PACIFIC: Time for a surgical IIIA uprising

Abstract

Feature Editor's Note-If you are not already committed based on the title alone, this is an article that should be read by all thoracic surgical oncologists. The PACIFIC trial is randomized trial recently published in the New England Journal of Medicine that showed improvement in progression-free survival in patients with unresectable stage IIIA-B non-small cell lung cancer treated with PD-L1 blockade (compared with placebo) after

How Effective Is Neoadjuvant Therapy Followed by Surgery for Pathologic Single-Station N2 Non–Small Cell Lung Cancer?

“…5 At one extreme, recently published results from the Pacific Trial-which demonstrated the efficacy of immunotherapy after chemoradiotherapy for unresectable locally advanced lung cancer-have been interpreted as a requiem for surgery for stage IIIA NSCLC. 16,17 Nevertheless, in previous randomized trials of patients with locally advanced lung cancer, OS was clearly better among patients managed with multimodality treatment that included surgery Figure 2. Disease-free survival showed no significant differences both before (A) and after (B) applying the matching-weights procedure for patients with cN0-pN2a1 nonÀsmall cell lung cancer who underwent NS versus patients who underwent SF for cN2-pN2a1 disease.…”

“…18 In addition, in the reporting on the Pacific Trial, the researchers do not acknowledge the prognostic distinction between subsets of N2 disease-in particular, the difference between single-station and multistation N2 disease is not noted. 17 At the other extreme, survival following SF for unsuspected occult pN2 disease may overlap survival for pN2a and even pN1 disease, and survival for occult pN2 disease is undisputedly the best for the entire N2 group. 7,19,20 One caveat when considering occult pN2 disease is that we may be focusing on a subset of patients with limited disease and, possibly, a peculiar biology.…”

Video‐assisted thoracoscopic surgery as the gold standard for lung cancer surgery

“…90 The evidence for the other non-surgical treatment options is even weaker. 83 Nevertheless, the hard facts proving that surgery remains oncologically and clinically superior may not be enough to overcome the wishful thinking of many patients (and even their clinicians) that there is some way to avoid being brought under the surgeon's knife. This is because there is an almost instinctive assumption that surgery causes more morbidity.…”

“…The misperception has persisted amongst some clinicians even though this paper has since been exposed as containing many significant flaws, including both trials in the pooled analysis being terminated early with only a very small number of patients recruited, short follow‐up, multiple areas of heterogeneity between the two trials being pooled for analysis, high proportion of patients who did not complete their assigned surgical procedure and many others 81 . Immunotherapy was also suggested to have rendered surgery obsolete for stage III lung cancer by the PACIFIC trial by some, 82,83 and it may only be a matter of time before the same is true for earlier stages of lung cancer.…”

“…found that despite patients in the surgical arm having worse lung function before treatment, they experienced no more complications than those in the SBRT arm at 90 days after treatment 90 . The evidence for the other non‐surgical treatment options is even weaker 83 …”