Abstract
For this guideline, we investigated the effectiveness of radiotherapy with curative intent in medically inoperable patients with early-stage non-small-cell lung cancer (nsclc). The guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of mainly retrospective studies, expert consensus, and formal internal and external reviews. ■ Stereotactic body radiation therapy (sbrt) with curative intent is an option that should be considered for patients with early-stage, node-negative, medically inoperable nsclc. Qualifying Statements■ Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety. Consistent patient positioning and 4-dimensional analysis of tumour and critical structure motion during simulation and treatment delivery are essential.■ Preliminary results for proton-beam therapy have been promising, but the technique requires further clinical study.■ Recommended fractionation schemes for sbrt should result in a biologically effective dose of 100 or greater by the linear quadric model, choosing an α/β value of 10 [bed10(LQ) ≥ 100]. Qualifying Statements■ Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation.■ Examples of dose-fractionation schemes used in the included studies have been provided.■ Based on the current evidence and the opinion of the authors, radiation doses at bed10(LQ) greater than 146 might significantly increase toxicity and should be avoided.■ Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypofractionated schemes used in sbrt.
Highlights
Non-small-cell lung cancer is the most common type of lung cancer[1]
Qualifying Statements ■■ Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety
Qualifying Statements ■■ Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation. ■■ Examples of dose–fractionation schemes used in the included studies have been provided. ■■ Based on the current evidence and the opinion of the authors, radiation doses at bed10(LQ) greater than 146 might significantly increase toxicity and should be avoided. ■■ Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypo fractionated schemes used in sbrt
Summary
Non-small-cell lung cancer (nsclc) is the most common type of lung cancer[1]. The standard treatment for patients with early-stage nsclc is surgery; some patients are unable to undergo surgery because of medical comorbidities such as abnormal underlying cardiovascular or pulmonary function[2]. Patients with early-stage nsclc who are medically inoperable were previously offered conventional radiotherapy [rt (60–66 Gy in 1.8–2.0 Gy fractions)] or were observed without specific cancer treatment. The outcomes for such patients were not ideal, with 2-year survival being less than 40% with either conventional radiation or observation, and local control being only 40%–50% with conventional rt[3,4]. Stereotactic rt uses specialized equipment to position patients so that high-dose fractions can be delivered precisely to a small target or volume of disease. The technique requires complex treatment planning to ensure the accuracy and precision of treatment delivery that is characterized by a steep dose gradient beyond the target volume. Stereotactic body rt (sbrt) and stereotactic ablative rt are considered synonymous for the purposes of this guideline and will be referred to as sbrt from this point forward
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