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Radiation Oncology

Do We Have Enough Evidence to Implement Particle Therapy as Standard Treatment in Lung Cancer? A Systematic Literature Review

^aDepartment of Radiation Oncology (Maastro Clinic) and ^bGROW, Maastricht University Medical Center, Maastricht, The Netherlands; ^cDepartment of Health Organization, Policy & Economics, Maastricht University, Maastricht, The Netherlands; ^dMcGill University, Montreal, Canada

Key Words. Hadron • Heavier charged particles • Carbon ion • Proton • Lung cancer • Radiotherapy

Correspondence: Madelon Pijls-Johannesma, Ph.D., Maastricht Radiation Oncology (MAASTRO) Clinic, Dr. Tanslaan 12, 6229 ET Maastricht, The Netherlands. Telephone: 31-88-44-55-666; Fax: 31-88-44-55-667; e-mail: madelon.pijls{at}maastro.nl

Received June 16, 2009; accepted for publication December 4, 2009; first published online in THE ONCOLOGIST Express on January 12, 2010.

Disclosures

Madelon Pijls-Johannesma: None; Janneke P.C. Grutters: None; Frank Verhaegen: None; Philippe Lambin: None; Dirk De Ruysscher: None.

Section editors Suresh Senan and Andrew Turrisi III have disclosed no financial relationships relevant to the content of this article.

The article discusses the investigational use of new radiotherapy beams.

The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias.

Background. The societal burden of lung cancer is high because of its high incidence and high lethality. From a theoretical point of view, radiotherapy with beams of protons and heavier charged particles, for example, carbon ions (C-ions), should lead to superior results, compared with photon beams. In this review, we searched for clinical evidence to justify implementation of particle therapy as standard treatment in lung cancer.

Methods. A systematic literature review based on an earlier published comprehensive review was performed and updated through November 2009.

Results. Eleven fully published studies, all dealing with non-small cell lung cancer (NSCLC), mainly stage I, were identified. No phase III trials were found. For proton therapy, 2- to 5-year local tumor control rates varied in the range of 57%–87%. The 2- and 5-year overall survival (OS) and 2- and 5-year cause-specific survival (CSS) rates were 31%–74% and 23% and 58%–86% and 46%, respectively. Radiation-induced pneumonitis was observed in about 10% of patients. For C-ion therapy, the overall local tumor control rate was 77%, but it was 95% when using a hypofractionated radiation schedule. The 5-year OS and CSS rates were 42% and 60%, respectively. Slightly better results were reported when using hypofractionation, 50% and 76%, respectively.

Conclusion. The present results with protons and heavier charged particles are promising. However, the current lack of evidence on the clinical (cost-)effectiveness of particle therapy emphasizes the need to investigate the efficiency of particle therapy in an adequate manner. Until these results are available for lung cancer, charged particle therapy should be considered experimental.