Trends in treatment patterns and survival outcomes in advanced non-small cell lung cancer: a Canadian population-based real-world analysis

Abstract

Background: As part of the multi-country I-O Optimise research initiative, this population-based study evaluated real-world treatment patterns and overall survival (OS) in patients treated for advanced non-small cell lung cancer (NSCLC) before and after public reimbursement of immuno-oncology (I-O) therapies in Alberta province, Canada.

Methods: This study used data from the Oncology Outcomes (O2) database, which holds information for ~ 4.5 million residents of Alberta. Eligible patients were adults newly diagnosed with NSCLC between January 2010 and December 2017 and receiving first-line therapy for advanced NSCLC (stage IIIB or IV) either in January 2010-March 2016 (pre-I-O period) or April 2016-June 2019 (post-I-O period). Time periods were based on the first public reimbursement of I-O therapy in Alberta (April 2017), with a built-in 1-year lag time before this date to allow progression to second-line therapy, for which the I-O therapy was indicated. Kaplan-Meier methods were used to estimate OS.

Results: Of 2244 analyzed patients, 1501 (66.9%) and 743 (33.1%) received first-line treatment in the pre-I-O and post-I-O periods, respectively. Between the pre-I-O and post-I-O periods, proportions of patients receiving chemotherapy decreased, with parallel increases in proportions receiving I-O therapies in both the first-line (from < 0.5% to 17%) and second-line (from 8% to 47%) settings. Increased use of I-O therapies in the post-I-O period was observed in subgroups with non-squamous (first line, 15%; second line, 39%) and squamous (first line, 25%; second line, 65%) histology. First-line use of tyrosine kinase inhibitors also increased among patients with non-squamous histology (from 26% to 30%). In parallel with these evolving treatment patterns, median OS increased from 10.2 to 12.1 months for all patients (P < 0.001), from 11.8 to 13.7 months for patients with non-squamous histology (P = 0.022) and from 7.8 to 9.4 months for patients with squamous histology (P = 0.215).

Conclusions: Following public reimbursement, there was a rapid and profound adoption of I-O therapies for advanced NSCLC in Alberta, Canada. In addition, OS outcomes were significantly improved for patients treated in the post-I-O versus pre-I-O periods. These data lend support to the emerging body of evidence for the potential real-world benefits of I-O therapies for treatment of patients with advanced NSCLC.

Keywords: Immune checkpoint inhibitors; Immunotherapy; Non-small cell lung cancer; Population based; Real-world evidence; Retrospective cohort study; Survival; Treatment patterns.

Fig. 1

First-line A and second-line B treatments received by patients with advanced NSCLC in the pre– and post–I-O periods. Percentages for treatment categories are only displayed if > 1%. Abbreviations: 1L first line; 2L second line; I-O immuno-oncology; IQR interquartile range; NSCLC non-small cell lung cancer; NSQ non-squamous; SQ squamous

Fig. 2

Treatment sequencing for patients who received first-line treatment for advanced NSCLC with NSQ A and B or SQ C and D histology in the pre– and post–I-O periods, respectively. Data for categories reflecting treatment of between 1 and 5 patients are masked and have been allocated a standardized line thickness in each of the Sankey diagrams, relative to the respective total number of patients. As such, the thickness of lines may not always correspond as patients transition through the sequence of treatments. Abbreviations: 1L first line; 2L second line; 3L third line; 4L fourth line; I-O immuno-oncology; mAb monoclonal antibody; Non-platinum non-platinum chemotherapy; NSCLC non-small cell lung cancer; NSQ non-squamous; Platinum platinum-based chemotherapy; SQ squamous; TKI tyrosine kinase inhibitor

Fig. 3

Overall survival in patients who received first-line treatment for advanced NSCLC in the pre– and post–I-O periods: A all patients, B patients with NSQ histology, and C patients with SQ histology. Abbreviations: CI confidence interval; I-O immuno-oncology; NSCLC non-small cell lung cancer; NSQ non-squamous; OS overall survival; SQ squamous.