Controversies in Lung Cancer: Heterogeneity in Treatment Recommendations for Stage III NSCLC According to Disease Burden and Oncogenic Driver Alterations

Jeremy P Harris; Dylann K Fujimoto; Misako Nagasaka; Eric Ku; Garrett Harada; Hari Keshava; Ali Mahtabifard; Javier Longoria; Niral Patel; Steven Seyedin; Aaron Simon; Allen Chen

doi:10.1016/j.cllc.2022.02.001

Controversies in Lung Cancer: Heterogeneity in Treatment Recommendations for Stage III NSCLC According to Disease Burden and Oncogenic Driver Alterations

Clin Lung Cancer. 2022 Jun;23(4):333-344. doi: 10.1016/j.cllc.2022.02.001. Epub 2022 Feb 10.

Authors

Affiliations

¹ Department of Radiation Oncology, University of California Irvine, Orange, CA. Electronic address: jeremy.harris@uci.edu.
² Department of Radiation Oncology, University of California Irvine, Orange, CA.
³ Division of Hematology/Oncology, Department of Medicine, University of California Irvine, Orange, CA.
⁴ Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of California Irvine, Orange, CA.
⁵ Division of Cardiothoracic Surgery, Department of Surgery, University of California Irvine, Orange, CA.

PMID: 35256282
DOI: 10.1016/j.cllc.2022.02.001

Abstract

Introduction: Therapeutic options for stage III non-small-cell lung cancer (NSCLC) consist of definitive chemoradiation, surgery combined with neoadjuvant/adjuvant chemotherapy, and trimodality therapy. More recently, biologically driven systemic therapy options, including immunotherapy and targeted therapy, have become increasingly available.

Methods: A customized, case-based survey was designed and distributed to members of the International Association for the Study of Lung Cancer (IASLC) to determine practice habits and preferences for NSCLC patients with stage III disease and N2 to N3 nodal involvement.

Results: Data were compiled from 87 respondents from 31 countries, including medical oncologists (49%), surgical oncologists (24%), and radiation oncologists (21%). Definitive chemoradiation was more likely to be recommended for stage IIIC (98.2%) or stage IIIB (75.8%) scenarios compared with stage IIIA (59.6%) without actionable driver alterations (P < .0001 and .0003, respectively); and chemoradiation was more likely for stage IIIB (57.7%) compared to stage IIIA (39.9%) with actionable EGFR/ALK alterations (P = .008). Surgery was more likely to be recommended in the presence of an actionable alteration (38.7% vs. 19%, P < .0001). Surgeons were more likely than medical oncologists to recommend surgical approaches in scenarios without actionable alterations (25.6% vs. 11.2%, P < .0001) or with actionable alterations (57.5% vs. 31.1%, P = .0001).

Discussion: The dominant recommended strategy for stage III NSCLC was chemoradiation, although respondents were more likely to recommend surgical approaches in the presence of actionable alterations. Despite the lack of reported clinical trial data, many IASLC lung cancer experts favored targeted therapy when actionable driver alterations were present.

Keywords: ALK; Chemoradiation; EGFR; Locally advanced; Surgery.

MeSH terms

Carcinoma, Non-Small-Cell Lung* / drug therapy
Combined Modality Therapy
Cost of Illness
Humans
Lung Neoplasms* / pathology
Neoplasm Staging