The Effect of Radiotherapy Practice Pattern on Survival of Patients with Locally Advanced Non-small Cell Lung Cancer

Sir d The treatment of inoperable stage III non-small cell lung cancer (NSCLC) is challenging as the group is heterogeneous. Many patients cannot receive curative radiotherapy doses of at least 60 Gy with concurrent or sequential chemotherapy and may receive a variety of treatments due to differing patterns of practice among physicians, cancer centres and countries. The International Cancer Benchmarking Partnership reported different survival rates among lung cancer patients in different countries, as well as different regions within the same country [1]. Canada and the province of Manitoba had relatively good results, but there is always scope for improvement. At our institution, patients with stage III NSCLC suitable for curative treatment receive radiotherapy to a total dose of 66 Gy with concomitant chemotherapy. Patients unfit for curative chemoradiotherapy but still with favourable performance status typically receive 40 Gy in 16 fractions, often without chemotherapy. A retrospective analysis of 221 patients with unresectable stage III NSCLC treated between 2005 and 2007 inclusive showed thatonly 48 (22%) received curative concurrent chemoradiotherapy [2]. Sixty-two (28%) received high dose radiotherapy (� 60 Gy), with or without chemotherapy, 74 (34%) received an intermediate dose (40e50 Gy) and 85 (38%) received low dose radiotherapy (� 30 Gy) Two year overall survival was 48, 27 and 12% for thehigh,intermediate andlow dose groups,respectively[2]. Patients treated with the intermediate dose did surprisingly well, comparable with patients receiving curative doses of radiotherapy [3,4]. Survival was better in patients with a good performance status treated to higher doses of radiotherapy. Overall survival might be further improved if the patients treated to an intermediate dose received higher doses. Appropriate patient selection is essential to ensure that patients are neither under- nor over-treated. Clinicians must offer the most appropriate treatment strategy that balances potential benefit and quality of life with treatment-related toxicities.