Standardization of Radiation Therapy Dose for Locally-advanced Non-small Cell Lung Cancer through Changes to a Lung Cancer Clinical Pathway in Large, Integrated Comprehensive Cancer Center Network

Publication date: Available online 8 July 2017
Source:Practical Radiation Oncology
Author(s): Pooja Karukonda, Brian J. Gebhardt, Zachary D. Horne, Dwight E. Heron, Sushil Beriwal
Purpose/Objective(s)The results of RTOG 0617 which randomized patients with Stages IIIA/IIIB NSCLC to definitive chemoradiotherapy (CRT) to 60Gy vs. 74Gy demonstrated a detrimental survival impact with high-dose RT. We evaluated the impact of changes to a provider-driven clinical pathway (CP) guiding management of NSCLC on practice throughout our cancer center network.Materials/MethodsIn 2001, we implemented a CP for management of Stage IIIA/IIIB NSCLC with definitive CRT. In 2013, the CP for NSCLC was amended (Amendment 1) to allow a dose range of 60–74Gy. The CP was amended (Amendment 2) in January 2016 to specify a dose range of 60–70Gy. Higher doses were considered off-pathway and subject to peer review. Data from decisions entered from 2012 to 2016 were obtained.ResultsFrom 2012 until publication of RTOG 0617 in February 2015, the median prescription dose was 66Gy delivered in 1.8–2.1Gy fractions. Doses ≤66Gy were prescribed for 52% of patients. From February 2015 to September 2016, the median prescription dose was 60Gy, and 91% of prescription doses were ≤66Gy. After Amendment 2, 99% of decisions were ≤66Gy. Dose ≤66Gy was associated with treatment following publication of 0617 (p<0.001) and treatment after Amendment 2 (p<0.001). On multivariable analysis, treatment after Amendment 2 was associated with dose ≤66Gy (OR 9.9, 95% CI 5.2–19.0, p<0.001). Lung V20Gy was lower following publication of 0617 (p<0.001). There was no difference in heart V40Gy.ConclusionCP eliminate variations in practice that lead to inferior outcomes. Recognizing that our CP for definitive treatment of patients with locally-advanced NSCLC allowed heterogeneous dose prescriptions, we modified the CP based upon the publication of RTOG 0617. We found that the CP was a tool to ensure patients receive evidence-based care across a large cancer center network.



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