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We read with great interest the article by Koshy et al. regarding the “inappropriate delivery of palliative thoracic radiotherapy for metastatic lung cancer” and will focus comments on the radiotherapy aspects (1). The authors explored the National Cancer Data Base and examined thousands of patients and concluded that approximately half of these patients received a higher number of treatments than are recommended in current guidelines and evidence. Patients with private insurance and those treated in the community cancer centers were more likely to receive longer courses and thus were “overtreated” to a greater extent. Clearly implied was that these patients were overtreated with obvious financial implications and without sufficient consideration for the evidence. However, Koshy et al. went further and published another analysis from the same database, which found that the longer higher-dose regimens were associated with improvements in survival on a thorough multivariable analysis (2). They found supporting data within a systematic review published in 2008 examining the findings from 13 randomized studies of palliative thoracic radiotherapy for stages III and IV disease (3). They thoughtfully did suggest prospective trials of higher-dose regimens be performed. However, it does appear that the authors used the same data to disparage radiation oncologists for overtreating patients and then strongly suggested that the very same higher-dose regimens they used improved patient survival. This appears to us as hypocritical. We should be more supportive of the community when a practice improves patient survival even when it is not clearly recommended in guidelines. We believe the authors knew or should have known the implications of the findings from both these studies when they were written and published in the same year, 2015. If a higher-dose regimen is associated with better survival, then its use is not overtreatment but rather appropriate care. These statements do not detract from our admiration for the authors and these pertinent and important analyses, but rather the presentation was divisive and insulting to a large segment of our radiation oncology community that employs higher-dose palliative regimens for stage IV lung cancer. Additionally, if insurers deny coverage for longer courses of therapy after reading the JNCI article, there may be potential implications on patient survival.

RE: Prevalence and Predictors of Inappropriate Delivery of Palliative Thoracic Radiotherapy for Metastatic Lung Cancer