Longer Course of Radiation Provides Better Palliation in Advanced NSCLC
In patients with advanced non-small cell lung cancer and a poor outlook, a longer, less intense course of radiation treatment improved patients’ life expectancy by 10.7 weeks, according to Dutch researchers. Although the longer course of therapy was more costly than a shorter, more intense course, the higher cost was justified because it lengthened patients’ lives, the researchers conclude in a new cost analysis.
Journal of the National Cancer Institute, December 20, 2006 (see the journal abstract)
(J Natl Cancer Inst. 2006 Dec 20;98(24):1786-94)
Journal of Clinical Oncology, May 1, 2005 (see the journal abstract)
(J Clin Oncol. 2005 May 1;23(13):2962-70)
Non-small cell lung cancer (NSCLC) accounts for about 80 percent of lung cancer cases in the United States. For patients whose tumors have spread to tissues and organs beyond the lung and cannot be removed surgically, intensive chemotherapy and chemoradiation can modestly improve survival and quality of life. However, many patients are too ill to tolerate these treatments.
Radiation therapy can relieve some of these patients’ symptoms, which may include chest pain, coughing up blood, painful swallowing, and shortness of breath. The best way to deliver such palliative therapy, however, has been controversial: Is it better to give a large number of low doses of radiation over a longer period of time, or a small number of high doses over a short period of time? And what are the cost implications of each approach? In May 2005, Dutch researchers published results from a study designed to address the symptom-management question; in December 2006, they published a cost analysis of those results.
The 297 patients in the original phase III trial had inoperable NSCLC that had spread within the chest cavity or to other organs. All of them had either already tried all of the available chemotherapy options or were not candidates for chemotherapy because of their generally poor condition. They were enrolled in the study between 1999 and 2002.
The patients were randomly assigned to receive either 10 doses of 3 Gy of radiation, given four or five times a week (long-course therapy), or two doses of 8 Gy given one week apart (short-course therapy). They were followed for a year. Patients completed questionnaires rating the severity of their symptoms (fatigue, lack of appetite, shortness of breath, chest pain, coughing, coughing up blood, hoarseness, and painful swallowing) and their quality of life. Researchers combined the scores for individual symptoms into a total symptom score for each patient.
Researchers also compared the “lifetime societal costs” of long-course and short-course therapy, using information from cost questionnaires filled out by a subgroup of 56 patients. In addition to the cost of the radiation treatment itself, the lifetime societal cost included patients’ time and travel costs, the costs of hospitalization, the costs of “informal care” (that is, care provided to patients by family members, friends, and volunteers), and the “costs of survival” (that is, the costs for health care that patients needed during the time they survived with their disease).
The principal investigator for the original study was Gijsbert W.P.M. Kramer, M.D., of Arnhems Radiotherapeutic Institute in Arnhem, the Netherlands. The principal investigator for the cost analysis was Wilbert B. van den Hout, Ph.D., of Leiden University Medical Center in Leiden, the Netherlands.
Average total symptom scores for both groups of patients were almost identical, indicating that long- and short-course radiation treatment were equally effective at relieving patients’ symptoms. Symptomatic relief occurred more quickly in patients who received short-course treatment, but lasted longer among patients who received long-course treatment.
Survival was also significantly better in the group that received long-course treatment: 19.6 percent of patients in that group were alive after one year, compared with 10.9 percent of those who received short-course treatment. The researchers estimated that a long-course patient could expect to live 38.1 weeks and a short-course patient 27.4 weeks.
In the cost analysis, the researchers estimated the lifetime societal cost of long-course radiation treatment to be $5,326 more per patient than that of short-course treatment. Using a concept called the Quality Adjusted Life Year, a measure of the benefit gained from medical treatment in terms of both quantity and quality of life, they estimated “quality-adjusted life expectancy” to be 20 weeks for patients in the long-course group and 13.7 weeks for those in the short-course group.
Thus, although the dollar cost of long-course treatment was higher, the additional cost was acceptable and justified by the patients’ improved survival, the researchers concluded.
The study’s finding of a significant survival advantage for long-course radiation therapy is “quite a remarkable feat in these poor-prognosis patients,” says Anurag Singh, M.D., a radiation oncology specialist with the National Cancer Institute’s Center for Cancer Research.
Most radiation oncologists in the United States already use long-course therapy, Singh notes, adding that this study’s results confirm the superiority of this approach.
“The short course does provide faster palliation,” he says. “Physicians have a decision to make about whether to favor speed or duration of palliation, but it seems from these data that they should err on the side of longer-course therapy, given the overall survival advantage.”
The findings of the cost analysis should be treated with caution, says Singh, because they were based on information provided by only 56 patients. In addition, because of differences between the health care systems in the Netherlands and the United States, the study’s cost estimates do not accurately reflect the cost of radiation treatment in this country.
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