Dose escalation of an antineoplastic modality such as radiotherapy (RT) may result in an increased therapeutic ratio with the use of effective strategies to mitigate normal tissue toxic effects. Successful execution of dose escalation using external beam RT (EBRT) approaches has yielded unintended outcomes.1,2 While increased disease control and survival are a focus of such strategies to increase the therapeutic ratio, quality of life (QOL), as measured by appropriate patient-related outcomes tools, are nearly as important. To that end, Movsas et al,3 in this issue of JAMA Oncology, document that an attempt to deliver nearly a quarter higher total dose (74 Gy vs 60 Gy) of EBRT given concomitantly with a platinum-taxane doublet for locally advanced non–small-cell lung cancer (LA-NSCLC) results in a clinically meaningful decrement in QOL at 3 months.3
However, the Radiation Therapy Oncology Group 0617 trial is not the definitive treatise regarding the RT dose-escalation question for LA-NSCLC. The QOL assessments, as well as the survival results, likely were influenced by numerous factors that are difficult to control for in a multi-institutional, cooperative group clinical trial setting. Emerging data on molecular signatures that may predict radiosensitivity and/or radioresistance of tumor, as well as normal tissues, may be helpful in future assessment of baseline patient characteristics for those enrolled in prospective, large-scale cancer clinical trials of RT-based treatment. Moreover, not all modes of potential RT delivery and dose escalation are equal. Currently, radiation oncologists see patients on a weekly basis and basically assess symptoms as a “snapshot in time.” This is fraught with recall bias and other factors that contribute to a diminished appreciation of real-time patient-related outcomes, which should ideally be recorded on a continuous 24/7 basis to assess QOL during treatment. Movsas and colleagues are to be congratulated for executing a trial that will help in the design of next-generation QOL trials for LA-NSCLC.
Conflict of Interest Disclosures: None reported.
Charles R. Thomas. The Importance of Quality of Life Assessment. JAMA Oncol. 2016;2(3):367–368. doi:10.1001/jamaoncol.2015.4087