Table 1.
Summary of the UK national guidelines for optimal management of stage III NSCLC patients.
| Topic | RCR guidance statement25 | Evidence level25 | NICE guidance statement6 | Supporting references | Consensus with ESMO guidelines2 |
|---|---|---|---|---|---|
| cCRT versus sCRT or radiotherapy alone | cCRT has been demonstrated in meta-analyses to give superior outcomes when compared with sCRT or radiotherapy alone | 1aa/Ab | There were limited data available on whether continuous radiotherapy with concurrent chemotherapy was more effective than alternating radiotherapy and chemotherapy | 4,7,10,15,24,25 | cCRT generally gives significantly better OS results than sCRT and radiotherapy protocols in unresectable IIIA and IIIB disease |
| CRT versus surgery | No recommendations provided for stage III | - | Consider CRT for patients with stage II or III NSCLC who are not suitable or decline surgery. Balance potential benefit in survival with the risk of additional toxicities. For people with operable stage IIIA–N2 NSCLC who can have surgery and are well enough for multimodality therapy, consider chemoradiotherapy with surgery | 4,5 | cCRT is the treatment of choice in patients evaluated as unresectable in stage IIIA and IIIB |
| Elderly patients | Elderly patients with good performance status (0–1) and few comorbidities derive equal benefit from concurrent therapies as their younger counterparts | 1ba | No recommendations provided | 25,80–83 | Age itself has not been shown to influence outcome following definitive cCRT. However, data are limited for the elderly population and, in particular, in patients above 75 years of age |
| Neoadjuvant or adjuvant chemotherapy | There is no evidence of benefit for chemotherapy delivered either neoadjuvantly or adjuvantly to those receiving cCRT | 1ba | No recommendations provided for stage III | 25 | In the stage III disease CRT strategy, there is no evidence for further induction or consolidation chemotherapy |
| Dose fractionation of concurrent radiotherapy | 55 Gy in 20 fractions over 4 weeks with cisplatin and vinorelbine, 60 Gy in 30 fractions over 6 weeks with cisplatin and etoposide and 66 Gy in 33 fractions over 6.5 weeks with cisplatin and etoposide | Ab | If conventionally fractionated radical radiotherapy is used, offer either 55 Gy in 20 fractions over 4 weeks or 60–66 Gy in 30–33 fractions over 6–6½ weeks. Accelerated radiotherapy fractionation schedules seem to improve outcomes in NSCLC | 24–26,28 | Promising outcome is achieved with accelerated radiotherapy. A potential radiation schedule could be the delivery of 66 Gy in 24 fractions |
| cCRT toxicity | Concurrent schedules have a higher incidence of grade ≥3 oesophageal toxicities | 1ba | No recommendations provided | 7,10,15–17,25 | No recommendations provided |
(c)(s)CRT (concurrent)(sequential) chemoradiotherapy, Gy grey, NSCLC non-small-cell lung cancer, OS overall survival.
aThe Oxford Centre for evidence-based medicine levels of evidence.84
bGuidelines on the radical management of patients with lung cancer.4
This table was created by the author, using guidance from refs. 4,5,7,10,15,17,24–26,28,80–84.
(c)(s)CRT, (concurrent)(sequential) chemoradiotherapy; Gy, grey; NSCLC, non-small-cell lung cancer; OS, overall survival.