Saffarzadeh Areo G, Canavan Maureen, Resio Benjamin J, Walters Samantha L, Flores Kaitlin M, Decker Roy H, Boffa Daniel J
Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, Connecticut.
JTO Clin Res Rep. 2021 Jun 24;2(8):100201. doi: 10.1016/j.jtocrr.2021.100201. eCollection 2021 Aug.
There are currently two recommended radiation strategies for clinical stage III NSCLC: a lower "preoperative" (45-54 Gy) and a higher "definitive/nonsurgical" (60-70 Gy) dose. We sought to determine if definitive radiation doses should be used in the preoperative setting given that many clinical stage III patients planned for surgery are ultimately managed with chemoradiation alone.
Using the National Cancer Database data from 2006 to 2016, we performed a comparative effectiveness analysis of stage III N2 patients who received chemoradiotherapy. Patients were stratified into subgroups across 2 parameters: (1) radiation dose: lower (45-54 Gy) and higher (60-70 Gy); and (2) the use of surgery (i.e., surgical and nonsurgical treatment approaches). Long-term survival and perioperative outcomes were evaluated using multivariable Cox proportional hazards and logistic regression models.
A cohort of 961 patients received radiation before surgery including 321 who received a higher dose and 640 who received a lower dose. A higher preoperative dose revealed similar long-term mortality risk (hazard ratio = 0.99, 95% confidence interval: 0.82-1.21, = 0.951) compared with a lower dose. There was no significant association between radiation dose and 90-day mortality ( = 0.982), 30-day readmission ( = 0.931), or prolonged length of stay ( = 0.052) in the surgical cohort. A total of 17,904 clinical-stage IIIA-N2 patients were treated nonsurgically, including 15,945 receiving higher and 1959 treated with a lower dose. A higher dose was associated with a reduction in long-term mortality risk (hazard ratio = 0.64, 95% confidence interval: 0.60-0.67, < 0.001) compared with a lower dose.
For clinical stage III NSCLC, the administration of 60 to 70 Gy of radiation seems to be more effective than the lower dose for nonsurgical patients without compromising surgical safety for those that undergo resection. This evidence supports the implementation of 60 to 70 Gy as a single-dose strategy for both preoperative and definitive chemoradiotherapy.
目前，临床Ⅲ期非小细胞肺癌（NSCLC）有两种推荐的放疗策略：较低的“术前”（45 - 54 Gy）剂量和较高的“根治性/非手术”（60 - 70 Gy）剂量。鉴于许多计划接受手术的临床Ⅲ期患者最终仅接受放化疗，我们试图确定在术前情况下是否应使用根治性放疗剂量。
利用2006年至2016年国家癌症数据库的数据，我们对接受放化疗的Ⅲ期N2患者进行了比较疗效分析。患者根据两个参数分层为亚组：（1）放疗剂量：较低（45 - 54 Gy）和较高（60 - 70 Gy）；（2）手术的使用情况（即手术和非手术治疗方法）。使用多变量Cox比例风险模型和逻辑回归模型评估长期生存和围手术期结局。
一组961例患者在手术前接受了放疗，其中321例接受了较高剂量，640例接受了较低剂量。与较低剂量相比，较高的术前剂量显示出相似的长期死亡风险（风险比 = 0.99，95%置信区间：0.82 - 1.21，P = 0.951）。在手术队列中，放疗剂量与90天死亡率（P = 0.982）、30天再入院率（P = 0.931）或住院时间延长（P = 0.052）之间无显著关联。共有17904例临床ⅢA - N2期患者接受了非手术治疗，其中15945例接受了较高剂量，1959例接受了较低剂量。与较低剂量相比，较高剂量与长期死亡风险降低相关（风险比 = 0.64，95%置信区间：0.60 - 0.67，P < 0.001）。
对于临床Ⅲ期NSCLC，60至70 Gy的放疗剂量对非手术患者似乎比低剂量更有效，且不影响接受手术切除患者的手术安全性。这一证据支持将60至70 Gy作为术前和根治性放化疗的单剂量策略。
