medwireNews: A US cohort study has identified low rates of use of certain standard treatments in patients with resectable, early-stage non-small-cell lung cancer (NSCLC).
“[J]ust 53% underwent adequate lymph node dissection, and 57% received adjuvant chemotherapy, despite indications for such treatment,” note Kenneth Kehl (Dana-Farber Cancer Institute, Boston, Massachusetts, USA) and co-investigators in JAMA Oncology.
They add: “This study suggests that efforts to optimize the use of standard therapy for early NSCLC are needed, and adjuvant trial results for NSCLC should be interpreted in light of potentially suboptimal standard therapy among participants.”
The researchers drew on the ALCHEMIST screening trial to identify 2833 individuals with stage IB–IIIA NSCLC who did not subsequently enroll in a therapeutic adjuvant clinical trial. Participants were aged a median of 67 years, 53% were women, and 86% had nonsquamous disease.
The rate of anatomic resection in the cohort was high, at 95%, they report, but adequate intraoperative lymph node dissection, as per National Comprehensive Cancer Network criteria, occurred in only 53% of patients.
The proportion of patients who received any adjuvant chemotherapy was 57%, while 44% received four or more cycles of platinum-based regimen and 34% received a cisplatin-based regimen.
“The apparent low rate of adjuvant chemotherapy was not solely due to treatment patterns among patients with earlier-stage disease (eg, stage IB per AJCC 7), who may derive less benefit from chemotherapy,” say Kehl and colleagues, noting that even among the 819 patients with stage IIIA disease, just 65% received adjuvant chemotherapy.
Multivariable analysis showed that patients aged at least 80 years were significantly less likely to receive adjuvant chemotherapy versus those aged 60–69 years, at a risk ratio (RR) of 0.55, whereas a diagnosis of stage II or IIIA disease was associated with a significantly greater likelihood for adjuvant treatment than stage IB disease, at RRs of 1.49 and 1.66, respectively.
“Notably, there was no significant association of race and ethnicity with any of these outcomes,” say the study authors.
Discussing the study limitations, they highlight that “this analysis examined process outcomes, including delivery of surgery and adjuvant chemotherapy, rather than clinical outcomes, such as survival.”
The team continues: “Still, associations between these process metrics and clinical outcomes have been described previously, and these associations will be examined as part of a planned survival analysis of the overall ALCHEMIST trial once there is a sufficient number of events.”
The authors of an accompanying commentary – Monica Tang (University of New South Wales, Sydney, Australia) and Chee Khoon Lee (University of Sydney, New South Wales, Australia) – believe that this research “provides impetus for future research into the barriers to widespread adoption of evidence-based treatment guidelines in routine practice.”
And they conclude: “If variations in the rates of guideline-recommended practice are attributable to health system or sociodemographic factors, then addressing these system-level barriers will be critical for promoting equitable cancer care and improving outcomes for all patients with early-stage NSCLC.”
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JAMA Oncol 2022; doi:10.1001/jamaoncol.2022.0039
JAMA Oncol 2022; doi:10.1001/jamaoncol.2022.0038