Societies update guideline on definitive local therapy for oligometastatic NSCLC
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Key takeaways:
- Definitive local therapy should be integrated into treatment for patients with up to five distant extracranial metastases.
- The guideline does not include recommendations for intracranial metastases.
American Society for Radiation Oncology, in collaboration with European Society for Radiotherapy and Oncology, has issued a guideline on use of definitive local therapy for patients with oligometastatic non-small cell lung cancer.
A multidisciplinary panel of experts — including radiation, medical and surgical oncologists; a radiation oncology resident; a pulmonologist; thoracic surgeons; a medical physicist and a patient representative — convened to develop the guidance based on a systematic review of articles published January 2006 through February 2022.
“Oligometastatic NSCLC is a phase in lung cancer development that may offer us new opportunities to improve patient outcomes, because it typically is more treatable than widely metastatic cancer,” Puneeth Iyengar, MD, PhD, co-chair of the guideline task force and an associate professor of radiation oncology at University of Texas Southwestern Medical Center, said in a press release. “The research on local therapy for oligometastatic cancer is still at a relatively early stage, but we already see indicators of potential benefits for patients. Adding local therapy to systemic therapy may lead to more durable cancer control, potentially improving [PFS], [OS] and quality of life.”
Key recommendations
The guideline, published in Practical Radiation Oncology, includes recommendations on patient selection, treatment planning and delivery techniques for definitive local therapy to manage oligometastatic NSCLC.
The guideline task force also developed algorithms on the optimal clinical scenarios for the different types of local therapies, according to the press release.
Key recommendations for patients with oligometastatic NSCLC include:
- Definitive local therapy should be integrated into treatment for patients with up to five distant extracranial metastases, but only when feasible and safe for all disease sites. It is conditionally recommended for carefully selected patients with synchronous oligometastatic, metachronous oligorecurrent, induced oligopersistent or induced oligoprogressive conditions for extracranial NSCLC.
- Radiation and surgery are the only recommended modalities for definitive local treatment of oligometastatic NSCLC. Radiation should be used if multiple organ systems are being treated or when the clinical priority is to reduce breaks from systemic therapy, whereas surgery should be used when large tissue sampling is needed for molecular testing to guide systemic therapy.
- At least 3 months of standard-of-care systemic therapy is recommended before starting definitive local therapy for asymptomatic patients with synchronous disease.
- Hypofractionated radiation therapy or stereotactic body radiation therapy is preferred when appropriate. Cancer care teams should consult guidelines from groups, such as National Comprehensive Cancer Network and EORTC.
- For disease that recurs or metastasizes after definitive local therapy for oligometastatic NSCLC, local therapy should be incorporated into standard treatment paradigms.
The guideline does not include recommendations for intracranial metastases due to the complexity involved in local therapy, according to the release.
Future directions
“Ultimately, our current definitions ... are insufficient to personalize therapy most effectively for the subsets of patients with true oligometastatic NSCLC who would most benefit from local therapy,” the expert panel wrote.
“The field in general lacks predictive and prognostic biomarkers for patients with limited metastatic disease,” they continued. “Until these biomarkers are identified, current trials will be enrolling patients based on a cross-sectional snapshot in time, making it difficult to enrich for patients who need local therapy to maintain durable control of their disease. All these shortcomings will eventually be answered with a better biologic understanding of what is happening to our patients with metastatic NSCLC before, and serially after, initiation of therapy.”
Several other methods, including those that involve use of circulating tumor DNA, minimal residual disease, functional imaging and other biomarkers to predict the oligometastatic state, still need to mature before they can be integrated into oligometastatic paradigms.
“More data are needed, especially from larger prospective trials using modern systemic therapies and local therapy approaches in different sequences and targeting different biology,” they said.
References:
- ASTRO and ESTRO issue clinical guideline on local therapy for oligometastatic lung cancer (press release). Available at: https://www.astro.org/News-and-Publications/News-and-Media-Center/News-Releases/2023/ASTRO-and-ESTRO-issue-clinical-guideline-on-local. Published April 25, 2023. Accessed May 26, 2023.
- Iyengar P, et al. Pract Radiat Oncol. 2023;doi:10.1016/j.prro.2023.04.004.
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