Radiotherapy Side Effects – PORT or Postoperative Risks

New study says radiation for advanced lung cancer doesn’t help. It’s routinely given after surgery in a bid to prevent cancer from recurring. But postoperative radiotherapy, or PORT, can damage the heart and lungs — thereby canceling out the potential benefits, particularly in seniors.

Now a new study even shows that for older people with a certain type and stage of lung cancer, giving radiation treatment after surgery may not extend survival. And while there are some young people who are diagnosed with lung cancer, most cases involve over-fifties who have a history of smoking.

Dr. Juan Wisnivesky, an associate professor of medicine at New York City’s Mount Sinai School of Medicine led the team that scrutinized survival outcomes in more than 1,300 lung cancer patients with locally advanced disease, 710 of whom were given the PORT.

Patients in the study, all 65 years or older, had stage 3 non-small cell lung cancer and involvement of N2 lymph nodes. All had cancer that had spread, but not widely. All had also been diagnosed from 1992 to 2005 and were included in the U.S. Surveillance, Epidemiology, and End Results database that is linked to Medicare.

Worldwide, lung cancer is the most common cancer and the leading cancer-related cause of death. Around 1.1 million new cases will be diagnosed across the world this year, with about 226,000 of that in the United States. Ninety percent of these cases will be non-small cell, according to the American Cancer Society.

Within non-small cell cancers, there are three main subtypes. One of the subtypes involves N2 lymph nodes.

Patients with stage 3 lung cancer aren’t usually given radiation therapy, but in this group being studied, the cancer had spread to lymph nodes in the chest.

Currently, doctors don’t agree on how to treat this group of patients and previous studies looking into the survival benefits of post-op radiation for this particular patient set have produced mixed results.

But Dr. Wisnivesky team found that no substantial survival benefits from PORT in his subjects, at one year or three years after.

“We found in this group of elderly patients, many of whom received the treatment, the use of the treatment did not appear to help them live longer,” Dr. Wisnivesky said.

The study, funded by the U.S. National Cancer Institute, was published online Feb. 13 in the journal Cancer.

Radiotherapy Side effects (PORT)
Radiation therapy carries risks. Aside from the immediate side effects of the additional treatments, PORT can cause irritation of the lungs and inflammation of the esophagus, according to Dr. Wisnivesky.

“Patients need to be well informed,” he said. “They have to have a good discussion with their doctor about what are the potential benefits,” he added. They also need to discuss possible side effects.

Another cancer expert not linked to the study notes that fatigue, skin reactions and pain when swallowing are some of the immediate side effects of radiation. But down the road, PORT may also weaken the heart and the lungs, said Dr. Benjamin Smith of Houston’s University of Texas MD Anderson Cancer Center.

“I don’t think that radiation is likely to cause life-threatening side effects, but it’s certainly inconvenient and can impair a patient’s quality of life,” Smith told Reuters Health.

Seniors
The new findings fuel an ongoing debate over how much treatment older cancer patients should get. According to Reuters Health, treatments are often tested in younger people and when these tests prove that a particular treatment is beneficial, it remains unclear whether seniors will reap the same benefits.

Side effects often take a higher toll on the health of seniors—and they may not live long enough to see the positive effects of their therapy, after all.

“The marginal benefit of the additional treatment gets smaller and smaller as patients get older,” said Dr. David J. Sher, a radiation expert at Rush University Medical Center in Chicago, who was not involved in the new study.

“Their overall fitness generally doesn’t warrant postoperative radiotherapy,” he told Reuters Health. “It’s a fine balance.”

Small subset
Indeed, a number of small studies done previously have also suggested that post-op radiation may be unnecessary in these particular set of patients, and the new findings bolster that, says Dr. Dan Raz, an assistant professor of surgery at City of Hope Comprehensive Cancer Center in Duarte, California

But he stressed that the study affects a “small subset” of all lung cancer patients, which he says is even a group very challenging to treat.

The study didn’t even look at all stage 3 lung cancer patients, but only a specific group—those with stage 3 non-small cell lung cancer that involved N2 lymph nodes.

“I think (the study) raises a very important point,” Dr. Raz says. But it “wouldn’t change the way I treat patients.”

A trial comparing the use of post-operative radiation and its non-use in this group of patients is what’s needed, he says. Such a study is being undertaken in France, says study author Dr. Wisnivesky, but will take several years to complete.

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