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www.thelancet.com/oncology Vol 15 October 2014 e482

Thoracic radiotherapy in small-cell lung cancerThe results of a randomised phase 3 trial have shown that thoracic radiotherapy (30 Gy, given in ten fractions) plus prophylactic cranial irradiation (20–30 Gy, given in fi ve to 15 fractions) given to patients with extensive-stage small-cell lung cancer improves survival compared with those given prophylactic cranial irradiation alone. The primary endpoint of overall survival at 1 year was 33% (95% CI 27–39) for 247 patients in the thoracic radiotherapy group versus 28% (22–34) for 248 patients in the irradiation alone group (hazard ratio 0·84, 95% CI 0·69–1·01; p=0·066). At 2 years, overall survival was 13% (95% CI 9–19) and 3% (2–8), respectively (p=0·004). The most common grade 3 or greater toxic eff ects in the radiotherapy and no radiotherapy groups were fatigue (11 [4%] vs nine [4%], respectively) and dyspnoea (three [1%] vs four [2%], respectively).

Apar Kishor Ganti (University of Nebraska Medical Center, Omaha, NE, USA) commends the investigators “for conducting this diffi cult trial in a disease that has been resistant to the development of new therapeutic options”, but he does not share the investigators’ optimism that everyone with extensive-stage disease should be off ered thoracic radiotherapy after completion of chemotherapy. “However, consolidation thoracic radiotherapy should be considered in the subset of patients with minimal extrathoracic disease, or in those who have had a complete response outside the chest”, he adds.

Unfortunately, the absence of a signifi cant diff erence in the “designated primary endpoint limits the potential of this study to change the current standards of care, but it can nonetheless inform practice”, says Gregory Videtic (Taussig Cancer

Institute, Cleveland Clinic, OH, USA). He adds that “one can argue that in this population of incurable patients, survival need not be the primary endpoint, but rather that the focus should be on prospectively demonstrating that radiotherapy may improve patient quality of life with minimal additional toxicity”.

Luhua Wang (Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China) notes that more than 10% of the patients in the thoracic radiotherapy group survived for more than 2 years and the overall survival curve seemed to plateau, which suggests that the cancer is curable in these patients. Slotman and colleagues’ results show “us a perfect example of how to use a combined modality therapy to further improve clinical outcomes”, says Wang.

Farhat Yaqub

Published OnlineSeptember 19, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70467-X

For Jors and colleagues’ survey see Cancer 2014; published online Sept 8. DOI:10.1002/cncr.28702

Dignifi ed death from a diff erent perspectiveAccording to the results of Karin Jors and colleagues’ cross-sectional survey of how physicians and nurses viewed end-of-life care in 16 hospitals belonging to ten cancer centres in Baden-Wuerttemberg, Germany, 564 (50%) respondents in palliative care and other wards rarely or never had enough time to care for patients who were dying. Of the 1131 surveys returned (50% response), 109 (95%) respondents in palliative care wards versus 524 (52%) in the other wards (p<0·001) believed that it was possible for patients to die with dignity in their wards. Strikingly, signifi cantly more doctors than nurses believed it was possible for patients to die with dignity on their wards (199 [72%] vs 409 [52%]; p<0·001).

According to 774 (69%) respondents, patients were given the appropriate amount of pain medication. However, 996 (89%) respondents believed

there was a “considerable need to off er more training on how to care for dying patients”. 209 (19%) respondents felt they were well prepared during their general education or training to care for dying patients.

Jors and colleagues’ fi ndings “suggest that dying of cancer in the hospital remains disturbingly undignifi ed”, says Holly Prigerson (Center for Research on End of Life Care, Weill Cornell Medical College, New York City, NY, USA). She continues, “given the selection biases in study participation, there is a strong possibility that the situation is much worse than the results suggest”.

Prigerson also wonders whether asking palliative care staff to report on the adequacy of their services for achieving the goals of palliative care (ie, a good or dignifi ed death) represents a confl ict of interest. In Prigerson’s opinion, Jors and colleagues’ report “should be recognised as

clinicians’ evaluations of the care they provide”.

Mark Steedman (Institute of Global Health Innovation, Imperial College London, UK) points out that the results of this comprehensive study show diff erences in how professionals in palliative care and other wards view end-of-life care for patients with cancer. He says, “overall, this study has shown that the perception medical professionals have in Germany is that much more needs to be done to improve patients’ experiences at the end of life”. Steedman stresses that although palliative care at the end of life does improve the fi nal hours, days, and weeks of patients’ lives, “it needs much more investment in education, training, planning, and integration with non-palliative care wards in order for all patients to have a dignifi ed death”.

Farhat Yaqub

Published OnlineSeptember 19, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70466-8

For Slotman and colleagues’ trial see Lancet 2014; published online Sept 14. http://dx.doi.org/10.1016/S0140-6736(14)61085-0

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