Abstract
Purpose:To examine national care patterns in proton radiation therapy (PBT) use for non–small cell lung cancer (NSCLC) and the effect of facility type on survival.Patients and Methods:Using the National Cancer Database, we identified 506 patients with a diagnosis of NSCLC from 2004-2014 who underwent PBT. Patients were categorized as having received treatment at an academic/research facility (ARF) or a form of community cancer program (CCP). Descriptive analysis was performed, and overall survival was analyzed by Kaplan-Meier methods and Cox proportional hazard models.Results:Treatments at ARFs and CCPs were equally distributed with 253 patients at each facility type. A positive trend in PBT use over time was observed with 2.8% of cases being treated in 2008 compared to 21.5% in 2014 (P = .001). Definitive doses (≥60 Gy) were more commonly given at ARFs than CCPs (72% versus 45%, respectively; P < .001). Five-year overall survival was 31% at ARFs and 18% at CCPs (P < .001). On multivariate analysis, outcomes were worse with treatments at CCPs (hazard ratio [HR] 1.61; 95% Confidence Interval, 1.14-2.27; P = .007). On subanalysis of nonsurgical patients treated with ≥60 Gy, facility type became insignificant and dose escalation was associated with improved outcomes (≥70 Gy HR 0.45; 95% CI, 0.25-0.81; P = .008).Conclusion:Use of PBT for management of NSCLC is on the rise. Community cancer programs were associated with higher rates of nondefinitive PBT doses and correspondingly worse outcomes. Differences in survival by facility became insignificant when definitive doses were used, warranting further investigation of practice patterns in CCPs at a national level.
Highlights
Lung cancer remains an aggressive oncologic disease affecting over 220,000 people annually and causing over 25% of all cancer-related deaths in 2017 [1]
The utilization of ablative radiation doses through stereotactic body radiation therapy (SBRT) is considered an acceptable treatment strategy for medically inoperable, stage I non–small cell lung cancer (NSCLC) after randomized clinical trials and retrospective studies demonstrated that SBRT yielded high local control rates and comparable survival outcomes relative to surgery [4, 5]
Caseload by type of treating facility was evenly distributed with 253 patients treated at an academic/research facility (ARF) and 253 patients at a cancer program (CCP)
Summary
Lung cancer remains an aggressive oncologic disease affecting over 220,000 people annually and causing over 25% of all cancer-related deaths in 2017 [1]. Surgical management or definitive radiation therapy (RT) is considered standard of care for earlystage non–small cell lung cancer (NSCLC), while multimodality therapy is preferred for locally advanced disease [2, 3]. Compared to photons, which continually deposit dose throughout tissue and exhibit an exit dose, the dose distribution of protons forms a Bragg peak, denoting maximal dose deposition at a finite tissue depth followed by a sharp dose falloff with virtually no exit dose. This dosimetric difference, in turn, can theoretically translate into a reduction of treatment-related morbidity and a beneficial impact on overall survival (OS)
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