Data Show Increasing Systemic Therapy Use in NSCLC Radiotherapy Population

CancerNetwork^® spoke with Patrick Oh, MD, a hospital resident at the Yale School of Medicine, about what his team’s study findings reveal about the current state of real-world use of systemic treatment modalities among patients with early-stage non–small cell lung cancer (NSCLC) undergoing radiotherapy. He discussed the findings in the context of a study he presented at the 2024 American Society of Radiation Oncology (ASTRO) Annual Meeting.

Oh began by explaining that the National Comprehensive Cancer Network (NCCN) guidelines suggest that very few, if any, patients with early-stage NSCLC should receive systemic therapy. He then stated that about 15% (n = 260) of his cohort of approximately 1700 patients assessed from the Flatiron Health database had received systemic therapy despite the guideline recommendations.

He further outlined the various modalities of systemic therapy reflected in the patient data, including 207 patients who underwent chemotherapy, 105 who received immunotherapy, and 33 patients who received individualized therapy in addition to radiotherapy.

He further explained that patients with higher T staging were more likely to have received systemic therapy, which aligns with NCCN guidelines. He revealed that patients underwent immunotherapy regardless of PD-L1 status, despite prior consideration that patients with higher PD-L1 status may receive more benefit from the treatment.

In the study, concurrent immunotherapy was given to 0.3%, 0.6%, and 1.5% of patients with T1, T2, and T3 disease, respectively (P = 0.081). Additionally, adjuvant or neoadjuvant therapies, respectively, were received by 2.8% and 0.3% with T1 disease, 6.8% and 0.6% with T2 disease, and 22% and 0.5% with T3 disease (P < .001; P = 0.3).

Furthermore, immunotherapy was given to 6.5% of patients with PD-L1–negative status, 9.9% of patients with 1% to 49% PD-L1 expression, and 9.8% of patients with PD-L1 expression of 50% or greater.

Transcript:

We had a large cohort. It was [approximately] 1700 patients in total whom we were able to include in our analysis….If we go by NCCN guidelines, currently, all, if not most, of these patients should not be receiving any form of systemic therapy because it is not indicated. What we found was a surprising result, that [approximately] 15% of these 1700 patients were receiving some form of systemic therapy in the node-negative setting.

Of these 260 patients who received some sort of systemic therapy, chemotherapy was given to 207 patients. Additionally, there was a handful of patients who also received immunotherapy. Also, with increasing indications to provide targeted therapy for [patients with] NSCLC, we found that 33 patients also received some form of individualized therapy. Initially, we found that with higher T staging, patients were more likely to have received some form of systemic therapy, and that seems to correlate with the guidelines for NCCN as well.

If you look at the fine print, there is a recommendation to consider adjuvant systemic therapy after radiation for patients deemed to be high risk. The question is, as a field, we have yet to truly come to a consensus to figure out who the high-risk patients truly are, meaning [those who are] at a greater risk of relapse following what we deem to be curative treatments. What we found is that patients with higher T staging, meaning larger tumors, were found to have received additional therapy on top of radiation.

With respect to the immunotherapy, we found that [patients received] immunotherapy [regardless] of their PD-L1 status. There is a thought that with a higher PD-L1 status, you might benefit more from the receipt of immunotherapy. What we found was that even if you were PD-L1-negative, there was a possibility that you might be a candidate to receive immunotherapy.

Then, ultimately, we found that, over time, there seems to be a particularly increasing use of immunotherapy and targeted therapy, which seems to suggest greater excitement for these therapies on top of radiation. The hope is that we would soon have the randomized clinical data to back that up as well, and ultimately potentially incorporate it as standard-of-care practice.

Reference

Oh P, Sasse A, Wells N, Kim SY, Goldberg SB, Park HS. Real-world practice patterns of immunotherapy, chemotherapy, and targeted therapy with radiation therapy in early-stage node-negative non-small cell lung cancer. Int J Radiat Oncol. 2024;120(suppl 2):e52-e53. doi:10.1016/j.ijrobp.2024.07.1893