Review
Consensus Statement on Palliative Lung Radiotherapy: Third International Consensus Workshop on Palliative Radiotherapy and Symptom Control

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Abstract

The purpose of this work is to disseminate a consensus statement on palliative radiotherapy (RT) of lung cancer created in conjunction with the Third International Lung Cancer Consensus Workshop. The palliative lung RT workshop committee agreed on 5 questions relating to (1) patient selection, (2) thoracic external-beam radiation therapy (XRT) fractionation, (3) endobronchial brachytherapy (EBB), (4) concurrent chemotherapy (CC), and (5) palliative endpoint definitions. A PubMed search for primary/cross-referenced practice guidelines, consensus statements, meta-analyses, and/or systematic reviews was conducted. Final consensus statements were created after review and discussion of the available evidence. The following summary statements reflect the consensus of the international working group.

1. Key factors involved in the decision to deliver palliative RT include performance status, tumor stage, pulmonary function, XRT volume, symptomatology, weight loss, and patient preference.

2. Palliative thoracic XRT is generally indicated for patients with stage IV disease with current/impending symptoms and for patients with stage III disease treated for palliative intent.

3. There is no evidence to routinely recommend EBB alone or in conjunction with other palliative maneuvers in the initial palliative management of endobronchial obstruction resulting from lung cancer.

4. There is currently no evidence to routinely recommend CC with palliative-intent RT. 5. Standard assessment of symptoms and health-related quality of life (QOL) using validated questionnaires should be carried out in palliative RT lung cancer trials. Despite an expanding literature, continued prospective randomized investigations to better define the role of XRT, EBB, and CC in the context of thoracic palliation of patients with lung cancer is needed.

Introduction

Palliative-intent thoracic radiotherapy (RT) has been used routinely to relieve tumor-related symptoms such as chest pain, hemoptysis, cough, shortness of breath, and bronchial obstruction.1 The majority of randomized controlled trials and meta-analyses/systematic reviews have focused on the areas of external-beam radiation therapy (XRT) dose fractionation, and the use of endobronchial brachytherapy (EBB) for thoracic palliation of lung cancer. The planned integration of concurrent chemotherapy (CC) with palliative RT has also been the subject of various investigations. Practice guidelines and consensus statements have been prepared previously to provide guidance to practitioners and patients with regard to treatment options relating to this patient population.1, 2, 3, 4, 5, 6, 7, 8

Two previous International Consensus Workshops on palliative RT and symptom control were conducted in 1990 and 2000. A narrative summary of these 2 meetings in relation to advanced/inoperable lung cancer was published by Timothy et al in 2001.9 In 1990 there seemed to be little agreement about the management of locally advanced lung cancer, with options ranging from radical RT (eg, 50-60 Gy) to palliative RT (eg, 30 Gy) or observation alone. There was however agreement on the need for clinical trials focusing on altered fractionation, the role of systemic chemotherapy, and the integration of health-related quality of life (QOL) outcomes.

This consensus statement from the Second Workshop discussed 3 groups of patient populations: a favorable (T1-2N01M0), intermediate (T1-2N2M0 or T3-4anyNM0 with good performance status), and an unfavorable group (stage I-IIIB poor performance status and all stage IV patients). The consensus statement indicated that patients with favorable but otherwise inoperable disease should be managed with radical RT (60 Gy/30 fractions or 50-55 Gy/16 fractions). Patients with an intermediate prognosis should be managed either with continuous hyperfractionated accelerated radiotherapy or combined radical chemoradiotherapy. For patients in the unfavorable cohort but with minimal symptoms, observation was thought to be a reasonable strategy because of a Medical Research Council/British Thoracic Society randomized clinical trial that showed no survival difference between immediate and delayed thoracic radiation for these patients.10 In symptomatic patients regimens of 1 or 2 fractions were found to provide equivalent symptom control and survival with reduced toxicity. The consensus statement also recommended that “unfavorable” patients with good performance status should also be considered for systemic chemotherapy with or without thoracic radiation. A general recommendation for further clinical trials in the areas of prognostic indices, treatment scheduling, novel antineoplastic therapy, and outcome measures was included at the end of the consensus statement.

The purpose of this article is to report and disseminate an updated consensus statement presented at the Third International Lung Cancer Consensus Workshop, which was recently held at the 2010 annual American Society of Radiation Oncology (ASTRO) meeting.

Section snippets

Formulation of Workshop Questions

Many patients with metastatic lung cancer, and selected patients with locally advanced disease, are treated with RT with palliative intent to relieve tumor-related symptoms (hemoptysis, bronchial obstruction, cough, shortness of breath, and chest pain) and improve health-related QOL. It is important to note that studies suggest that higher dose palliative RT can extend life, particularly in patients with good performance status.

In a preliminary evaluation of the medical literature, the working

Question 1: Palliative Vs. Radical Management Criteria

There is very little published research about prognostic factors that could allocate patients with advanced lung cancer into distinct cohorts for palliative or radical management. However several groups have published consensus criteria to identify those who are not appropriate for radical management. Brundage et al published a Canadian consensus document in 1996 about the role of palliative lung RT in the management of lung cancer.11 They recommended that patients with symptomatic local

Disclosure

All authors report no relevant relationships to disclose.

Acknowledgements

The authors would like to thank Shari Siuta, Sidrah Abdul, and Anushree Vichare for their administrative and statistical support during the conduct of this project.

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