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Are Patients Receiving Guideline-Concordant Treatment for Lung Cancer?
Adequate surgery and adjuvant cisplatin chemotherapy have been shown to improve overall survival in patients with resectable non–small-cell lung cancer (NSCLC) who are able to undergo surgery. Investigators retrospectively assessed rates of these guideline-recommended treatments in patients screened for ALCHEMIST (Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial), a clinical trial platform of the National Cancer Institute that supports randomized trials of novel adjuvant therapies. The cohort included 2833 patients with stage IB–IIIA NSCLC (tumors ≥4 cm and/or positive lymph nodes) enrolled at academic and community sites across the U.S.
Findings were as follows:
- 95% underwent anatomic surgical resection
- 53% had adequate lymph node dissection (as defined by National Comprehensive Cancer Network guidelines)
- 57% received any adjuvant chemotherapy
- 34% received any cisplatin-based adjuvant chemotherapy
- 44% received at least four cycles of adjuvant chemotherapy.
Unlike in other studies, no significant disparities were noted in use of lymph node dissection based on region, race, or age. However, there were differences in use of adjuvant chemotherapy, with patients older than 80 being less likely and patients with stage IIIA disease being more likely to receive it.
This study reveals a low rate of guideline-concordant lung cancer care at centers across the U.S. These patients were being considered for clinical trial participation, and clinical trial participants are typically younger and have better performance status and fewer comorbid conditions than patients in routine care; hence, they are more likely to receive guideline-recommended therapies. It is surprising that rates of guideline-recommended therapy for patients recruited to ALCHEMIST were not substantially higher than those reported in broader population-based cohorts.
This study also highlights the difficulties of extrapolating clinical trial findings to broader patient populations. For example, the EGFR tyrosine kinase inhibitor osimertinib and the PD-L1 inhibitor atezolizumab have been integrated into routine adjuvant therapy based on trials in which the primary endpoint was disease-free survival, rather than overall survival. If nodal dissection were inadequate in those trials, that could mean that micrometastatic disease was being controlled during adjuvant therapy.
Lastly, it is important to identify barriers to guideline-concordant care and implement strategies to address inadequate treatment.
Kehl KL et al.
Title: Rates of guideline-concordant surgery and adjuvant chemotherapy among patients with early-stage lung cancer in the US ALCHEMIST study (Alliance A151216).
Source: JAMA Oncol 2022 Mar 17; [e-pub]. (Abstract/FREE Full Text)