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Postoperative radiation improves lung cancer survival for some
by: Will Boggs, MD

Postoperative radiation therapy extends non-small-cell lung cancer survival in patients with N2 nodal disease, but shortens survival in those with stage N0 or N1 disease, according to a report in the June issue of the Journal of Clinical Oncology.

"The main thrust of the paper was to examine the impact of postoperative radiation therapy in a time era that we felt was dominated by the use of clinical linear accelerator, the current standard of care," Dr. Brian E. Lally from Wake Forest University School of Medicine, Winston-Salem, North Carolina told Reuters Health.

In light of an earlier meta-analysis that suggested a detrimental effect of postoperative radiation therapy on survival, Dr. Lally and colleagues investigated the relationship between postoperative radiation therapy using current technology and survival in 7465 lung cancer patients randomized to postoperative radiation therapy or to observation (controls).

When all patients were included in the analysis, postoperative radiation therapy was associated with significantly worse survival, the authors report. In a multivariate analysis, older age, T3-4 disease, N2 nodal disease, male sex, fewer sampled lymph nodes and a greater number of involved lymph nodes had a negative impact on survival, but postoperative radiation therapy had no significant impact on survival.

When patients were analyzed by nodal stage, however, survival differences emerged. In patients treated with postoperative radiation therapy, slight decreases in survival were seen for patients with N0 and N1 nodal disease, the researchers note, whereas patients with N2 nodal disease realized a significant increase in survival.

"In the N2 population, the (survival) curves diverge late," Dr. Lally explained. "This would be consistent with sterilization of residual microscopic disease. In the N0/N1 populations, the curves diverged early. This would be consistent with postoperative radiation therapy being a surrogate for a positive margin, a potential marker for a more aggressive tumor but also one of the prognostic factors we were unable to account for."

"These results should be taken in the context that the adjuvant therapy for lung cancer has changed," Dr. Lally said. "Chemotherapy is now considered standard. As a profession, we need to watch and see if the use of chemotherapy is going to impact the patterns of failure for N0/N1 patients." If it does, "radiotherapy will likely be needed."

"We are getting better at imaging and thus targeting tumors," Dr. Lally added. "We are getting better at delivery the dose of radiation. As a result I think patients who have their lung cancer resected should have discussions with a radiation oncologist to determine if they would benefit from the use of radiation. These decisions should be made on a case by case basis."

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