Dirk De Ruysscher, MD, PhD: There are actually 2 big reasons to keep the supportive care optimal and also the chemotherapy and the radiation schedule optimal to avoid adverse effects. First of all, because it’s humane to avoid adverse effects and second, patients should be in very good condition to be able to receive immune treatment afterward. First of all, I think we should start with supportive care before adverse effects occur. So that means quit smoking. From the moment that the patient receives the diagnosis of lung cancer, that is the moment, literally at the same time to discuss quitting smoking, so a smoking cessation program, to discuss nutrition, and to discuss physical exercise. Because you try to avoid this type of conversation to spare the patients, but it has been shown that it’s just reverse.

You should really take the opportunity to discuss this because then you have the highest likelihood not only that the patient will change the way of living but also that he will keep on doing this for a long time, even after 1 or 2 years. So it’s a kind of crisis intervention. You should not wait until after the crisis. You take the opportunity, then you have the biggest chance for success. So it should start before, and it’s also important I think to have a dietician directly involved with those patients because food is so important, taking into account protein intake taking into account that a lot of patients don’t have healthy food habits. Also physical exercise, not necessarily walking or biking but some fitness, and possibly also with a physiotherapist. So that’s where it all starts.

Then, from a technical point of view, stick to the EORTC [European Organization for Research and Treatment of Cancer] guidelines, for instance, for the technical delivery of radiation and to avoid the dose to the normal tissues as much as possible. That’s more technical published ones. Then during the treatment, apart from dietary advice, also painkillers, treatment of infections also of the esophagus, all of this is important to have the patients in the best shape possible. And we have now projects with ESTRO [European Society for Radiotherapy and Oncology] and ESMO [European Society for Medical Oncology] together, so the 2 European societies together, which will be launched at the meeting of ESMO in Munich this year. They will come with evidence-based supportive care measures for patients receiving concurrent chemoradiation.

The European guidelines for supportive care during concurrent chemoradiation are new because there’s no guidelines specifically in this case. So that’s really lacking. What we did is actually look at the 3 pillars for supportive care—so smoking cessation, nutrition, physical exercise. And we looked also at some technical points. But really also what is the evidence, if they are involved, what would be the effect if we do a certain intervention. And for the future, more importantly, we define some knowledge gaps where there’s more research needed to close the gap. But the guidelines will be very practical. So basically, I think that everybody involved in lung cancer care, including the patient, will be able to read it. And even though the background will be quite, let’s say, specialist care, recommendations are very clear and something that everybody could do. For instance, it will be written down that you should do at least 20 to 30 minutes of physical exercise a day, which includes walking or some basic fitness. That’s one possibility or 1 to 1.5 grams of protein a day, something like that. And of course, when it comes to the technical guidelines, we refer to the ones published before.

For the community radiation oncologist, I believe that it’s important to stick to the published guidelines. So really stick to the guidelines according to techniques, how to delineate all risk, how to prescribe the dose, that’s more technical, how to calculate which algorithms should be used. This is really important on one hand. On the other hand, take into account the systemic treatment because some systemic treatment cannot be given with radiation like gemcitabine, as an historical example. That is, I think, the most important message. Stick to the current guidelines, technical guidelines, which drugs to use and which supportive care to use. Don’t say, “Well, it may work with a little bit of difference because it’s more practical,” because you never know at the very end of the day what will come out of it from the point of view of toxicity and even survival.

Transcript Edited for Clarity