I congratulate Drs. Rabatic and Kong on their excellent review of the merits and clinical trial information supporting the use of concurrent chemoradiation for stage III locally advanced non-small cell lung cancer. As they rightly point out, if the goal is the improvement in survival then, on average, the best course of action given the current understanding of this disease entity is the application of concurrent chemoradiation for unresectable patient populations.
As I mentioned in my primary paper, this is an approach that I use routinely and would consider a default treatment stance for this patient population. However, the goal of my paper was to impress upon the reader that there are circumstances where patient goals may be different than those of treating physicians. In particular, often patients are very concerned regarding the treatment side effect profile of concurrent chemoradiation and inquire about other less aggressive but still radical approaches for treatment. Based on the various clinical trials assessing sequential chemoradiation and radiation alone (as referenced in the primary paper), I believe a rational and informed patient can select these less toxic therapies as an alternative to the concurrent chemoradiation paradigm. Additionally, there may be circumstances where pre-treatment tumor volumes may be too great to safely treat concurrently and a sequential approach may convert a palliative situation into a radical one.
Fortunately, our ability to deliver concurrent chemoradiation appears to be improving given the favourable results in the RTOG 0617 60 Gy standard arm compared to historical controls (and other previously published clinical trials). Ultimately, however, this issue all comes down to patient selection by clinicians, informed consent, and patient preferences in order to optimize the various treatment goals of survival, cure, toxicity reduction and treatment completion based on the available clinical trial evidence. Clinical trials to further improve BOTH survival and treatment toxicity profiles should be a priority in this patient population.
Conflicts of Interest: The author has no conflicts of interest to declare.