Value judgement.

Top Line: Prophylactic cranial irradiation (PCI) for non-small cell lung cancer (NSCLC) works.

The Study: And by that we mean it effectively prevents symptomatic brain mets among patients with stage III NSCLC remaining progression-free after definitive chemoradiation as proven in the large prospective NVALT-11 trial and the smaller poorly-accrued RTOG 0214. Now, this is where we get into the “art” of oncology because it’s a lot easier to come to an agreement on a statistically significant value when measuring a predefined endpoint than to come to an agreement on which endpoint is valuable. Enter this secondary analysis of NVALT-11 with a primary endpoint of health-related quality of life. This was measured using three different validated questionnaires touching on topics like mobility, self-care, pain and anxiety/depression, as well as more global functional and symptom scales. In the end, there were no clear differences across any of the three measures at any of the specified time points up to 36 months. Why? Because detriments were more likely in two populations: those with symptomatic brain mets (clearly more common in the observation arm) and in those with neurocognitive impairment in the absence of brain mets (clearly more common in the treatment arm). In other words, this endpoint was a wash. Granted, the authors do recognize that only a fraction of patients followed-up at 36 months, probably skewing the population towards those without brain mets.

TBL: You have the facts: PCI for NSCLC improves disease-free survival by preventing symptomatic brain mets with no clear improvement in overall survival nor objectively measured quality of life—it’s up to you and your patients to decide which is more valuable. | Witlox, Radiother Oncol 2019