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Cover of Local Nonsurgical Therapies for Stage I and Symptomatic Obstructive Non–Small-Cell Lung Cancer

Local Nonsurgical Therapies for Stage I and Symptomatic Obstructive Non–Small-Cell Lung Cancer

Comparative Effectiveness Reviews, No. 112

Investigators: , PhD, , PhD, , MPH, , MD, and , PhD.

Blue Cross and Blue Shield Association Technology Evaluation Center, Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 13-EHC071-EF

Structured Abstract

Objectives:

We prepared this report on the comparative effectiveness and harms of lung-directed nonsurgical therapies for non–small-cell lung cancer (NSCLC) in three distinct patient populations: (1) patients with stage I NSCLC who are not surgical candidates (Key Question 1), (2) patients with stage I NSCLC who are deemed operable but decline surgery (Key Question 2), and (3) patients with endoluminal NSCLC causing obstruction (Key Question 3). For stage I NSCLC, the local nonsurgical interventions could include conformal radiotherapy modalities and radiofrequency ablation (RFA). For patients with airway obstruction due to an endoluminal NSCLC, local nonsurgical interventions could include those for the stage I setting, as well as conventional wide-field radiotherapy, brachytherapy, laser and mechanical debridement, endoluminal stents, cryoablation, and photodynamic therapy. Surgical resection of any type is not considered as a comparator for any of the Key Questions.

Data sources:

MEDLINE®, Embase®, and the Cochrane Controlled Trials Registry were searched from January 1, 1995, to July 25, 2012. A search of the gray literature included databases with regulatory information, clinical trial registries, abstracts and conference papers, and information from manufacturers.

Review methods:

We sought studies reporting overall survival, cancer-specific survival, local control, symptom relief, adverse events, and quality of life among our populations of interest. Data were abstracted for each Key Question by a team of reviewers, with independent data verification. Study quality and the risk of bias of randomized controlled trials (RCTs) were assessed using the United States Preventive Services Task Force criteria. The quality and risk of bias of single-arm studies were assessed using the Carey and Boden criteria. The strength of the body of evidence was assessed according to the Agency for Healthcare Research and Quality Methods Guide.

Results:

In our searches, we identified 4,648 unique titles and screened 1,178 in full text. Of the latter, 55 met the inclusion criteria. Thirty-five studies were relevant to Key Question 1, considering medically inoperable patients with stage I NSCLC; 6 were relevant to Key Question 2, considering medically operable patients with stage I NSCLC who decline surgery; and 17 were relevant to Key Question 3, considering patients with inoperable endoluminal NSCLC causing symptoms of obstruction. Three studies addressed both Key Questions 1 and 2. All studies relevant to Key Questions 1 and 2 were single-arm design, prospective (n=15), retrospective (n=21), or not specified (n=2). Among 17 papers included for Key Question 3, 5 were RCTs, 1 was a nonrandomized comparative study, and 11 were single-arm studies. Because comparative study evidence on RFA and debridement and stenting was unavailable for Key Question 3, we included evidence from two single-arm studies involving stents and one on RFA. All RCTs were of poor quality. Only one comparison was available per study, with no two studies examining the same set of interventions. Outcomes of therapy for all Key Questions included overall survival, adverse effects, and quality of life.

Conclusions:

Evidence on localized nonsurgical therapies for patients with stage I NSCLC who are not surgical candidates or who decline surgery consists only of single-arm studies, with no direct comparisons among interventions. The best evidence for NSCLC patients with endoluminal obstruction consists of poor-quality single RCTs for each comparison; we did not identify evidence that permitted us to draw conclusions based on indirect comparisons. Overall, evidence is insufficient to permit conclusions on the comparative effectiveness of local nonsurgical therapies for inoperable or operable patients with stage I NSCLC or inoperable NSCLC patients with endoluminal tumor causing pulmonary symptoms.

Contents

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10058-I, Prepared by: Blue Cross and Blue Shield Association Technology Evaluation Center, Evidence-based Practice Center, Chicago, IL

Suggested citation:

Ratko TA, Vats V, Brock J, Ruffner BW Jr, Aronson N. Local Nonsurgical Therapies for Stage I and Symptomatic Obstructive Non–Small-Cell Lung Cancer. Comparative Effectiveness Review No. 112. (Prepared by Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-2007-10058-I.) AHRQ Publication No. 13-EHC071-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10058-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov

Bookshelf ID: NBK148716PMID: 23865091
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