Supportive care in lung cancer patients receiving concurrent chemotherapy and radiotherapy: ESTRO and ESMO Guideline

Concurrent chemotherapy and radiotherapy (CCRT) followed by durvalumab immune therapy in appropriate patients is considered to be the standard of care in most fit stage III non-small-cell lung cancer (NSCLC) patients. However, CCRT is a toxic treatment that affects all organ systems and may cause acute and permanent side effects, some of which may be lethal. Supportive care is therefore of utmost importance in this clinical setting.

A group of experts from the European Society for Therapeutic Radiology and Oncology (ESTRO) and the European Society of Medical Oncology (ESMO) identified the following items of importance for further improvement of supportive care: smoking cessation; nutrition before and during CCRT (including treatment and prevention of anorexia); physical exercise before and during CCRT; prevention and treatment of acute esophagitis and dysphagia; treatment of cough and dyspnea; treatment of skin reactions; treatment of fatigue; prophylaxis of nausea and emesis; prevention, diagnosis, and treatment of cardiac disease and damage; and optimization of radiotherapy techniques and chemotherapy adjustments to reduce toxicity in the era of immune therapy. The resulting recommendations are summarized in this manuscript and knowledge gaps identified, in which future investments are needed to improve supportive care and hence the quality of life and survival for our stage III NSCLC patients.

Following are the major recommendations:

Smoking cessation

Smoking cessation should actively be supported in all patients, also before the beginning of treatment as it may improve long-term survival, decrease side effects and risk of developing second primary cancers (level III, grade A).

Prevention and treatment of acute esophagitis and dysphagia

• The administration of a proton pump inhibitor at a daily dose of 40 mg, from the beginning of radiotherapy up to 3 months after the end is recommended (level V, grade B).
• Because esophageal candidosis frequently occurs, patients with grade 2 or more esophagitis may be given appropriate antifungal drugs (level V, grade B).
• Symptomatic care, such as the administration of local anesthetics (e.g. lidocaine), systemic analgesics including opioids, is essential (level V, grade A).

Nutrition before and during CCRT, including treatment and prevention of anorexia

• All patients should be offered assessment of nutritional risk and counselling by a trained professional before the start, during, and after concurrent chemoradiotherapy (level III, grade A).
• Independent of the route of delivery, nutritional intake should cover at least 30 kcal and 1.0–1.5 g protein per kg body weight as well as the recommended daily allowance for all micronutrients (level III, grade A).
• Enteral or parenteral feeding should be initiated promptly if oral intake is inadequate resulting in loss of ≥5% of body weight despite meticulous care and support (level III, grade A).

Physical exercise before and during CCRT

• Resistance training improves and restores functional exercise capacity and should be offered to patients after concurrent chemoradiotherapy (level III, grade B).

Treatment of cough and dyspnea

• The cause of cough and dyspnea should always be determined, and treatment should be initiated according to the etiology (level V, grade A)
• The cause of cough and dyspnea should always be determined, and treatment should be initiated according to the etiology (level V, grade A).

Treatment of skin reactions

• No preventive measures have to be taken to avoid skin toxicity (level V, grade A).
• Dry desquamation may be treated with a moisturizing cream (level V, grade A).
• Moist desquamation is treated as superficial burns (level V, grade A)

Treatment of fatigue

• Only the short-term use of corticosteroids (dexamethasone: 4 mg twice a day for 14 days; methylprednisolone: 16 mg twice a day for 7 days) might be considered as pharmacological intervention to treat fatigue (level II, grade C).
• Drugs other than corticosteroids, as well as dietary supplements have not convincingly shown a beneficial effect (level of evidence II, grade of recommendation B).
• Moderate-intensity exercises such as walking, running, swimming, or cycling two to three times per week for 30–60 min if possible should be offered to the patients (level II, grade B).

Prophylaxis of nausea and vomiting

• As chemotherapy is the most emetogenic part of concurrent chemotherapy and radiotherapy treatment, antiemetics should be given according to standard guidelines (level I, grade A).
• Thoracic radiotherapy has a low emetogenic risk; prophylactic antiemetics are therefore generally not recommended on the days in which only radiotherapy is administered (level I, grade A).
• Durvalumab has a low emetogenic potential (level I, grade A).

Prevention, diagnosis, and treatment of cardiac disease and damage

• Patients should avoid cardiovascular risk factors such as smoking, being overweight, eating an unhealthy diet, and sedentary behavior (level V, grade A).
• Radiotherapy techniques to decrease the dose to the heart as much as possible should be used (level II, grade A).
• Cardiac disease should be diagnosed and treated as in non-irradiated patients (level V, grade A).

Radiotherapy techniques and chemotherapy adjustments to prevent toxicity in the era of immune therapy

• Radiotherapy techniques, doses, and fractionation, as well as chemotherapy regimen, should be delivered according to international guidelines and similar to what has been used in randomized clinical trials for concurrent chemotherapy and radiotherapy with or without immunotherapy (level II, grade A).
• The radiation dose to organs at risk, including all parts of the heart, should be kept as low as possible (level II, grade A)

For more details click on the link: https://doi.org/10.1016/j.annonc.2019.10.003