The Impact of the Availability of Immunotherapy on Patterns of Care in Stage III NSCLC: A Dutch Multicenter Analysis

Abstract

Introduction: Treatment patterns in stage III NSCLC can vary considerably between countries. The PACIFIC trial reported improvements in progression-free and overall survival with adjuvant durvalumab after concurrent chemoradiotherapy (CCRT). We 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.

Methods: Details of patients presenting with stage III NSCLC were retrospectively collected. Both CCRT and multimodality schemes incorporating planned surgery were defined as being radical-intent treatment (RIT).

Results: Of 855 eligible patients, most (95%) were discussed at a thoracic multidisciplinary tumor board, which recommended a RIT in 63% (n = 510). Only 52% (n = 424) of the patients finally received a RIT. Predictors for not recommending RIT were age greater than or equal to 70 years, WHO performance score greater than or equal to 2, Charlson comorbidity index greater than or equal to 2 (excluding age), forced expiratory volume in 1 second less than 80% of predicted value, N3 disease, and period of diagnosis. Between 2015 to 2017 and 2018 to 2019, the proportion of patients undergoing CCRT increased from 34% to 42% (p = 0.02) and use of sequential chemoradiotherapy declined (21%-16%, p = 0.05). Rates of early toxicity and 1-year mortality were comparable for both periods. After 2018, 57% of the patients who underwent CCRT (90 of 159) received adjuvant durvalumab.

Conclusions: After publication of the PACIFIC trial, a significant increase was observed in the use of CCRT for patients with stage III NSCLC with rates of early toxicity and mortality being unchanged. Since 2018, 57% of the patients undergoing CCRT went on to receive adjuvant durvalumab. Nevertheless, approximately half of the patients were still considered unfit for a RIT.

Keywords: Immunotherapy; Multidisciplinary tumor board (MDT); Non–small cell lung cancer (NSCLC); Patterns of care; Stage III.

Figure 1

Flow diagram of all patients. Final treatment rates were as follows: in 13% surgery (of which 42% [n = 45] underwent surgery combined with CCRT); 38% CCRT; 19% SCRT; 9% RT greater than or equal to 50 Gy; 22% palliative care; 1% unknown. Thoracic radiotherapy of at least 50 Gy (RT ≥ 50 Gy). CCRT, concurrent chemoradiotherapy; CT, chemotherapy; IMT, immunotherapy; MDT, multidisciplinary tumor board; RT, radiotherapy; SCRT, sequential chemoradiotherapy; TKI, tyrosine kinase inhibitor.

Figure 2

In the period from 2015 to 2017, 46% of patients underwent RITs, and this increased to 55% during the period from 2018 to 2019 (p = 0.01), with no differences observed among the three regions (p = 0.39). See Supplementary Appendix 1 for an overview of each region. CCRT, concurrent chemoradiotherapy; n-RIT, non–radical-intent treatment; RIT, radical-intent treatment; RT, radiotherapy; SCRT, sequential chemoradiotherapy.

Figure 3

Overview of MDT recommendations versus the actual treatments received by patients with stage III NSCLC. The percentage displayed in the figure represents patients who ultimately received MDT-recommended therapy. Only for those for whom SCRT (D) was the MDT-recommended treatment, a significant difference was observed between the period from 2015 to 2017 and 2018 to 2019, with significantly more switchers to palliative care in the period of 2018 to 2019 (14%–33%, p = 0.006). Data on six patients without follow-up data are omitted. CCRT, concurrent chemoradiotherapy; MDT, multidisciplinary tumor board; RT, radiotherapy; SCRT, sequential chemoradiotherapy.