Survey Confirms Different Practice Patterns for Treatment of NSCLC

NASHVILLE--Medical and radiation oncologists have distinctly different views on how best to treat non-small-cell lung cancer (NSCLC), results of a nationwide survey suggest.

The two specialties disagree on the appropriate application of chemotherapy vs radiation therapy and on the use of combination chemoradiotherapy. Moreover, physician specialty and training era dictate preferences for chemotherapy regimens, Hak Choy, MD, reported at an ASCO poster session.

The findings point to a need to reconcile the information reported in the literature of the two specialties and presented at continuing education programs, said Dr. Choy, associate professor of radiation oncology, Vanderbilt University.

"Two factors clearly influence the choice of therapy for NSCLC: whether the physician is a medical oncologist or radiation oncologist and the year the physician began practicing medicine," he said. "Instead, choices should reflect current standards of care."

These conclusions come from responses to a nationwide survey that included 492 medical oncologists and 455 radiation oncologists. Most of the respondents (679) completed their medical training prior to 1980 or between 1980 and 1989. More than half (524) said they see between 20 and 50 newly diagnosed lung cancer patients each year.

Overall, 55% of oncologists said they base their treatment decisions on information from the medical literature. However, the proportion of physicians relying primarily on the medical literature ranged from 48% of those who completed training before 1980 to 70% of those who finished after 1995.

Similarly, the proportion of oncologists who said they rely primarily on personal experience for treatment choices declined from 22% of physicians who completed training before 1980 to 11% to 13% for those who finished after 1990.

Adjuvant Therapy

Specialty and age figured prominently in the physicians’ choices for adjuvant therapy after surgery for T1-3, N1-2 cancer (see Table). More medical oncologists (25%) than radiation oncologists (5%) said that no further therapy is required after surgery.

About 55% of the radiation oncologists recommended mediastinal radiation after surgery, while almost 38% preferred chemoradiotherapy, as did about half the medical oncologists.

When the responses were evaluated by training years, 51% of the pre-1980 group preferred chemoradiotherapy vs 33% of the oncologists who finished training between 1990 and 1994 and 39% of those who finished in 1995 or later. About 42% of the oncologists who completed training more recently said they favor mediastinal radiotherapy as the sole adjuvant therapy after surgery.

When combined chemoradiation therapy is contemplated, about a third of physicians in both specialties said they recommend concurrent chemotherapy with radiation. About another third expressed a preference for induction chemotherapy with radiation. The preferences were fairly similar across all years of training.

Chemotherapy Preferences

Physicians who completed their training in 1995 or later preferred etoposide (VePesid) and a platinum compound (52.5%) as first-line chemotherapy for combined modality treatment of nonmetastatic NSCLC. In contrast, oncologists who completed training prior to 1980 preferred the combination of paclitaxel (Taxol) and carboplatin (Paraplatin) (50.2% vs 28.3% of physicians who began practicing in 1995 or later).

Specialty figured prominently in chemotherapy preferences for symptomatic, metastatic lung cancer. Most medical oncologists (58%) recommend the combination of paclitaxel and carboplatin, compared with 30% of radiation oncologists. About 38% of radiation oncologists prefer etoposide-cisplatin, as opposed to fewer than 10% of the medical oncologists.

Medical oncologists are more likely to consider chemotherapy appropriate for patients who have poor performance status (30% vs 17% of radiation oncologists). The specialty-specific preference was apparent across the spectrum of training eras.

"Medical oncologists and radiation oncologists need to be closer in their views because combined modalities are becoming more important in the treatment of many lung cancers, actually all types of tumors," Dr. Choy said. "There are efforts being made to try to bring oncologists in the different specialties together, including large symposia."