally Advanced Non-Small-Cell Lung Cancer: A
Stephen G Chun1, Chen Hu1, Hak Choy1
1Stephen G. Chun and Ritsuko U. Komaki, University of Texas MD Anderson Cancer Center, Houston; Hak Choy, Robert D. Timmerman, and Puneeth Iyengar, University of Texas Southwestern Medical Center, Dallas; Vivek S. Kavadi, Texas Oncology-Sugar Land, Sugar Land, TX; Chen Hu and Rebecca Paulus, NRG Oncology Statistics and Data Management Center; James M. Galvin, Imaging and Radiation Oncology Core, Philadelphia; Raymond B. Wynn, UPMC Cancer Center, Pittsburg, PA; Chen Hu, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Steven E. Schild, Mayo Clinic, Scottsdale, AZ; Jeffrey A. Bogart, State University of New York Upstate Medical University, Syracuse, NY; Michael C. Dobelbower, University of Alabama at Birmingham, Birmingham, AL; Walter Bosch, Clifford G. Robinson, and Jeffrey D. Bradley, Washington University in Saint Louis, St Louis, MO; Samir Narayan, Michigan Cancer Research Consortium Community Clinical Oncology Program, Ann Arbor, MI; Adam Raben, Christiana Care Health Services Community Clinical Oncology Program, Newark, DE; Mark E. Augspurger, Florida Radiation Oncology Group; Baptist Health, Jacksonville, FL; and Robert M. MacRae, The Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada.
Abstract:
Purpose Although intensity-modulated radiation therapy (IMRT) is increasingly used to treat locally advanced non-small-cell lung cancer (NSCLC), IMRT and three-dimensional conformal external beam radiation therapy (3D-CRT) have not been compared prospectively. This study compares 3D-CRT and IMRT outcomes for locally advanced NSCLC in a large prospective clinical trial. Patients and Methods A secondary analysis was performed to compare IMRT with 3D-CRT in NRG Oncology clinical trial RTOG 0617, in which patients received concurrent chemotherapy of carboplatin and paclitaxel with or without cetuximab, and 60- versus 74-Gy radiation doses. Comparisons included 2-year overall survival (OS), progression-free survival, local failure, distant metastasis, and selected Common Terminology Criteria for Adverse Events (version 3) ≥ grade 3 toxicities. Results The median follow-up was 21.3 months. Of 482 patients, 53% were treated with 3D-CRT and 47% with IMRT. The IMRT group had larger planning treatment volumes (median, 427 v 486 mL; P = .005); a larger planning treatment volume/volume of lung ratio (median, 0.13 v 0.15; P = .013); and more stage IIIB disease (30.3% v 38.6%, P = .056). Two-year OS, progression-free survival, local failure, and distant metastasis-free survival were not different between IMRT and 3D-CRT. IMRT was associated with less ≥ grade 3 pneumonitis (7.9% v 3.5%, P = .039) and a reduced risk in adjusted analyses (odds ratio, 0.41; 95% CI, 0.171 to 0.986; P = .046). IMRT also produced lower heart doses ( P < .05), and the volume of heart receiving 40 Gy (V40) was significantly associated with OS on adjusted analysis ( P < .05). The lung V5 was not associated with any ≥ grade 3 toxicity, whereas the lung V20 was associated with increased ≥ grade 3 pneumonitis risk on multivariable analysis ( P = .026). Conclusion IMRT was associated with lower rates of severe pneumonitis and cardiac doses in NRG Oncology clinical trial RTOG 0617, which supports routine use of IMRT for locally advanced NSCLC.
