Uptake of Immune Checkpoint Inhibitors and Survival Among Younger and Older Patients With Advanced NSCLC

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In a U.S. cohort study reported in JAMA Oncology, Voruganti et al found that the uptake of immune checkpoint inhibitor therapy for patients with advanced non–small cell lung cancer (NSCLC) has been associated with “modest” improvements in overall survival, particularly among older patients.

As stated by the investigators, “The introduction of immune checkpoint inhibitors has transformed the care of advanced NSCLC. Although clinical trials suggest substantial survival benefits, it is unclear how outcomes have changed in clinical practice.”

Study Details

The study used Flatiron Health database data from approximately 280 predominantly community-based cancer clinics on patients aged ≥ 18 years diagnosed with stage IIIB, IIIC, or IV NSCLC between January 2011 and December 2019. Overall, approximately 80% of patients were from community oncology practices and approximately 20% were from academic centers. Follow-up was through the end of December 2020. The primary outcome measures were median overall survival and 2-year survival probability; the predicted probability of 2-year survival was calculated using a model adjusting for demographic and clinical characteristics.

Key Findings

The study population consisted of 53,719 patients; the mean age was 68.5 years, 52.8% were male, 67.6% were White, and 33.1% were aged ≥ 75 years.

Overall, receipt of cancer-directed therapy increased from 69.0% in 2011 to 77.2% in 2019. After the first U.S. Food and Drug Administration (FDA) approval of an immune checkpoint inhibitor for NSCLC in 2015, the use of immune checkpoint inhibitors increased from 4.7% of patients in 2015 to 45.6% in 2019 (P < .001). Use of immune checkpoint inhibitors in 2019 was similar among the youngest and oldest patients: in 45.2% of those aged < 55 years and in 43.8% of those aged ≥ 75 years (P = .59).

From 2011 to 2018, the predicted probability of 2-year survival increased from 37.7% to 50.3% (P < .001) among patients aged < 55 years and from 30.6% to 36.2% (P < .001) among those aged ≥ 75 years (P = .001 for comparison).

Over the study period, median overall survival increased from 11.5 months to 16.0 months (P = .001) among patents aged < 55 years and from 9.1 months to 10.2 months (P = .007) among those aged ≥ 75 years. Among patients receiving cancer-directed treatment, median overall survival increased from 14.8 months in 2015 to 19.0 months in 2019 (P = .01) among patients aged < 55 years and from 12.3 to 13.0 months (P = .02) among those aged ≥ 75 years.

Over the study period, median overall survival increased from 12.9 months to 15.0 months (P = .02) among patients aged 55 to 64 years and from 11.2 months to 13.3 months (P < .001) among patients aged 65 to 74 years.

The investigators concluded, “This cohort study found that, among patients with advanced NSCLC, the uptake of immune checkpoint inhibitors after [FDA] approval was rapid across all age groups. However, corresponding survival gains were modest, particularly in the oldest patients.”

Cary P. Gross, MD, of the Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, is the corresponding author for the JAMA Oncology article.

Disclosure: For full disclosures of the study authors, visit

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