Best supportive care in non-small cell lung cancer: is there a role for radiotherapy and chemotherapy?

Best Supportive Care (BSC) is the treatment of choice when cure is not achievable with anticancer treatments and involves management of disease-related symptoms. In the palliative treatment of non-small cell lung cancer (NSCLC) radiation therapy has for a long time been the cornerstone of symptom management, although the best schedule is still to be defined. Chemotherapy, on the other hand, has been excluded from classical definitions of BSC and has been reserved only for selected patient populations in which a survival benefit was demonstrated using cisplatin-based regimens. We reviewed randomized trials on both palliative radiotherapy and chemotherapy in order to assess the impact of anticancer treatments on quality of life in advanced NSCLC patients. While no randomized trials compared radiation therapy with a control arm not including it, several randomized trials assessed the use of different schedules. Hypofractionated schedules seem to have comparable palliative activity when compared with the standard fractionated regimens, at least in metastatic, poor-prognosis patients. In locally advanced, inoperable NSCLC higher radiation doses administered with conventional fractionation achieve better results in terms of local control and survival. The rate of palliation of local symptoms is high, being 60-80% for chest pain and hemoptysis, while breathlessness and cough are controlled at a somewhat lower rate (50-70%). General symptoms (fatigue, anorexia, and depression) are affected in a minority of patients. Chemotherapy was compared with BSC in several randomized trials, in some of which an analysis of the quality of life was included. Results are consistent in favor of its palliative role and, when local symptom control is assessed, rates of palliation seem similar to those achieved by radiation. Benefits apply to metastatic NSCLC patients with good performance status, low body weight loss, age below 70-75. However, some studies support the use of chemotherapy also in patients with poor prognostic features. A comparison in terms of quality of life and symptom palliation between different chemotherapy regimens is the object of few trials. Both chemotherapy and radiation have an important role in the palliative treatment of advanced NSCLC patients and should be included in BSC programs. Future randomized trials should assess the best way of combining these two approaches.