Results from 47 trial comparisons and 11,107 patients demonstrate the clear benefit of adjuvant chemotherapy for these patients, irrespective of whether chemotherapy was given in addition to surgery or surgery plus radiotherapy. This is the most up-to-date and complete systematic review and individual participant data (IPD) meta-analysis that has been carried out.
The significant improvements in PFS and ORR with pembrolizumab plus PC versus PC alone observed in the primary analysis were maintained, and the HR for OS with a 24-month median follow-up was 0.56, favoring pembrolizumab plus PC.
As compared with radiotherapy alone, adjuvant radiotherapy and chemotherapy with cisplatin and etoposide does not decrease the risk of intrathoracic recurrence or prolong survival in patients with completely resected stage II or IIIa non-small-cell lung cancer.
p53 mutations and protein overexpression are not significant prognostic or predictive factors in resected stage II or IIIA NSCLC. K-ras mutations may be a weak prognostic marker. p53 or K-ras should not be routinely used in the clinical management of these patients.
SUMMARYBackgroundAdjuvant chemotherapy for resected early stage NSCLC provides modest
survival benefit. Bevacizumab, a monoclonal antibody directed against
vascular endothelial growth factor, improves outcomes when added to
platinum-based chemotherapy in advanced stage non-squamous NSCLC. We
conducted a phase III study to evaluate the addition of bevacizumab to
adjuvant chemotherapy in early stage resected NSCLC (E1505). The primary
endpoint was overall survival.MethodsAdult patients (≥ 18 years old) with ECOG performance status
0 or 1 with completely resected stage IB (≥4 centimeters) to IIIA
(AJCC 6th edition) NSCLC were enrolled within 6–12 weeks of surgery
and stratified by chemotherapy regimen, stage, histology, and sex. Minimum
mediastinal lymph node sampling at specified levels was required (level 7
and 4 for right-sided tumors or level 7 and 5 and/or 6 for left-sided
tumors). Normal laboratory values within two weeks of randomisation were
required for enrollment. Chemotherapy, which was selected for each patient
prior to randomisation, consisted of four, 3-week (21-day) cycles of
cisplatin (75 mg/m2 in all regimens) with either vinorelbine 30
mg/m2 days 1 and 8; docetaxel 75 mg/m2 day 1; OR
gemcitabine 1200 mg/m2 days 1 and 8; OR, starting in 2009 with an
amendment, pemetrexed 500 mg/m2 day 1 along with B12 and folic
acid supplementation. Patients were randomised 1:1 to Arm A (chemotherapy)
or Arm B, adding bevacizumab at 15 mg/kg every 3 weeks starting with cycle 1
of chemotherapy and continuing for one year. Randomisation to treatment arm
was performed centrally and determined using permuted blocks within strata
with dynamic balancing on institution. The study had 85% power to
detect a 21% reduction in the overall survival (OS) hazard rate with
a one-sided 0·025-level test. The primary endpoint was overall
survival, which was defined as the time from randomisation to death from any
cause, and patients who were thought to be alive at the time of final
analysis were censored at the last date of contact with analysis done based
on intention to treat. This is final analysis of the primary endpoint of
overall survival of E1505 (NCT00324805).FindingsFrom July 2007 to September 2013, 1501 patients were enrolled, of
whom 26% (N=383) had stage IB, 44% (N=636)
stage II, and 30% (N=439) stage IIIA) with 28%
(N=422) squamous cell histology. Cisplatin-based chemotherapy
regimens utilized were vinorelbine 25% (N=377), docetaxel
23% (N=343), gemcitabine 19% (N=283), and
pemetrexed 33% (N=497). At a median follow-up time of
50·3 months (IQR 32.9–68.0), estimated OS hazard ratio (B/A)
was 0·99 (95% CI: 0·82–1·19,
p=0·90). The median OS on Arm A has not been reached and is
85.8 months (95% CI 74.9-NA) on Arm B. Statistically significantly
increased grade 3–5 toxicities of note (all attributions) included:
overall worst grade (ie all grade 3/4/5 toxicities)
(67%(N=496) versus 83%(N=610)); hypertension
(8%(N=60) versus 30%(N=219)), and
neutropenia (33%(N=241) versus 37%(N=275))
on Arms A and B, respectively. There was no s...
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