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Long-Term Recurrences after SBRT: We Haven’t Replaced Lung Cancer Surgery Yet

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One of the lung cancer surgeons I work closely with sent me and a couple of the radiation oncologists at my center a report that just came out from a group in Kyoto highlighting that they have a seen a notable proportion of their patients develop late recurrences, even well beyond five years, among their patients who underwent stereotactic body radiation therapy (SBRT) for node-negative early stage NSCLC many years earlier (see Dr. Loiselle’s great summary of SBRT for a review of the topic).  Many Japanese centers have been pioneers in SBRT, doing it for more than a decade, but over the past 3-5 years the strategy has become far more widely practiced, based on very encouraging local control and outcomes going out several years, which lead to the question of whether SBRT might be an effective and  alternative to surgery (hence the keen interest among thoracic surgeons about whether newer radiation techniques will lead to reduced demand for their services).  The authors of this report, who are radiation oncologists, highlight that it’s possible we’ll see late recurrences beyond the time when we’d be inclined to declare a victory for SBRT.  In general, if we see patients doing well 3-5 years after diagnosis and the start of treatment, we begin to think we’re getting out of the woods.

The longer-term outcomes for a total of 66 patients who had undergone SBRT for node negative NSCLC between 1999 and 2005 were reviewed, though the median follow-up was only three years.  Given the fact that these treatments were done 6-12 years ago, this median reflects that many people were lost to follow-up or died in the first few years.  As is typical for retrospective reviews of patients who underwent radiation for potentially resectable NSCLC, many of the patients who died (14 of 39) had other significant medical problems had no evidence of active cancer at the time of their death.  Sixteen patients remained alive and without evidence of disease beyond five years from the time of SBRT, and the authors noted that four of them (25%) had recurrences beyond that point — in fact, three of the four had recurrences more than eight years after treatment.  In three of the four cases, the recurrences were local (one patient had both local and distant recurrence in another part of the body).   Past history with surgery for early stage NSCLC has generally shown that the risk of recurrence beyond 5 years is in the range of 5-7%.

This isn’t a large series of patients, and it’s the experience from just a single (well experienced) center.  They also note that the dose used (48 Gray (Gy) over 4 treatments is less than the 60 Gy over three fractions that is often used in some places now, so results could be different with these different techniques.  Of course, no local treatment — neither excellent surgery nor the best radiation therapy — will cure disease that is destined to recur distantly from micrometastatic disease outside of the local area visible on scans.  But the promise of SBRT, of providing comparable long-term local disease control and perhaps working as effectively as the historical gold standard of surgery, still awaits a test of time to really clarify whether it looks very favorable beyond the first few years.


0 Responses to Long-Term Recurrences after SBRT: We Haven’t Replaced Lung Cancer Surgery Yet

  • CancerHater says:

    Dr. West,

    First and foremost, I can’t thank you enough for this website. I know it probably consumes a lot of your time but it is a priceless resource for families with this disease.

    My mother was dignosed July 2010 (60, good health). She had surgery to remove the middle lobe (baseball size tumor) and parts of the lower lobe (8 small nodules). The biopsy showed it was BAC (KRAS and EGFR). The next visit, 3 months later showed 4 small tumors in her right lung. Fast forward to Nov 2011 she has multiple small (10, 1cm). We had another scan last week and it grew by a milimeter. It seems to be growing but at a slow rate. Right?

    Now for the question(s)…….She has decided to do the phase III trial ECOG 5508. What do you know about this trial for BAC (KRAS and EGFR)? This will be her first line of defense other than surgery. I am concerned that using an arrow out of the quiver this soon could be a mistake. I read a lot about the SBRT. Is that an option for her? If so at what point do you go down that path?

    Thank you for your time.

  • Dr West
    Dr West says:

    I’m sorry for the delay in responding to you. Your comment, as a new member, was stuck in blog limbo, and I accidentally overlooked it.

    To answer your question, I don’t think SBRT makes any real sense at all for a recurrent/metastatic cancer in which there are multiple lesions. This issue is described here:

    http://cancergrace.org/cancer-101/2011/01/01/cancer-101-faq-i-have-metastatic-cancer-but-why-cant-it-just-all-be-surgically-removed-or-radiated/

    This isn’t to say that it’s critical to start systemic therapy. That decision really depends on whether there’s clinically significant progression, but that point is really a judgment call that requires seeing the actual changes in the scans over time, and it also incorporates the preferences/concerns of the patients.

    While the timing of systemic therapy is somewhat controversial, I don’t think SBRT in this situation is. I would have to say that it just isn’t the right treatment for this setting.

    Please let me know if you have follow-up questions.

    -Dr. West

  • cards7up says:

    Dr. West, did this trial include chemo after SBRT? I chose not to have surgery, had 4 SBRT on the two lesions-one each in upper and lower lobes. Then did chemo carbo/alimta 4x and now NED. I don’t worry about it recurring, if it does I’ll deal with it then. Take care, Judy

  • CancerHater says:

    Thank you for your response. I will say that starting the systemic therapy is more for a concern from her. She wants to do something rather than sit and wait. They did another scan including her brain before she started the trial. It has not spread that we can see. Is there a chance that the ECOG 5508 trial chemo kills the cancer and it does not come back for years or at all? What is a realistic expectation if it does work?

    Thank you again for your time.
    Charlie

  • Dr West
    Dr West says:

    Judy,

    I don’t believe that it was mentioned, but I believe that chemo wasn’t administered, and certainly not in most patients. It’s fair to conclude that good chemo could reduce the risk of recurrence along the lines of adjuvant chemotherapy after surgery — a very analogous situation.

    Charlie,

    It’s possible that systemic therapy will lead to a coomplete resolution of all visible cancer, but that’s quite unlikely — in the range of a 1-2% chance. Many more people (about 25-35%) have significant tumor shrinkage that continues without progression for 6, 9, or perhaps even 12+ months, and another 30-40% will have more or less stable disease and then perhaps a few more months of nonprogression before the cancer begins to show evidence of progression.

    -Dr. West

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