Real-World Treatment of Stage III NSCLC: The Role of Trimodality Treatment in the Era of Immunotherapy

Abstract

Introduction: Curative intent treatment of stage III NSCLC is variable and influenced by both patient and disease characteristics. We performed a real-world analysis of curative therapies in stage III NSCLC, and explored the impact of known prognostic factors on outcome. Methods: A retrospective review was completed of all patients with stage III NSCLC between January 2005 and December 2012. Cases were filtered to identify those receiving curative intent therapy including surgery, radiotherapy (RT), chemoradiotherapy (CRT), and combined modality with surgery (S þ RT). Information was collected on known prognostic and predictive factors, and immunotherapy eligibility per the PACIFIC trial. The primary outcome measure was overall survival. Results: A total of 638 patients with stage III NSCLC were referred and received curative intent treatment. Of these, 66 (10%) received surgery, 95 (15%) RT, 410 (64%) CRT, and 67 (11%) combined S þ RT. Median overall survival (OS) was similar for surgery (28.6 mo) and CRT (27.0 mo), inferior for RT alone (17.5 mo), and superior for S þ RT (55.8 mo). In a multivariate model only, Eastern Cooperative Oncology Group performance status (ECOG PS) and treatment cohort significantly influenced OS. In a case-matched analysis, the median OS for CRT was 31.9 months, compared to 55.8 months with trimodality treatment. Overall, 61% of patients receiving CRT and 88% of those receiving trimodality therapy would have been potentially eligible for adjuvant immunotherapy. Conclusions: In stage III NSCLC, the performance of surgery and CRT are similar after controlling for known prognostic factors. Radiotherapy alone is associated with worse outcomes. Combined S þ RT appears to provide a significant benefit above other modalities, albeit in highly selected patients.

Care of patients with non-small-cell lung cancer stage III – the Central European real-world experience

“…In comparison to our study, the proportion of females were slightly higher in the American study (44.8%) and the Canadian study (46%). 20,22 The percentages of stage IIIA patients were similar between our and the American study but higher (77%) in the Canadian study. 20,22 A major goal of our study was to determine the diagnostic and staging procedures ( Table 2).…”

“…20,22 The percentages of stage IIIA patients were similar between our and the American study but higher (77%) in the Canadian study. 20,22 A major goal of our study was to determine the diagnostic and staging procedures ( Table 2). Computer tomography of the chest, supplemented by CT or ultrasonography of the upper abdomen, was performed in most patients.…”

“…Our real-world data can also be compared with those from other recent real-world studies. [20][21][22][23] All studies were similar in terms of median age (around 65 years), good PS (75-86%), never-smokers (4-9%) and percentage of adenocarcinomas (around 40%). In comparison to our study, the proportion of females were slightly higher in the American study (44.8%) and the Canadian study (46%).…”

“…In the Canadian real-world study, 58% of patients received a PET scan as part of staging and 74% had baseline brain imaging. 22 Bronchoscopy was performed in 89% of patients, thereby being the most frequent intervention for obtaining tumour material for histopathological diagnosis. Only 13.5% of patients had histopathological mediastinal nodal staging prior to therapy.…”

“…The American and Canadian real-world studies did not provide data on histopathological assessment of mediastinal lymph nodes prior to treatment. 20,22 In a retrospective analysis of 106 patients who had been treated with definitive radiotherapy (plus chemotherapy in most patients), 48.1% of patients had pathological confirmation of nodal disease. 24 Treatment of our patients involved surgery, radiotherapy and chemotherapy (Table 4).…”