A recent study published by Ronden et al in JTO Clinical and Research Reports highlights the gap between treatment guidelines and real-world care with the monoclonal antibody durvalumab for patients with non–small cell lung cancer. Researchers studied treatment decision-making by three Dutch regional thoracic multidisciplinary tumor boards between 2015 and 2019 to identify changes in practice when adjuvant durvalumab became available.
Study Methods and Findings
The team analyzed records of 855 patients presenting with stage III NSCLC between January 2015 and December 2019. Both concurrent chemoradiotherapy as well as multimodality schemes incorporating planned surgery were defined as being radical-intent treatments.
The majority of patients (95%) were discussed at a thoracic multidisciplinary tumor board which recommended radical-intent treatments in 63% (n = 510; 47% concurrent chemoradiotherapy, 16% surgery). Only 52% (n = 424) of patients finally received radical-intent treatments. Predictors for not recommending a radical-intent treatment included age ≥ 70 years, a World Health Organization performance score of ≥ 2, a Charlson Comorbidity Index of ≥ 2 (excluding age), a FEV1 < 80% of predicted value, N3-disease, and period of diagnosis (2015–2017).
Between 2015 to 2017 and 2018 to 2019, the proportion of patients undergoing concurrent chemotherapy increased from 34% to 42% (P = .02), the use of surgery was unchanged, and use of sequential chemoradiotherapy declined (21% to 16%, P = .05). Rates of early toxicity and the 1-year mortality were comparable for both periods. After 2018, 57% of patients who underwent concurrent chemoradiotherapy (90 of 159) received adjuvant durvalumab. No significant differences in patient population and treatment decision-making were observed between the three regions.
Following publication of the results of the PACIFIC trial, a significant increase was observed in the use of concurrent chemotherapy for patients with stage III NSCLC in these three Dutch regions, although the rates of early toxicity and mortality were unchanged. Since 2018, the majority of patients undergoing concurrent chemoradiotherapy also received adjuvant durvalumab.
“Our study highlights the gap between guideline-recommended treatments and real-world care of patients with stage III NSCLC, and it also demonstrates a timely incorporation of evidence-based medicine into oncology practice,” the researchers reported.
They concluded, “In conclusion, after publication of the PACIFIC study, and with availability of consolidation durvalumab for routine care, an increase in the use of concurrent chemoradiotherapy in stage III NSCLC was observed with rates of early toxicity and mortality being unchanged. Since 2018, most patients undergoing concurrent chemoradiotherapy received durvalumab. Nevertheless, nearly 50% of patients who present with stage III NSCLC were considered unfit to undergo a radical-intent treatment. The current treatment guidelines are less explicit on how such patients should be managed, and data from ongoing trials evaluating durvalumab after sequential chemotherapy and radiation in less-fit patients are awaited. Our findings suggest that there is room for multidisciplinary tumor boards to increase the rate of use of concurrent chemoradiotherapy for stage III NSCLC. The findings also highlight the need for novel clinical trials to address the unmet needs of patients who cannot receive treatment with radical intent, in an era of significant advances in systemic therapies for NSCLC.”
Disclosure: For full disclosures of the study authors, visit jtocrr.org.
