Future Horizons in Lung Cancer
Future directions in radiation medicine
Dr David Landau - Guy's and St Thomas' NHS Trust, London, UK
What were you discussing at this meeting?
The title was Future of Radiation Medicine, so the idea was to see what clinical trials are up and running so that we may have an idea of what sort of medicine we’ll be practising in two or three years’ time from now. One example was the SABRTooth trial and the VALOR trial in America which are looking at randomising patients with early lung cancer between radiotherapy, stereotactic radiotherapy and surgery. There have already been two failed trials, they’ve failed to recruit, so hopefully we’ll be able to get good data to demonstrate what the comparison might be.
Was this quite a small trial?
There were very few people in this study compared to what they wanted and the trials failed to recruit in early lung cancer rather like they do in other types of early cancer when you’re trying to randomise patients between surgery and non-surgery. So prostate cancer, bladder cancer, all sorts of cancers have really struggled to recruit, to take patients away from surgery; patients really see surgery as their way towards a cure and not having surgery as a bad thing. It’s difficult to communicate that there is genuine doubt about which one is better.
What other studies are underway?
There’s a SABRTooth trial started in the UK which has already recruited 15 patients. At the moment it’s in a feasibility stage and if they can recruit enough patients over the next six months then hopefully we can carry on, do a full phase III trial.
What are they looking for in this trial?
They’re looking at stage T1N0 non-small cell lung cancer where there is a feeling in the local multidisciplinary team that this would be as appropriate for radiotherapy as it is for surgery. In those patients, defined by the local teams, there will be a randomisation. The information will be given to the patients primarily by the chest physicians and specially trained nurses, rather than by the surgeon and the radiotherapist. So we take the personalities and the passion out of it and we leave it to the chest physician or the specially trained nurses to actually do the randomisation.
What direction do you feel that these trials will take us?
What it’s trying to show is that patients don’t need to have surgery for early stage lung cancer. This is not the majority of radiotherapy for lung cancer, this is really rather a new niche in the last 5-10 years. The question is whether radiotherapy, which doesn’t require patients to have an operation, will do just as good a job as surgery or, perhaps better than that, can we select which patients might be best treated with surgery and might be best treated by avoiding surgery and having radiotherapy instead.
Would this mean improving treatment and stopping unnecessary treatment?
Most people would agree that if you could get exactly the same outcomes and avoid surgery with having stereotactic radiotherapy then that’s what you should do, avoid the morbidity of surgery.
Are there any other parts to your talk?
The other big part of the talk was talking about patients who have got metastatic disease but only between one and six, and highlighting primarily a study called SARON which has just started recruiting in the UK for patients with up to three metastases where patients have chemotherapy with or without radiotherapy to all of the sites of tumour. It could be radical radiotherapy or stereotactic radiotherapy. That’s a phase III trial, fairly unique in the world at the moment, looking at an overall survival endpoint. The point there is will patients live longer and better when you give them extra radiotherapy at diagnosis after chemotherapy or not. So that’s a very important study that’s taking place in the UK.
The other main part of the talk was really to look at what the evidence is so far for adding immune therapy to radiotherapy, or adding radiotherapy to immune therapy, either of which are potentials. There has already been some trials completed like the PACIFIC trial, other trials are waiting to be completed. So that’s another area that could be quite exciting in the next two or three years.
How is the PACIFIC trial progressing?
The PACIFIC trial have had excellent luck because they’ve actually completed a recruitment in an over 700 patient study. So all we’re doing there is waiting for the follow-up, getting the information on patients as they are followed up in their local clinics. There are over 700 patients and hopefully in a year and a half or so we’ll start getting results to see whether there’s an impact in progression free survival and eventually overall survival. Did adding immune therapy to curative or radical radiotherapy improve survival?
