|
|
Postoperative radiotherapy in non-small-cell lung cancer: update of an individual patient data meta-analysis
2005年更新
We report an updated systematic review and individual patient data meta-analysis of the effectiveness of postoperative radiotherapy (PORT) in non-small-cell lung cancer. Results continue to show PORT to be detrimental, with an 18% relative increase in the risk of death. Similar detriments were observed for local recurrence-free survival, distant recurrence-free survival and overall recurrence-free survival. There continues to be evidence that the effects of PORT are more harmful in those patients with stage I disease than those with stage II disease.
Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomized controlled trials. PORT Meta-analysis Trialists Group. Lancet. 1998;352:257–63.
BACKGROUND: The role of postoperative radiotherapy in treatment of patients with completely resected non-small-cell lung cancer (NSCLC) remains unclear. We undertook a systematic review and meta-analysis of the available evidence from randomised trials. METHODS: Updated data were obtained on individual patients from all available randomised trials of postoperative radiotherapy versus surgery alone. Data on 2128 patients from nine randomised trials (published and unpublished) were analysed by intention to treat. There were 707 deaths among 1056 patients assigned postoperative radiotherapy and 661 among 1072 assigned surgery alone. Median follow-up was 3.9 years (2.3-9.8 for individual trials) for surviving patients. FINDINGS: The results show a significant adverse effect of postoperative radiotherapy on survival (hazard ratio 1.21 [95% CI 1.08-1.34]). This 21% relative increase in the risk of death is equivalent to an absolute detriment of 7% (3-11) at 2 years, reducing overall survival from 55% to 48%. Subgroup analyses suggest that this adverse effect was greatest for patients with stage I/II, N0-N1 disease, whereas for those with stage III, N2 disease there was no clear evidence of an adverse effect. INTERPRETATION: Postoperative radiotherapy is detrimental to patients with early-stage completely resected NSCLC and should not be used routinely for such patients. The role of postoperative radiotherapy in the treatment of N2 tumours is not clear and may warrant further research.
Does the routine use of postoperative radia- tion therapy improve outcomes in patients with surgically resected non-small cell lung cancer? Several trials had evaluated this question with no clear resolution, and the PORT Meta-analysis Trialists Group believed that these individual trials lacked sufficient power to provide a clear answer. Therefore, the group performed a meta- analysis of nine randomized trials including 2128 total patients that evaluated immediate postoper- ative radiation therapy versus no immediate fur- ther treatment. The doses and methods of treatment planning varied greatly in these trials with doses ranging from 30 to 60 Gy in 10–30 fractions. The trials included patients with com- pletely resected non-small cell lung cancer that was no greater than stage IIIA.
Key Point The results of the meta-analysis dem- onstrated worse survival with the addition of postoperative radiation therapy (HR = 1.21, 95% CI 1.08–1.34, P = 0.001). There was a 21% rela- tive increase in risk of death with the addition of radiation therapy compared with no radiation therapy. The absolute 2-year overall survival rate was 7% lower in the postoperative radiation ther- apy patients, 48% versus 55%, respectively
(Figs. 3.6 and 3.7).
Overall recurrence-free survival was also worse in patients who received radiation therapy, with 2-year recurrence-free survival of 50% and 46% for patients who did not and who did receive radiation therapy, respectively.
Key Point On subgroup analysis, there was more detriment to postoperative radiation therapy in the earlier-stage patients, with more detriment in stage I versus stage II patients and no detri- ment with stage III patients. There was also a trend that postoperative radiation was more detri- mental for lower nodal involvement status patients (Fig. 3.8).
Fig. 3.6 Hazard ratio plot for survival from PORT meta-analysis.
Fig. 3.7 Kaplan-Meier curve for overall survival from PORT meta-analysis.
The investigators discussed the detriment observed in their analysis for local recurrence- free survival. The results were largely driven by deaths forming the majority of events, suggesting there may be antitumor activity with radiation and that increased deaths may be coming from other causes. It is important to note that those patients with the earliest stages of disease and least nodal burden had the most to lose when receiving radiation therapy, and this meta-analysis disease, and further research may be justifiable in these patients.”
The investigators discussed the detriment observed in their analysis for local recurrence-free survival. The results were largely driven by deaths forming the majority of events, suggesting there may be antitumor activity with radiation and that increased deaths may be coming from other causes. It is important to note that those patients with the earliest stages of disease and least nodal burden had the most to lose when receiving radiation therapy, and this meta- analysis data strongly argues for very carefully selecting patients who may benefit from adjuvant radiation therapy after complete surgical resection. Inappropriately chosen patients, especially those with earlier stages of disease, would have an overall survival detriment with postoperative radiation therapy according to this analysis.
The authors stated, “this meta-analysis has demonstrated a clear adverse effect of postoperative radiotherapy on survival for patients with completely resected stage I and II tumors, such that further research with similar radiotherapy techniques on similar patients would not be warranted. The results are less clear for stage III (N2) disease, and further research may be justifiable in these patients.”
参考文献：
Burdett S, Stewart L; PORT Meta-analysis Group. Postoperative radiotherapy in non-small-cell lung cancer: update of an individual patient data meta-analysis. Lung Cancer. 2005 Jan;47(1):81-3. doi: 10.1016/j.lungcan.2004.09.010. PMID: 15603857.
Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. PORT Meta-analysis Trialists Group. Lancet. 1998 Jul 25;352(9124):257-63. PMID: 9690404.
|
|
