A rapid recommendation update to an ASCO guideline offers revised parameters for adjuvant therapy in patients with resected non–small cell lung cancer (NSCLC) who have stage IB to IIIA disease.1,2 The new guidance reflects the findings from two randomized clinical trials that assessed the use of targeted therapy and immunotherapy in this patient population.3,4
“These two trials are of great importance because they check all the boxes,” said Mark G. Kris, MD, of Memorial Sloan Kettering Cancer Center and guideline expert panel member. “The trials’ results were presented at large international meetings, they have both been published in well-known medical journals, and both [agents] have received approval from the U.S. Food and Drug Administration specifically for this use. They’re already incorporated into other guidelines, so we felt ASCO needed to be in that same group and have these new developments put into their guideline as well.”
Mark G. Kris, MD
Both randomized clinical trials found an improvement in disease-free survival with the use of osimertinib or atezolizumab. Dr. Kris noted that the need for more curative treatments for patients with early-stage lung cancer underscores the urgency of swiftly incorporating these results into the original 2017 guideline.2
The panel made three new recommendations: first, that patients with stage IB disease who have sensitizing EGFR mutations receive adjuvant osimertinib; second, that the routine use of adjuvant cisplatin-based chemotherapy and/or atezolizumab should be avoided for patients with stage IB NSCLC; and third, that all patients with stage IIA, IIB, or IIIA disease be offered adjuvant cisplatin-based chemotherapy.
Dr. Kris noted that the findings from these randomized clinical trials have already started to shape patient care. For instance, before publication of the data from Wu et al, there were no specific guideline-recommended systemic therapies for patients with stage IB NSCLC. Now, adjuvant osimertinib can be offered to the subset of such patients with EGFR-positive lung cancer.3
“The second thing these papers did is, they have now made testing of tumor tissues for targets part of the standard of care, because it’s only through more detailed testing of tumor tissues that we find the characteristics that lead us to recommend these additional therapies—like testing for PD-L1 allows us to be able [to] recommend atezolizumab in the postoperative setting for patients with some expression of PD-L who have stage II, IIA, and IIIA lung cancers,” he added. “Before these data, those tests would not have been a part of routine care, and now they will be.”
The newer studies also make clear that patients who have target mutations, such as EGFR or ALK, are much less likely to benefit from immunotherapies, such as atezolizumab; thus, finding a target will likely help oncologists make treatment decisions that are more aligned with that target, rather than centering therapy around immune-modulating agents. This also opens the door to future research by encouraging the exploration of new, more effective treatments for patients with EGFR and ALK mutations who are unlikely to experience a benefit from immunotherapy.
Although the updated guideline represents some major shifts in the care of patients with early-stage NSCLC, Dr. Kris expressed optimism that oncologists will be ready to embrace these changes because of the established and well-known benefits of atezolizumab and osimertinib. These agents are already used to treat patients with advanced disease; they are effective, safe, and have a low patient burden.
“We very much wanted to, as quickly as possible, do everything we could to make the new therapies that the two randomized clinical trials supported available to physicians, patients, and caregivers throughout the world. That was our hope in doing this update,” Dr. Kris said. “And it’s our belief that this will be practice-changing.”
REFERENCES
1. Pisters K, Kris MG, Gaspar LE, et al: Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancer: ASCO Guideline Rapid Recommendation Update. J Clin Oncol. February 15, 2022 (early release online).
2. Kris MG, Gaspar LE, Chaft JE, et al: Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario Clinical Practice Guideline Update. J Clin Oncol 35:2960-2974, 2017.
3. Wu YL, Tsuboi M, He J, et al; ADAURA Investigators: Osimertinib in resected EGFR-mutated non-small-cell lung cancer. N Engl J Med 383:1711-1723, 2020.
4. Felip E, Altorki N, Zhou C, et al; IMpower010 Investigators: Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010): A randomised, multicentre, open-label, phase 3 trial. Lancet 398: 1344-1357, 2021.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, February 16, 2022. All rights reserved.
