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. 2018 Mar;13(3):426-435.
doi: 10.1016/j.jtho.2017.11.135. Epub 2018 Jan 8.

The Addition of Chemotherapy to Radiation Therapy Improves Survival in Elderly Patients with Stage III Non-Small Cell Lung Cancer

Eric D Miller  1 , James L Fisher  2 , Karl E Haglund  1 , John C Grecula  1 , Meng Xu-Welliver  1 , Erin M Bertino  3 , Kai He  3 , Peter G Shields  3 , David P Carbone  3 , Terence M Williams  1 , Gregory A Otterson  3 , Jose G Bazan  4
Affiliations

The Addition of Chemotherapy to Radiation Therapy Improves Survival in Elderly Patients with Stage III Non-Small Cell Lung Cancer

Eric D Miller et al. J Thorac Oncol. 2018 Mar.

Abstract

Introduction: Elderly patients account for the majority of lung cancer diagnoses but are poorly represented in clinical trials. We evaluated the overall survival (OS) of elderly patients with stage III NSCLC treated with definitive radiation compared with that of patients treated with definitive chemoradiation.

Methods: We conducted a comparative effectiveness study of radiation therapy versus chemoradiation in elderly (≥70 years old) patients with stage III NSCLC not treated surgically diagnosed from 2003 to 2014; the patients were identified by using the National Cancer Database. Two cohorts were evaluated: patients (n = 5023) treated with definitive radiation (≥59.4 Gy) and patients (n = 18,206) treated with definitive chemoradiation. Chemoradiation was further defined as concurrent (radiation and chemotherapy started within 30 days of each other) or sequential (radiation started >30 days after chemotherapy). We compared OS between the treatment groups by using the Kaplan-Meier method and Cox proportional hazards regression before and after propensity score matching (PSM).

Results: Treatment with chemoradiation was associated with improved OS versus that with radiation both before PSM (hazard ratio [HR] = 0.66, 95% confidence interval [CI]: 0.64-0.68, p < 0.001) and after PSM (HR = 0.67, 95% CI: 0.64-0.70, p < 0.001). Relative to concurrent chemoradiation, sequential chemoradiation was associated with a 9% reduction in the risk for death (HR = 0.91, 95% CI: 0.85-0.96, p = 0.002).

Conclusions: We found that definitive chemoradiation resulted in a survival advantage compared with definitive radiation in elderly patients. Sequential chemotherapy and radiation was superior to concurrent chemoradiation. Although prospective trials are needed, this analysis suggests that chemoradiation should be strongly considered for elderly patients and the optimal sequencing of chemotherapy and radiation remains an unanswered question for this patient population.

Keywords: Chemotherapy; Elderly; Non–small cell; Radiation therapy; Stage III.

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Conflict of interest statement

Authors’ Disclosures of Potential Conflicts of Interest: The authors have no conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Study flow diagram for analytic cohorts. NCDB, National Cancer Database; SBRT, stereotactic body radiation therapy.
Figure 2
Figure 2
Overall survival of patients treated with definitive chemoradiation (CRT) compared to those treated with definitive radiation therapy (RT) alone. Panel A represents the unmatched patient population while panel B represents propensity-score matched elderly patients. All curves represent actual survival as estimated by Kaplan-Meier.
Figure 3
Figure 3
Overall survival of patients treated with either single (sCRT) or multi-agent chemoradiation (mCRT) compared to those treated with radiation therapy alone (RT). Panel A is a comparison of sCRT vs. definitive RT alone and panel B represents mCRT vs. definitive RT alone. Panel C is a comparison of mCRT vs. sCRT. All analysis was performed using the propensity-score matched patients and all curves represent actual survival as estimated by Kaplan-Meier.
Figure 4
Figure 4
Overall survival of patients treated with definitive concurrent chemoradiation (Con CRT) and definitive sequential chemoradiation (Seq CRT). Panel A represents the unmatched patient population while panel B represents the propensity-score matched elderly patients. All curves represent actual survival as estimated by Kaplan-Meier.
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