Post Operative Radiation Therapy (PORT) Improves Survival in Resected N2 Non-Small Cell Lung Cancer

SUMMARY: Lung cancer is the second most common cancer in both men and women and accounts for about 13% of all new cancers and 27% of all cancer deaths. It is the leading cause of cancer death among both men and women. The American Cancer Society estimates that over 221,200 new cases of lung cancer will be diagnosed in the United States in 2015 and over 158,000 patients will die of the disease. Non-Small Cell Lung Cancer (NSCLC) accounts for approximately 85% of all lung cancers. Based on the extent of the disease and the treatment approach, patients with localized or locally advanced NSCLC can be divided into two groups – 1) Surgically resectable disease group (stage I, stage II, and selected stage III tumors) for whom postoperative Cisplatin-based combination chemotherapy may provide a survival advantage (particularly for those with resected stage II or stage IIIA NSCLC). 2) Locally (T3–T4) and/or regionally (N2–N3) advanced disease group who have unresectable disease, who benefit with radiation therapy in combination with chemotherapy. Based on available evidence, postoperative chemotherapy is not recommended outside of a clinical trial for patients with completely resected stage I NSCLC. Although there is sufficient evidence for postoperative chemotherapy in patients with stage II or stage IIIA NSCLC, its usefulness in patients with stage IB NSCLC remains unclear. The value of adjuvant Post Operative Radiation Therapy (PORT) has been evaluated and has not been found to improve the outcome of patients with completely resected stage I NSCLC. The risk of locoregional recurrence (LRR) is 20-40% in patients with resected node-positive disease and this in turn may independently contribute to worsened Overall Survival in patients with NSCLC. Nonetheless, a large meta-analysis from trials conducted mainly in the 1960’s and 1970’s showed that adjuvant Post Operative Radiation Therapy (PORT) in stages IIA NSCLC and IIB NSCLC was associated with an 18% relative increase in the risk of death compared with surgery alone. This decrease in Overall Survival has been attributed to outmoded RT techniques and doses resulting in cardiac and pulmonary toxicity. This study was conducted to evaluate the impact of modern (Computed Tomography simulation and at least Linear accelerator- Linac based, three-dimensional, conformal RT) Post Operative Radiation Therapy (PORT) on Overall Survival (OS) in a large population-based registry of patients with completely resected stage IIIA (N2) NSCLC, when compared with adjuvant chemotherapy alone. The authors identified 4,483 patients in the National Cancer Data Base from 2006 to 2010 with pathologic N2, NSCLC, who underwent complete resection and adjuvant chemotherapy. This large patient population was representative of typical patients treated throughout the United States. Of these large cohort of patients, 1,850 had received PORT (45 Gy or more) and 2,633 patients did not. The authors evaluated the impact of patient and treatment variables on OS. The median follow-up time was 22 months. The use of PORT was associated with an increase in median and 5-year OS compared with no PORT (median OS, 45.2 vs 40.7 months, respectively; 5-year OS, 39.3% vs 34.8% respectively; P= 0.014). The improved OS remained, independently predicted by younger age, female sex, urban population, fewer comorbidities, smaller tumor size, multiagent chemotherapy, resection with at least a lobectomy, and PORT. The authors concluded that modern Post Operative Radiotherapy Therapy confers an additional OS advantage beyond that achieved with adjuvant chemotherapy alone, for patients with N2, NSCLC after complete resection and adjuvant chemotherapy. Postoperative Radiotherapy for Pathologic N2 Non–Small-Cell Lung Cancer Treated With Adjuvant Chemotherapy: A Review of the National Cancer Data Base. Robinson CG, Patel AP, Bradley JD, et al. J Clin Oncol. 2015; 33:870-876