The evolving role of radiotherapy in advanced non-small cell lung cancer: beyond symptom control.

Abstract

Non-small cell lung cancer (NSCLC) remains the leading cause of cancer mortality in the UK, with most patients presenting with locally advanced or metastatic disease. While palliative radiotherapy has historically aimed to alleviate symptoms, rapid advances in imaging, planning, and delivery-particularly stereotactic ablative body radiotherapy (SABR)-have expanded its role toward disease control. This review summarises the evolving evidence for external beam radiotherapy (EBRT) and SABR in advanced NSCLC. Low-dose thoracic EBRT remains effective for symptom relief, though higher-dose regimens may offer improved control in selected patients. Growing data support the use of local consolidative therapy, particularly SABR, to improve disease control in oligometastatic NSCLC. Trials such as SABR-COMET and that by Gomez et al. demonstrate substantial improvements in progression-free and overall survival with local consolidative therapy, though results are tempered by small sample sizes and heterogeneous populations. Multiple large-scale phase III trials are currently underway to further assess benefits of SABR in oligometastatic cancer and better define dose regimens. Systemic therapies have also rapidly evolved with significant advancements in targeted therapies, immunotherapy, and combination regimens. These are often used alongside radiation therapy, leading to concerns over increased toxicity. Large contemporary randomised trials are underway to update the evidence base in the context of modern systemic therapies. Ultimately, palliative radiotherapy remains central to advanced NSCLC management, with its role expanding from symptom control toward modifying disease progression and improving survival outcomes.