Krisztian Süveg1, Cecile Le Pechoux2, Corinne Faivre-Finn3, Paul M Putora4, Dirk De Ruysscher5, Joachim Widder6, Paul Van Houtte7, Esther G C Troost8, Ben J Slotman9, Sara Ramella10, Christoph Pöttgen11, Stephanie T H Peeters5, Ursula Nestle12, Fiona McDonald13, Rafal Dziadziuszko14, José Belderbos15, Umberto Ricardi16, Farkhad Manapov17, Yolande Lievens18, Xavier Geets19, Karin Dieckmann6, Matthias Guckenberger20, Nicolaus Andratschke20, Markus Glatzer21. 1. Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland. Electronic address: Krisztian.sueveg@kssg.ch. 2. Departement Oncologie Radiotherapie, Gustave Roussy, Villejuif, France. 3. Division of Cancer Sciences, University of Manchester & The Christie NHS Foundation Trust Manchester, Manchester, UK. 4. Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Radiation Oncology, University of Bern, Bern, Switzerland. 5. Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht, The Netherlands. 6. Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Austria. 7. Department of Radiation Oncology, Institut Bordet, Université Libre Bruxelles, Belgium. 8. Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany; German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany; National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany. 9. Department of Radiation Oncology, Amsterdam University Medical Center, VUMC, Amsterdam, The Netherlands. 10. Department of Radiation Oncology, Campus Bio-Medico University, Rome, Italy. 11. Department of Radiation Oncology, West German Tumor Centre, University of Duisburg-Essen Medical School, Germany. 12. Department of Radiation Oncology, Kliniken Maria Hilf, Moenchengladbach, Germany; Department of Radiation Oncology, University Hospital Freiburg, Germany. 13. Department of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK. 14. Department of Oncology and Radiotherapy, Gdansk, Poland. 15. Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands. 16. Radiation Oncology, Department of Oncology, University of Turin, Italy. 17. Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany. 18. Radiation Oncology Department, Ghent University Hospital, Ghent, Belgium. 19. Department of Radiation Oncology, Cliniques universitaires Saint-Luc, MIRO - IREC Lab, UCL, Belgium. 20. Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland. 21. Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
Abstract
BACKGROUND: The role of postoperative radiation therapy (PORT) in stage III N2 NSCLC is controversial. We analyzed decision-making for PORT among European radiation oncology experts in lung cancer. METHODS: Twenty-two experts were asked before and after presentation of the results of the LungART trial to describe their decision criteria for PORT in the management of pN+ NSCLC patients. Treatment strategies were subsequently converted into decision trees and analyzed. RESULTS: Following decision criteria were identified: extracapsular nodal extension, incomplete lymph node resection, multistation lymph nodes, high nodal tumor load, poor response to induction chemotherapy, ineligibility to receive adjuvant chemotherapy, performance status, resection margin, lung function and cardiopulmonary comorbidities. The LungART results had impact on decision-making and reduced the number of recommendations for PORT. The only clear indication for PORT was a R1/2 resection. Six experts out of ten who initially recommended PORT for all R0 resected pN2 patients no longer used PORT routinely for these patients, while four still recommended PORT for all patients with pN2. Fourteen experts used PORT only for patients with risk factors, compared to eleven before the presentation of the LungART trial. Four experts stated that PORT was never recommended in R0 resected pN2 patients regardless of risk factors. CONCLUSION: After presentation of the LungART trial results at ESMO 2020, 82% of our experts still used PORT for stage III pN2 NSCLC patients with risk factors. The recommendation for PORT decreased, especially for patients without risk factors. Cardiopulmonary comorbidities became more relevant in the decision-making for PORT.
BACKGROUND: The role of postoperative radiation therapy (PORT) in stage III N2 NSCLC is controversial. We analyzed decision-making for PORT among European radiation oncology experts in lung cancer. METHODS: Twenty-two experts were asked before and after presentation of the results of the LungART trial to describe their decision criteria for PORT in the management of pN+ NSCLC patients. Treatment strategies were subsequently converted into decision trees and analyzed. RESULTS: Following decision criteria were identified: extracapsular nodal extension, incomplete lymph node resection, multistation lymph nodes, high nodal tumor load, poor response to induction chemotherapy, ineligibility to receive adjuvant chemotherapy, performance status, resection margin, lung function and cardiopulmonary comorbidities. The LungART results had impact on decision-making and reduced the number of recommendations for PORT. The only clear indication for PORT was a R1/2 resection. Six experts out of ten who initially recommended PORT for all R0 resected pN2 patients no longer used PORT routinely for these patients, while four still recommended PORT for all patients with pN2. Fourteen experts used PORT only for patients with risk factors, compared to eleven before the presentation of the LungART trial. Four experts stated that PORT was never recommended in R0 resected pN2 patients regardless of risk factors. CONCLUSION: After presentation of the LungART trial results at ESMO 2020, 82% of our experts still used PORT for stage III pN2 NSCLC patients with risk factors. The recommendation for PORT decreased, especially for patients without risk factors. Cardiopulmonary comorbidities became more relevant in the decision-making for PORT.