We have demonstrated that modern radiotherapy is safe and effective in carefully selected older patients with small-cell lung cancer

Professor Corinne Faivre-Finn

It’s been an exciting few months recently as my colleagues and I at The Christie, collaborating with researchers throughout the world, have made some important discoveries relating to the treatment of older patients with small-cell lung cancer.

Small-cell lung cancer is a type of cancer that we diagnose in around 13% of all people with lung cancer. This type of cancer tends to spread quite quickly and many of our patients are diagnosed at an advanced stage. Unfortunately, despite a lot of advances in the field, survival rates have not significantly improved. To address this challenge, my team and I at The Christie have been doing research aiming to find better treatment options for these patients.

This week, The Journal of Thoracic Oncology has published the age analysis of the CONVERT trial which specifically looks at the outcomes of older patients in the trial compared to those of younger patients.

The CONVERT trial was an international clinical trial in which 547 patients with small-cell lung cancer that had not spread outside the chest, received radiotherapy delivered either twice-daily over three weeks (standard treatment) or once-daily at a higher dose over six and a half weeks (experimental treatment). All participating patients received standard chemotherapy together with radiotherapy.

The trial recruited patients from the UK, France, Spain, Belgium, Poland, Slovenia, Canada and the Netherlands and closed in November 2013. We have been analysing the results ever since and the publication this week is a very important step forward in our knowledge of the disease and the best way to treat it.

The results showed similar survival times and side effects from treatment in both radiotherapy groups. However, these results were much more favourable compared to previous studies that did not use modern radiotherapy techniques. We concluded that twice-daily radiotherapy should remain the standard treatment, but once-daily treatment could be offered in cases where twice-daily radiotherapy is not available or where there are logistical challenges.

A large proportion of the patients we see in our clinics are over the age of 70. Unfortunately, there isn’t a lot of robust information coming out of clinical trials regarding which treatment options are safe and effective in older patients. In the past, patients above the age of 70 or 75 have typically been excluded from clinical trials. This was mainly because of strict criteria excluding patients with a number of additional medical conditions or those on a lot of medications. The lack of information makes it more difficult for both the patients and their doctors to reach the best possible treatment decisions. With this in mind, we looked at the outcomes of patients that were 70 years old and above, who participated in CONVERT, and compared them to those of patients younger than 70.

My colleague Dr Marianna Christodoulou has been instrumental in analysing these results. Her work identified that out of 490 patients in total, 67 were 70 years old and above. The results in this age group were very promising, demonstrating similar survival times and side effects from treatment between the older and younger groups. Encouragingly, the proportion of patients in the older group that had life-threatening infections, needed to stay in hospital or have blood transfusions was not significantly higher compared to those in the younger group.

The CONVERT trial is the largest randomised trial to date investigating treatment combining modern radiotherapy and chemotherapy in patients with small-cell lung cancer that has not spread outside the chest. Being able to demonstrate that these treatment options are possible, safe and effective in older patients in the context of this trial will influence clinical practice, and benefit older patients with this disease in the future.

Perhaps the most important take-home message of this analysis should be that selecting patients for such intense treatments should be very careful. In this study, most patients in the older group who tolerated treatment did not have any other significant medical conditions or restrictions on their daily activities. In patients who are less fit, more information is needed as to which treatment options are best and firm conclusions cannot be drawn at the moment. Furthermore, only three patients in CONVERT were above the age of 80, preventing us from making treatment recommendations for this group. The design of more clinical trials that specifically look at the outcomes of older patients will be an important step for further research.

Dr Christodoulou and I are very pleased with the results of the study and the interest shown amongst the lung cancer research community. We would like to thank everyone involved in the CONVERT trial for their tireless, hard work and dedication.

Dr Christodoulou presented this work in 2016 at the 17th World Conference on Lung Cancer and won the Heine Hansen Lectureship Award. This was a fantastic tribute in recognition of the hard work the CONVERT trial team has put into this large collaborative project.

The study was funded by Cancer Research UK and was developed with, set-up and co-ordinated by the Manchester Academic Health Science Centre Clinical Trials Unit.

Visit www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-study-to-find-the-best-way-to-give-radiotherapy-for-people-with-small-cell-lung-cancer for more information about the CONVERT trial and visit www.christie.nhs.uk/professionals/research/clinical-trials/for information about clinical trials at The Christie.