Hypofractionated Radiotherapy for Breast Cancer: is Grade 3 an exclusion criteria

A very interesting letter to the editor in the NEJM about the Whelan Hypofractionation trial for breast cancer. In the manuscript, a subset analysis was performed suggesting that high grade cancers did worse with hypofractionation. In a letter, the investigators of the START A and B trial reanalyzed their data looking for a similar finding and found no difference, in fact the trend was for G3 cancers to do better with hypofx in their data set.

I have been shying away from hypofx in G3 patients until now, but this data will make me much more comfortable offering it to our patients.

Link:

Hypofractionated Radiotherapy for Breast Cancer:

JCO: Meta-Analysis of Concurrent Versus Sequential CTRT in NSCLC

In the JCO this week -

A meta-analysis from Auperin is published confirming a survival benefit from concurrent CTRT vs sequential chemo then RT, at the expense of acute esophageal symptoms. No surprise here, and concurrent CTRT has been the standard in our department for quite a while, however, it is good to have more data to support a new standard of care.

Link and Abstract

Meta-Analysis of Concomitant Versus Sequential Radiochemotherapy in Locally Advanced Non-Small-Cell Lung Cancer [Thoracic Oncology]: "Purpose

The previous individual patient data meta-analyses of chemotherapy in locally advanced non–small-cell lung cancer (NSCLC) showed that adding sequential or concomitant chemotherapy to radiotherapy improved survival. The NSCLC Collaborative Group performed a meta-analysis of randomized trials directly comparing concomitant versus sequential radiochemotherapy.

Methods

Systematic searches for trials were undertaken, followed by central collection, checking, and reanalysis of updated individual patient data. Results from trials were combined using the stratified log-rank test to calculate pooled hazard ratios (HRs). The primary outcome was overall survival; secondary outcomes were progression-free survival, cumulative incidences of locoregional and distant progression, and acute toxicity.

Results

Of seven eligible trials, data from six trials were received (1,205 patients, 92% of all randomly assigned patients). Median follow-up was 6 years. There was a significant benefit of concomitant radiochemotherapy on overall survival (HR, 0.84; 95% CI, 0.74 to 0.95; P = .004), with an absolute benefit of 5.7% (from 18.1% to 23.8%) at 3 years and 4.5% at 5 years. For progression-free survival, the HR was 0.90 (95% CI, 0.79 to 1.01; P = .07). Concomitant treatment decreased locoregional progression (HR, 0.77; 95% CI, 0.62 to 0.95; P = .01); its effect was not different from that of sequential treatment on distant progression (HR, 1.04; 95% CI, 0.86 to 1.25; P = .69). Concomitant radiochemotherapy increased acute esophageal toxicity (grade 3-4) from 4% to 18% with a relative risk of 4.9 (95% CI, 3.1 to 7.8; P < .001). There was no significant difference regarding acute pulmonary toxicity.

Conclusion

Concomitant radiochemotherapy, as compared with sequential radiochemotherapy, improved survival of patients with locally advanced NSCLC, primarily because of a better locoregional control, but at the cost of manageable increased acute esophageal toxicity.

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