Palliative endobronchial brachytherapy for non-small cell lung cancer

Abstract

This is an updated version of the original review published in Issue 2, 2008 of The Cochrane Library. Non-small cell lung cancers (NSCLC) constitute about 80% of all lung cancer cases. Although surgery is the only curative treatment of NSCLC, fewer than 20% of tumors can be radically resected. Radiotherapy is one of the main treatment modalities in lung cancer, contributing to both its cure and palliation. Endobronchial brachytherapy (EBB) has been used as one approach to improve local control either alone or in combination with other treatments. To assess the effectiveness of palliative EBB compared with external beam radiation therapy (EBRT) or other alternative endoluminal treatments in controlling thoracic symptoms and increasing survival in patients with advanced NSCLC. We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 1 2012), MEDLINE (OvidSP) (1966 to January 2012), EMBASE (Ovid) (1974 to January 2012) and other databases as well as reference lists, and we handsearched selected journals and conference proceedings. Randomized controlled trials (RCTs) comparing different regimens of palliative EBB with EBRT or other endobronchial interventions in patients with advanced NSCLC. Two review authors independently extracted data and conducted risk of bias assessment. We included fourteen RCTs involving 953 participants. We included a new study assessing a variety of different fractionation schedules of high dose rate palliative EBB in this update. There were important differences in the doses of radiotherapy investigated, in the patient characteristics and in the outcomes measured. We found trials comparing EBB to EBRT alone, EBB plus EBRT to EBRT alone, EBB plus chemotherapy to EBB alone, EBB to neodymium: yttrium-aluminum-garnet (Nd-YAG) laser and comparisons between various fractionation schedules of high dose rate EBB. From the heterogeneous information obtained from several small RCTs, we concluded that EBRT alone is more effective for palliation of NSCLC symptoms than EBB alone. Our findings did not provide conclusive evidence to recommend EBB plus EBRT to relieve symptoms compared to EBRT alone. Overall, for the primary endpoint of survival there was no evidence of benefit for EBB compared to EBRT and Nd-YAG laser or for the combination of EBB with chemotherapy. Additionally, findings from one trial suggested that twice 7.4 Gy was superior to the four times per week 3.8 Gy schedule for mean time of local control and fatal hemoptysis. No significant differences were found for fatal hemoptysis as an adverse event of EBB. The evidence did not provide conclusive results that EBB plus EBRT improved symptom relief over EBRT alone. We were not able to provide conclusive evidence to recommend EBB with EBRT, EBB in preference to EBRT, chemotherapy or Nd-YAG laser. From heterogeneous information obtained from several small RCTs, we conclude that EBRT alone is more effective for palliation than EBB alone. For patients previously treated by EBRT who are symptomatic from recurrent endobronchial central obstruction, EBB may be considered in selected cases.