In a retrospective cohort study reported in JAMA Oncology, Kenneth L. Kehl, MD, MPH, and colleagues found that only a slight majority of patients with early-stage non–small cell lung cancer (NSCLC) who were enrolled in a U.S. screening study (ALCHEMIST) received guideline-recommended adequate lymph node dissection and adjuvant chemotherapy.
As stated by the investigators, “Standard treatment for resectable NSCLC includes anatomic resection with adequate lymph node dissection and adjuvant chemotherapy for appropriate patients. Historically, many patients with early-stage NSCLC have not received such treatment, which may affect the interpretation of the results of adjuvant therapy trials.”
Study Details
The study included a cohort of 2,833 patients enrolled in the Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial (ALCHEMIST) screening study (Alliance A151216) from August 2014 to April 2019 who did not enroll in a therapeutic adjuvant clinical trial. Patients had large stage IB (primary tumor ≥ 4 cm) to stage IIIA NSCLC.
Outcomes of the analysis included five measures: 1) delivery of anatomic surgical resection; 2) adequate intraoperative lymph node dissection, defined by the National Comprehensive Cancer Network® (NCCN®) as sampling of at least one of lymph node stations 10 or 11, plus at least three mediastinal nodal stations (2R, 2L, 4R, 4L, 5, 6, 7,8, 9R, or 9L) regardless of primary tumor location; 3) delivery of any adjuvant chemotherapy; 4) delivery of at least four cycles of adjuvant platinum-based (cisplatin or carboplatin) chemotherapy; and 5) delivery of any cisplatin-based chemotherapy.
This cohort study found that among participants in a screening protocol for adjuvant clinical trials for resected early-stage NSCLC, just 53% underwent adequate lymph node dissection, and 57% received adjuvant chemotherapy, despite indications for such treatment. These results may affect the interpretation of adjuvant trials. Efforts are needed to optimize the use of proven therapies for early-stage NSCLC.— Kenneth L. Kehl, MD, MPH, and colleagues
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Key Findings
Among the 2,833 patients, 2,697 (95%) underwent anatomic resection; 1,513 (53%) had adequate intraoperative lymph node dissection per NCCN criteria; 1,617 (57%) received any adjuvant chemotherapy; 1,237 (44%) received at least four cycles of platinum-based adjuvant chemotherapy; and 965 (34%) received any cisplatin-based adjuvant chemotherapy. Among 819 patients with stage IIIA disease, 529 (65%) received adjuvant chemotherapy.
On multivariate analyses, compared with patients with stage I disease, those with stage II (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.97–1.20) and those with stage IIIA disease (OR = 1.20, 95% CI = 1.07–1.35) were more likely to have adequate lymph node dissection (overall P < .01); and those with stage II (OR = 1.49, 95% CI = 1.33–1.67) and stage III disease (OR = 1.66, 95% CI = 1.47–1.87) were more likely to receive any adjuvant chemotherapy (overall P < .01). Older age was associated with reduced likelihood of adjuvant chemotherapy use (ORs of 0.89, 95% CI = 0.82–0.96, and 0.55, 95% CI = 0.46–0.66, for 70–79 years and ≥ 80 years vs 60–69 years; overall P < .01). Race and ethnicity were not significantly associated with either likelihood of adequate node dissection or use of adjuvant chemotherapy.
The investigators concluded, “This cohort study found that among participants in a screening protocol for adjuvant clinical trials for resected early-stage NSCLC, just 53% underwent adequate lymph node dissection, and 57% received adjuvant chemotherapy, despite indications for such treatment. These results may affect the interpretation of adjuvant trials. Efforts are needed to optimize the use of proven therapies for early-stage NSCLC.”
Dr. Kehl, of Dana-Farber Cancer Institute, is the corresponding author for the JAMA Oncology article.
Disclosure: The study was supported by grants from the National Cancer Institute and others. For full disclosures of the study authors, visit jamanetwork.com.
