Postoperative Radiotherapy in Non—Small-Cell Lung Cancer Warrants Further Exploration in the Era of Adjuvant Chemotherapy and Conformal Radiotherapy

that PORT was not associated with an overall improvement in survival and was associated with a detrimental effect on survival for the subgroup of patients with stage I and II disease. Numerous authors have examined the trials that were included in the metaanalysis. These analyses have concluded that many trials lacked appropriate methodology for randomized trials or appropriate treatment regarding recent standards for care. 2,5,7-11 The PORT meta-analysis included trials in which a majority of patients received treatment with cobalt machines, and some groups of patients were treated with just one radiotherapy field each day (an anterior field one day and a posterior field the next). It has been shown that these treatments result in suboptimal dose distributions, which may potentially increase toxicity. 2,4,7 Additionally, a large proportion of the patients who were included in the meta-analysis (more than 30%) were participants in one randomized trial of Dautzenberg et al. 12 This trial allowed physicians to treat patients with daily fractions of 2.50 Gy and total doses of 60 Gy. These doses exceed the doses that have been considered the standard of care in North America for many years. 5,8-10 These high doses do not comply with recent practices because physicians have had concerns about dose-related toxicity and the potential for treatment-related deaths. Both of these suboptimal outcomes were augmented by PORT in the study of Dautzenberg et al. Additionally, a majority of patients who were entered onto the randomized trial of Dautzenberg et al were part of an effort to increase accrual by relaxing the protocol requirements (simplified protocol). It is possible that this simplification detracted from the balance that was sought with the randomization procedure. The analysis of the Surveillance, Epidemiology, and End Results (SEER) database, as highlighted in this issue, demonstrated several similar findings compared with the meta-analysis, with the striking exception of the results for patients with involvement of N2 lymph nodes (N2 disease). Overall, PORT did not have a significant effect on survival and was associated with a survival decrement for patients with N0 or N1 disease. However, PORT was associated with an improvement in survival for patients with N2 disease, unlike the metaanalysis. Therefore, how does the clinician assess the available literature regarding PORT in resected NSCLC and make rational treatment recommendations for patients?