Esophagitis Outcomes With or Without Contralateral Esophagus Sparing in Locally Advanced Lung Cancer

Abstract

Purpose/Objective(s): Patients receiving concurrent chemo/radiation therapy (CRT) for non-small cell (NSCLC) or small cell (SCLC) lung carcinoma are at risk for severe acute esophagitis (AE) (≥ grade (G) 3). We sought to compare AE in a cohort of patients treated with an empiricallyderived contralateral esophagus sparing technique (CEST) to historical patients treated without this technique. This data will inform nurses and nurse practitioners when anticipating and managing CRT side effects in lung cancer patients. Materials/Methods: In this retrospective IRB-approved study, we reviewed the records of patients with locally advanced (stage III by AJCC 7th ed +/-solitary brain metastasis) NSCLC or limited-stage SCLC who had gross tumor within 1 cm of the esophagus. All patients were planned with intensity-modulated radiation therapy (IMRT) to a prescription dose of at least 60 Gy with concurrent chemotherapy. Cohort A represents a secondary analysis of an institutional phase I trial that enrolled patients during 7/2015-2/2019. Cohort B consists of consecutive patients treated with standard of care IMRT during 7/2008-12/2012, before the implementation of CEST at our institution. We tabulated patient, tumor, and treatment characteristics and graded AE using CTCAEv4 from baseline to 3-month posttreatment follow-up appointments. Results: We identified a total of 52 CRT patients (A, n = 26; B, n = 26). Median ages for cohorts A and B were 67 and 69.5 years, respectively. In each cohort there were 10 females and 16 males. Stage distribution was: IIIA 50%, IIIB 42%, IV 8% for cohort A and IIIA 65%, IIIB 35% for cohort B. In cohorts A and B, median radiation dose was 70 Gy (range 68-70 Gy) and 68.7 Gy (range 45-74 Gy), respectively. Overall rates of G2+ AE in cohorts A and B were 31% (n = 8) and 58% (n = 15) (P = 0.03), respectively. This difference was evident by week 4 of CRT when for cohorts A and B the rates were 15% and 35%, respectively. By 3 months post-treatment, each cohort had 1 patient with G2+ AE. There were no G4/ 5 events, and the only G3 AE was in cohort B leading to early termination of treatment at 52.2 Gy. Twelve percent (n = 3) of patients in cohort A and 27% (n = 7) of patients in cohort B required IV fluids. Forty six percent (n = 12) patients in cohort A and 62% (n = 16) of patients in cohort B required diet adjustments, while 27% (n = 7) of patients in cohort A and 73% (n = 19) of patients in cohort B required pain medications. Overall, CEST allowed patients to maintain a more normal diet, spend less time receiving IV fluids, and take fewer pain medications. Conclusion: Advances in IMRT-based treatment techniques have enabled a considerable reduction in G2-3 AE rates. Reduced AE is expected to lead to improved quality of life and treatment adherence. Nurses and nurse practitioners can use this data to perform a more focused assessment, create patient-specific interventions, and streamline patient education.