Expert Analysis Reveals Critical Insights for Optimizing Care in LA-NSCLC

An expert analysis has concluded that evidence-based guidance from the American Radium Society Appropriate Use Criteria (ARS AUC) Thoracic Committee on several treatment modalities for locally advanced non–small cell lung cancer (LA-NSCLC)—which accounts for 20% to 30% of lung cancer cases at diagnosis—does have utility for optimizing multidisciplinary care in this challenging patient population.

Findings were published online today in JAMA Oncology, with the study investigators noting the need for their review stems from the most recent appropriate use criteria for these patients came out in 2014 and the publication since then of studies examining radiation therapy technique and dosing, and systemic therapy selection. Their systematic literature review involved relevant articles from PubMed—69 references comprising 30 well-designed studies, 9 moderately well-designed studies, 2 studies with design limitations, and 28 nonprimary data references—that were published between January 1966 and December 2022 and focused on combined chemoradiation therapy, dose escalation, consolidation systemic therapy, and palliative radiotherapy.

“Information regarding the treatment of recurrent disease either locally or with oligometastatic disease after primary treatment for LA-NSCLC is increasingly available and should be integrated into modern clinical decision-making,” they wrote. “Additionally, the use of molecular markers such as EGFR, ALK, and PD-L1 has significantly informed systemic therapy options for many patients with NSCLC, and their integration into LA-NSCLC treatment pathways needs to be clarified.”

This consensus-based document encompasses key practice paradigms and 6 typical clinical scenarios in patients with unresectable disease, which covers most patients who have LA-NSCLC, the authors noted:

• Treatment of a patient with unresectable LA-NSCLC and good performance status
• Treatment of a patient with unresectable LA-NSCLC and good performance status and bulky disease
• Treatment of a patient with EGFR-positive unresectable LA-NSCLC and good performance status
• Treatment of a symptomatic patient with unresectable LA-NSCLC and poor performance status
• Treatment of an asymptomatic patient with unresectable LA-NSCLC and poor performance status
• Treatment of a patient with unresectable LA-NSCLC and local recurrence

The ARS AUC Thoracic Committee, citing a lack of uniform guidance, delivers 3 summary recommendations from their review:

1. For unresectable patients who have LA-NSCLC, appropriate standard-of-care disease management should encompass combined concurrent radical (60-70 Gy) platinum-based chemoradiation and consolidation therapy with durvalumab per PD-L1/EGFR status.
2. Intensity-modulated radiotherapy, because it is conformal in delivery and widely available, should be used when clinicians are planning how to best deliver radiotherapy regimens; tumor bulk and treatment availability, however, may necessitate a switch to 3-dimensional conformal radiotherapy or intensity-modulated proton therapy.
3. In patient cases with either poor performance status and/or pulmonary status, potential for treatment-related toxicity should be a primary consideration, with the authors citing the variety of available palliative and radical fractionation schedules and the benefits of either sequential therapy or radiation therapy alone vs concurrent regimens.

“Treatment appropriateness of a variety of LA-NSCLC scenarios was assessed by a consensus-based modified Delphi approach using a range of 3 points to 9 points to denote consensus agreement,” the authors explained regarding how they arrived at their recommendations.

The authors also highlight the importance of multidisciplinary input and shared decision-making with patients who have LA-NSCLC during treatment discussions, concluding that “various surgical, radiotherapeutic, and systemic options are available to manage this challenging patient population.”

Reference

Rodrigues G, Higgins KA, Rimner A, et al. American Radium Society appropriate use criteria for unresectable locally advanced non–small cell lung cancer. JAMA Oncol. Published online April 11, 2024. doi:10.1001/jamaoncol.2024.0294