Surgery after chemoradiotherapy in patients with stage III (N2 or N3, excluding T4) non-small-cell lung cancer: a systematic review.

Background: Chemoradiation with curative intent is considered the standard of care in patients with locally advanced, stage iii non-small-cell lung cancer (nsclc). However, some patients with stage iii (N2 or N3, excluding T4) nsclc might be eligible for surgery. The objective of the present systematic review was to investigate the efficacy of surgery after chemoradiotherapy compared with chemoradiotherapy alone in patients with potentially resectable locally advanced nsclc. Methods: A search of the medline, embase, and PubMed databases sought randomized controlled trials (rcts) comparing surgery after chemoradiotherapy with chemoradiotherapy alone in patients with stage iii (N2 or N3, excluding T4) nsclc. Results: Three included rcts consistently found no statistically significant difference in overall survival between patients with locally advanced nsclc who received surgery and chemoradiotherapy or chemoradiotherapy alone. Only one rct found that progression-free survival was significantly longer in patients treated with chemoradiation and surgery (hazard ratio: 0.77; 95% confidence interval: 0.62 to 0.96). In a post hoc analysis of the same trial, the overall survival rate was higher in the surgical group than in matched patients in a chemoradiation-only group if a lobectomy was performed (p = 0.002), but not if a pneumonectomy was performed. Furthermore, fewer treatment-related deaths occurred in patients who underwent lobectomy than in those who underwent pneumonectomy. Conclusions: For patients with locally advanced nsclc, the benefits of surgery after chemoradiation are uncertain. Surgery after chemoradiation for patients who do not require a pneumonectomy might be an option.

Guideline for radiotherapy with curative intent in patients with early-stage medically inoperable non-small-cell lung cancer.

OBJECTIVES: For this guideline, we investigated the effectiveness of radiotherapy with curative intent in medically inoperable patients with early-stage non-small-cell lung cancer (nsclc). METHODS: The guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of mainly retrospective studies, expert consensus, and formal internal and external reviews. RECOMMENDATIONS: ■ Stereotactic body radiation therapy (sbrt) with curative intent is an option that should be considered for patients with early-stage, node-negative, medically inoperable nsclc. Qualifying Statements■ Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety. Consistent patient positioning and 4-dimensional analysis of tumour and critical structure motion during simulation and treatment delivery are essential.■ Preliminary results for proton-beam therapy have been promising, but the technique requires further clinical study.■ Recommended fractionation schemes for sbrt should result in a biologically effective dose of 100 or greater by the linear quadric model, choosing an α/ß value of 10 [bed10(LQ) ≥ 100]. Qualifying Statements■ Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation.■ Examples of dose-fractionation schemes used in the included studies have been provided.■ Based on the current evidence and the opinion of the authors, radiation doses at bed10(LQ) greater than 146 might significantly increase toxicity and should be avoided.■ Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypofractionated schemes used in sbrt.

Optimisation of preoperative assessment in patients diagnosed with rectal cancer.

AIMS: Treatment decision making for patients with rectal cancer is complex and optimal preoperative assessment is important to ensure patients receive appropriate and high-quality care. Therefore, our objective was to develop an evidence-based, multidisciplinary guideline to assist physicians treating rectal cancer to ensure that preoperative assessment is optimal. MATERIALS AND METHODS: A multidisciplinary expert panel of physicians who treat rectal cancer was selected as members of the Cancer Care Ontario Preoperative Assessment for Rectal Cancer Guideline Development Group (GDG). This group initially met to identify important clinical questions with respect to optimisation of preoperative assessment in patients diagnosed with rectal cancer. A systematic review, specific to each of these clinical questions, was then conducted using MEDLINE, EMBASE and the Cochrane Library databases. The GDG met at regular intervals to review the evidence and to develop guidelines to address each of the clinical questions. RESULTS: The GDG identified seven important clinical questions with respect to the optimisation of preoperative assessment in patients diagnosed with rectal cancer. The clinical questions pertained to: (i) investigations required to assess distant metastasis (one question); (ii) imaging for local staging of rectal cancer (five questions); (iii) multidisciplinary cancer conference (MCC) (one question); (iv) restaging-magnetic resonance imaging (one question). The systematic reviews related to these clinical questions yielded 31 articles that were abstracted and reviewed by the GDG. Based on the systematic reviews, a guideline was developed containing seven recommendations that were either adapted from existing guidelines, based on review of the evidence or by consensus when evidence was limited. CONCLUSIONS: A set of seven recommendations have been developed in order to optimise pretreatment assessment in patients with rectal cancer by promoting evidence-based practice. These guidelines are based on the best available evidence and have been peer reviewed by two independent multidisciplinary expert panels for relevance and validity.

Cancer care Ontario guideline recommendations for hormone receptor testing in breast cancer.

Hormone receptor testing (oestrogen and progesterone) in breast cancer at the time of primary diagnosis is used to guide treatment decisions. Accurate and standardised testing methods are critical to ensure the proper classification of the patient's hormone receptor status. Recommendations were developed to improve the quality and accuracy of hormone receptor testing based on a systematic review conducted jointly by the American Society of Clinical Oncology/College of American Pathologists and Cancer Care Ontario's Program in Evidence-Based Care. Evidence-based recommendations were formulated to set standards for optimising immunohistochemistry in assessing hormone receptor status, as well as assuring quality and proficiency between and within laboratories. A formal external review was conducted to validate the relevance of these recommendations. It is anticipated that widespread adoption of these guidelines will further improve the accuracy of hormone receptor testing in Canada.