Use of Prophylactic Cranial Irradiation for Extensive-Stage Small-Cell Lung Cancer May Be Dropping

By Will Boggs MD

August 24, 2019

NEW YORK (Reuters Health) - Prophylactic cranial irradiation (PCI) for patients with extensive-stage small-cell lung cancer (ES-SCLC) appears to have become less common in the U.S., according to a new survey.

Based on a recent phase 3 trial by Takahashi et al. (https://bit.ly/2r1jjNl) that showed no overall survival benefit with PCI versus active MRI surveillance, the National Comprehensive Cancer Network established equipoise between the two strategies in patients with ES-SCLC.

Dr. Steven H. Lin from the University of Texas MD Anderson Cancer Center, in Houston, and colleagues surveyed 3,851 U.S.-based radiation oncologists to assess changes in the use of PCI for such patients following publication of the trial in 2017, but only 487 (12.6%) completed the survey.

Among the 454 respondents who were aware of the study by Takahashi and colleagues, 72% reported that they routinely offered PCI to ES-SCLC patients prior to publication of the trial, but only 44% continued to do so.

Current PCI utilization rates did not differ between academic (43%) and private practice (45%) radiation oncologists, the researchers report in JAMA Network Open, online April 14. And there was no difference in the likelihood of offering PCI based on practice setting, location, or size; volume of patients treated for lung cancer; or years in practice.

In contrast, 85% of respondents who were not aware of the Takahashi et al. study continued to offer PCI to patients with ES-SCLC.

Just under half (47%) of all respondents reported a willingness to enroll both patients with limited-stage SCLC and ES-SCLC in a randomized trial comparing PCI with MRI surveillance, 15% would enroll only patients with limited-stage SCLC, and 20% would enroll only patients with ES-SCLC.

"These results highlight the continued lack of consensus for PCI in SCLC and support ongoing investigations such as the proposed SWOG-1827 trial attempting to investigate PCI versus MRI surveillance in all patients with SCLC," the authors conclude.

Dr. Steven E. Schild from Mayo Clinic's department of radiation oncology, in Scottsdale, Arizona, who recently reviewed the role of PCI for patients with ES-SCLC, told Reuters Health by email, "PCI is less popular now. This will merely translate to instead of PCI, the majority of ES-SCLC patients will receive brain radiotherapy (RT) when they have a brain relapse. The majority of patients fail at some point in the brain and will receive RT to the brain."

"There will be another PCI trial performed by one of the cooperative groups," said Dr. Schild, who was not involved in the survey. "The results will likely also be negative as it will be underpowered to detect a 5% survival advantage (that detected in the 2 meta-analyses)."

In his review from 2017 (https://bit.ly/2L4ttXj), Dr. Schild concludes, "Future research is the key to improving therapy and outcomes for patients with ES-SCLC. Unfortunately, the controversies regarding PCI will likely remain."

Dr. Lin did not respond to a request for comments.

SOURCE: https://bit.ly/2L0UB9r

JAMA Netw Open 2019.

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