Provider decision regret—a useful method for analysis of palliative thoracic re-irradiation for lung cancer?

Abstract

Background: The overall usefulness of palliative thoracic re-irradiation depends on the balance between efficacy, survival and toxicity, and is difficult to judge from previous studies. In the absence of patient-reported data, we developed a method for provider decision regret that addresses the question "would we re-irradiate this patient again in light of the known outcome?" Furthermore, we analyzed different reasons for decision regret and defined a subgroup at increased risk.Patients and Methods: A retrospective analysis of 33 patients with lung cancer reirradiated with 17-45 Gy was performed. Reasons for decision regret included reirradiation within the last 30 days of life, immediate radiological progression after re-irradiation (as opposed to stable disease or objective response), radiation myelopathy, any grade 4-5 toxicity, grade 3 pneumonitis, other grade 3 toxicity in the absence of a symptomatic benefit or a time period of at least 3 months without worsening of the treated tumor.Results: Median survival time was 5.2 months (95% confidence interval 3.4-7.0 months). Symptomatic and radiological responses were observed. Provider decision regret was declared in 12 patients (36%, two patients with grade 3 pneumonitis, three patients with a short survival (radiotherapy during the last 30 days of life), seven patients with progression). Decision regret was declared only in patients with ECOG performance status (PS) 2 or 3 and was associated with time interval to re-irradiation <6 months. Conclusion:Our data support the usefulness and acceptable side effect profile of palliative re-irradiation for lung cancer. Patients with reduced PS are at increased risk of futile treatment. Future research should aim at prediction of immediate disease progression (the prevailing cause of decision regret). Evaluation of provider decision regret has the potential to improve the way we learn from retrospective databases and should also be considered for other scenarios where high-quality prospective outcome data are lacking.

Re-Irradiation for Locally Recurrent Lung Cancer: A Single Center Retrospective Analysis

“…In fact, the current cohort was comparable to other studies in terms of performance score (PS) and time interval between the two radiation courses [4,5,10,17,22,23]. Reports on radical re-irradiation usually include patients with PS ≤2 because it directly affects OS [21,30]. Higher PS implies difficulties to complete RT, which negatively influences clinical outcome [4,5,10,17,[21][22][23]31,32].…”

Impact of reirradiation, chemotherapy, and immunotherapy on survival of patients with recurrent lung cancer: A single‐center retrospective analysis

“…Our finding is consistent with a concept published in a review by Evans 5 intended for recurrent lung cancer patients who already have limited chances of successful curative treatment 5,19,26,27 . According to Evans, 5 the combination of the two therapy modalities would have a synergistic effect in terms of both local and systemic disease control, given the high potential for local and systemic failure, possibly due to radiation resistance and the aggressiveness of the disease in recurrent lung cancer patients 5 .…”