Different fractionation regimes in palliative thoracic radiotherapy: Some facets.

Sir,

Despite much research, carcinoma lung remains an important scourge of mankind. The study by Saurav Sau et al.[1] was a welcome refreshment to our knowledge on palliative radiotherapy regimes in metastatic carcinoma lung. However, we would like to mark certain important inadequacies in the study.

The inclusion criteria included ‘patients who had intrathoracic symptoms’. Thoracic external beam radiotherapy was indicated in a variety of symptoms: Hemoptysis, cough, chest pain, dyspnea, obstructive pneumonia, dysphagia related to esophageal compression, superior vena cava syndrome, hoarseness, and so on. It would be interesting if the different thoracic symptoms, besides pain, were also evaluated in the different study arms. There was an important group of patients in whom pain was not a symptom even in advanced disease. The benefit of different interventions in such patients needs to be detailed

Another inclusion criterion that was mentioned in the study was, ‘expected survival of more than three months’. As this was a subjective criterion it was likely to differ among evaluators, and other objective criteria would definitely have been better

Bronchoscopy is an important examination, which had not been mentioned. The diagnostic yield of bronchoscopy for visible lesions exceeded 80%[2] and it definitely deserved to be an important part of the workup of patients

The standard treatment of advanced non-small-cell carcinoma lung was platinum-based chemotherapy,[3] with proven benefits, both in the overall survival as well as quality of life. As the performance score of eligible patients in this study was good (Performance status ≤ Eastern Cooperative Oncology Group (ECOG) 3), the standard chemotherapeutic regimes that were started upfront could also have provided valuable symptom relief to patients and at the same time would have been effective in controlling the systemic metastasis. Palliative radiotherapy could have been administered when symptom relief was not adequate. The rationale of providing upfront radiotherapy to good performance score patients also needs to be detailed

Overall survival of patients was definitely impacted by the site of the metastasis. Did the site or number of metastases impact survival? The answer would be important for the readers

An important side effect of hypofractionated regimes in thoracic radiotherapy was radiation myelitis, which was noticed with hypofractionated regimes.[4] It had devastating consequences for the patients. It needs to be stressed that even though it was a fairly large study this side effect was not seen in patients treated with hypofractionated regime.

Thus, this study has some limitations. However, it still manages to emphasize the value of shorter radiotherapy regimes in the palliative setting and the consequential benefits to the already ill patients.