NCDB Analysis Shows Survival Benefit With Surgery vs Chemoradiation in NSCLC

Janeesh Sekkath Veedu, MBBS

Surgery-based treatment prolongs survival compared with definitive chemoradiation (CRT) followed by immunotherapy consolidation in patients with stage IIIA non–small cell lung cancer (NSCLC) who are eligible for resection, according to Janeesh Sekkath Veedu, MBBS.

A National Cancer Database (NCDB) analysis evaluating the survival outcomes of surgery-based treatment vs CRT and immunotherapy–based treatment in patients with stage IIIA NSCLC was presented at the 2023 European Lung Cancer Conference (ELCC). This analysis showed that patients who received surgery during the years 2017 through 2019 had a consistent survival advantage over those who received CRT plus immunotherapy during this period, with a hazard ratio of 0.81 (95% CI, 0.75-0.88; P < .001). However, in the patients who received CRT, the addition of immunotherapy improved survival outcomes compared with CRT alone. The overall survival (OS) in patients who received CRT alone in 2014 through 2016 was 39.1%, and the OS in those who received CRT plus immunotherapy from 2017 through 2019 was 56.5%.¹

In 2018, the FDA approved durvalumab (Imfinzi) in patients with locally advanced, unresectable stage III NSCLC who have not progressed after prior CRT, marking the first immunotherapy approval in this patient population. This regulatory decision was based on findings from the phase 3 PACIFIC trial (NCT02125461), in which the PD-L1 inhibitor induced a median progression-free survival of 16.8 months vs 5.6 months with placebo.²

“If [a patient has] stage IIIA NSCLC that is operable and resectable, definitely remove it,” Sekkath Veedu said in an interview with OncLive®. “If there are patients [for whom] you cannot do surgery, that is okay [because] CRT followed by immunotherapy is a good, viable alternative.”

In an interview with OncLive, Sekkath Veedu discussed the need for research comparing outcomes with surgery-based treatment with outcomes with CRT and immunotherapy in stage IIIA NSCLC, shared the findings from the NCDB analysis, and emphasized the importance of continuing this research as updated data become available to follow the evolution of immunotherapy in this disease and determine how this novel treatment affects racial disparities.

Sekkath Veedu is a GME fellow of Internal Medicine at the University of Kentucky College of Medicine in Lexington.

OncLive: What was the rationale behind examining survival outcomes with surgery-based treatment vs definitive CRT and immunotherapy in patients with NSCLC?

Sekkath Veedu: We [evaluated patients with] stage IIIA NSCLC, who have 2 treatment options. One option is surgery-based, and the other is CRT followed by immunotherapy. There has never been a study investigating which [approach] was better for survival and long-term disease control. We thought we should do a large-scale, real-world, database analysis to determine whether surgery-based treatment or chemoimmunotherapy-based treatment was better.

What patient population was included in this analysis?

The NCDB database included patients [ages] 18 years to 99 years of both sexes and all genders. We looked at all patients with [stage IIIA NSCLC who were included in] the NCDB database. We did not [find] any unmet needs. However, many of the patients received CRT and not surgery, despite both [treatment approaches] having the same recommendations for patients with stage IIIA NSCLC. Many patients received CRT in 2014 through 2016 and CRT followed by immunotherapy in 2017 through 2019.

Which treatment approach did this study find to be most effective?

We have an answer for whether surgical-based treatment is better than CRT followed by immunotherapy for patients with stage IIIA lung cancer. [Our analysis showed that], for patients [with resectable] stage IIIA NSCLC, surgery [provided] a survival benefit compared with CRT from 2014 to 2016. When immunotherapy came into play in late 2017 and 2018, surgery still [offered] an advantage over CRT followed by immunotherapy. If [patients are] operable, do surgery. If not, chemoimmunotherapy is still a viable option.

What next steps should be considered for this research?

The next step would be to look at a much larger database, maybe including some patients from the SEER analysis or some cancer registries in different states, as well as investigating more racial differences. Additionally, when the NCDB data are updated, we will have probably a much larger number of patients to study. The cutoff date for the data we had was 2019. We are hoping that in the next 6 months to a year, we will have data from 2020 through 2021.

It is important that we have the newer data because immunotherapy in stage IIIA lung cancer is [relatively new, around] 5 years old. [With a] longer duration of immunotherapy treatment, we can find out whether there is a definite difference between surgery-based and CRT/immunotherapy-based treatments. That’s what we’re looking forward to [evaluating] with the long-term follow-up data.

In addition to submitting these data to the 2023 ELCC, we also submitted [research] to the 2023 ASCO Annual Meeting. For that analysis, we looked at the racial differences between survival in these groups and found that the [outcomes with chemoimmunotherapy were] unexpectedly better for African American patients [than for White patients]. African American patients don’t get enough survival benefit from surgical-based treatment or other treatments. We do believe that it is because of immunotherapy that this disparity has been overcome [in this population]. Stage-by-stage matched [analyses show that] most African Americans don’t get offered surgery. However, if offered chemoimmunotherapy, African Americans have survival outcomes that are the same as or better [than those of White patients]. We are interested in this. If this abstract is accepted, we will spread this message to our ASCO colleagues.

Editor’s Note: Dr Sekkath Veedu reports no disclosures.

References

1. Sekkath Veedu J, Hao Z, Chen Q, Huang B, Shah-Jadeja MM. Survival outcomes of surgery-based treatment or definitive chemoradiation with immunotherapy consolidation in stage IIIA NSCLC in the immune therapy era: an NCDB analysis. J Thorac Oncol. 2023;18(4):S107. doi:10.1016/S1556-0864(23)00372-6
2. Antonia SJ, Villegas A, Daniel D, et al. Durvalumab after chemoradiotherapy in stage III non–small-cell lung cancer. N Engl J Med. 2017;377(20):1919-1929. doi:10.1056/NEJMoa1709937