Definitive Chemoradiotherapy vs. Surgery After Induction for Stage III Lung Cancer

Summary and Comment |
November 10, 2015

Definitive Chemoradiotherapy vs. Surgery After Induction for Stage III Lung Cancer

  1. Anne S. Tsao, MD

Outcomes were similar with both treatments.

  1. Anne S. Tsao, MD

Stage III non–small-cell lung cancer (NSCLC) is highly variable in its presentation and is usually treated with multimodality therapy tailored to each patient. To compare surgery versus definitive concurrent chemoradiotherapy boost after induction in this setting, investigators conducted a multicenter, phase III trial (ESPATUE) involving good-performance patients (status, 0–1) with medically operable, pathologically proven stage IIIA (N2) or IIIB (N3 contralateral mediastinal nodes or T4) disease. Because the trial was closed due to slow accrual after only 246 of the planned 500 patients were enrolled, it was underpowered for the primary endpoint of overall survival (OS).

Patients received three cycles of neoadjuvant cisplatin-paclitaxel chemotherapy followed by concurrent chemoradiation (45 Gy) using weekly cisplatin and vinorelbine. During the last week of concurrent chemoradiation, the 161 patients who were still resectable were randomized to a chemoradiotherapy boost (65 to 71 Gy) or surgery.

Five-year OS was similar with a chemoradiotherapy boost or surgery (40% and 44%, respectively), as was 5-year progression-free survival (PFS; 35% and 32%). Among patients who received a chemoradiotherapy boost, two died from pneumonia. Among patients who underwent surgery, three died from lung bleeding and two died from pneumonia and empyema.

Comment

The ESPATUE trial showed that definitive chemoradiation performs as well as trimodality therapy in this patient population. This finding is in line with the Intergroup 0139 study of patients with IIIA (N2) NSCLC (Lancet 2009; 374:379), which showed no OS benefit from surgery, although the Intergroup study did show a PFS benefit with lobectomy resection. Although underpowered, ESPATUE lends supportive evidence that bimodality aggressive therapy is sufficient in IIIA (N2) and IIIB (N3, T4) NSCLC patients.

Editor Disclosures at Time of Publication

  • Disclosures for Anne S. Tsao, MD at time of publication Consultant / Advisory board Genetech; Roche; Medimmune; Novartis; Astellas; Boehringer-Ingelheim; Eli Lilly Speaker’s bureau Genetech; Roche; Medimmune; Novartis; Astellas; Boehringer-Ingelheim; Eli Lilly Grant / Research support Department of Defense; SWOG Leadership positions in professional societies American Medical Association (Member); American Association of Cancer Research (Member); American Society of Clinical Oncology (Member); AACR-Women in Cancer Research (Member); International Mesothelioma Interest Group (Member); SWOG (Member); International Association for the Study of Lung Cancer (Communications Committee Chair); American Radium Society (Chair); RTOG (Member)

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