Continuous Hyperfractionated Accelerated Radiotherapy (CHART) for Non-small Cell Lung Cancer (NSCLC): 7 Years' Experience From Nine UK Centres.

AIM: Continuous hyperfractionated accelerated radiotherapy (CHART) remains an option to treat non-small cell lung cancer (NSCLC; NICE, 2011). We have previously published treatment outcomes from 1998-2003 across five UK centres. Here we update the UK CHART experience, reporting outcomes and toxicities for patients treated between 2003 and 2009. MATERIALS AND METHODS: UK CHART centres were invited to participate in a retrospective data analysis of NSCLC patients treated with CHART from 2003 to 2009. Nine (of 14) centres were able to submit their data into a standard database. The Kaplan-Meier method estimated survival and the Log-rank test analysed the significance. RESULTS: In total, 849 patients had CHART treatment, with a median age of 71 years (range 31-91), 534 (63%) were men, 55% had undergone positron emission tomography-computed tomography (PET-CT) and 26% had prior chemotherapy; 839 (99%) patients received all the prescribed treatment. The median overall survival was 22 months with 2 and 3 year survival of 47% and 32%, respectively. Statistically significant differences in survival were noted for stage IA versus IB (33.2 months versus 25 months; P = 0.032) and IIIA versus IIIB (20 months versus 16 months; P = 0.018). Response at 3 months and outcomes were significantly linked; complete response showing survival of 34 months against 19 months, 15 months and 8 months for partial response, stable and progressive disease, respectively (P < 0.001). Age, gender, performance status, prior chemotherapy and PET-CT did not affect the survival outcomes. Treatment was well tolerated with <5% reporting ≥grade 3 toxicity. CONCLUSION: In routine practice, CHART results for NSCLC remain encouraging and we have been able to show an improvement in survival compared with the original trial cohort. We have confirmed that CHART remains deliverable with low toxicity rates and we are taking a dose-escalated CHART regimen forward in a randomised phase II study of sequential chemoradiotherapy against other accelerated dose-escalated schedules.

Volume definition in radiotherapy planning for lung cancer: how the radiologist can help.

Effective treatment for carcinoma of the lung remains one of the biggest challenges in oncology. Radical radiotherapy may be a curative option for patients who are unsuitable for radical surgery either because of disease stage or because of co-morbidity. Long-term disease control with radical radiotherapy is disappointing with only about 6% of patients treated being alive at 5 years. Technological advances involved in the planning and delivery of radiotherapy may improve this. The advent of conformal radiotherapy, utilizing computed tomography and three-dimensional planning systems, allows much more accurate shaping of the radiation fields. This greater accuracy of target volume definition facilitates a reduction in the radiation dose to normal tissues, allowing for dose escalation to the tumour. Delineation of the target volume can be problematic. Conventional CT has limitations in term of distinguishing between benign and malignant tissues, e.g. the size criteria for involved lymph nodes. The oncologist uses a combination of radiological and clinical information when defining the target volume but their radiological interpretation of imaging is inferior to that of a radiologist. The Royal College of Radiologists (RCR) issued guidance in 2004 on the optimal imaging strategies for common cancers. These guidelines address issues regarding the localisation and staging of cancers and treatment planning, and also reporting and training. They recommend the development of closer links between radiologists and oncologists to optimise the interpretation of imaging and target volume definition. This article aims to briefly explain the planning process involved in irradiating lung cancers, highlight problematic areas and suggest ways in which co-operation with radiologists may improve the delivery of radiotherapy and therefore the treatment outcomes for this group of patients.