Radiotherapy Patterns of Care for Locally-advanced Non-small Cell Lung Cancer in the Pre- and Post-durvalumab Era: A Region-wide Survey in a Japanese Prefecture

Abstract

The promising results of the PACIFIC study led to the approval of consolidation durvalumab for coverage by the National Health Insurance (NHI) in 2018 for patients with locally-advanced unresectable non-small cell lung carcinoma (NSCLC) treated with definitive concurrent chemoradiotherapy (CCRT). However, the effect of NHI coverage on the patterns of care for this population remains unclear. Here, we conducted a questionnaire-based survey to determine the patterns of care for patients with stage II–III NSCLC treated with definitive radiotherapy in 2017 (pre-durvalumab era) or in 2019 (post-durvalumab era). Data were obtained from 11 radiotherapy facilities in Gunma prefecture, which has a population of 1.94 million. We identified 80 and 83 patients with stage II–III NSCLC who received definitive radiotherapy in Gunma in 2017 and 2019, respectively. At a given facility, CCRT was the treatment of choice in a significantly greater proportion of patients in 2019 than in 2017 (66% ± 20% vs 51% ± 29%, P = 0.041). Intensity-modulated radiotherapy (IMRT) was more frequent in 2019 than in 2017 (24% vs 1.2%). Carboplatin plus paclitaxel was used for CCRT at higher rate in 2019 than in 2017 (73% vs 44%). Consolidation durvalumab was performed in 73% (40/55) of CCRT-treated patients in 2019, and the treatment was performed for the planned 12 months in 45% (18/40) of patients. These data indicate that NHI coverage of durvalumab might be a possible reason for choosing CCRT in patients with stage II–III NSCLC in the real-world setting.

Learning curve of lung dose optimization in intensity‐modulated radiotherapy for locally advanced non‐small cell lung cancer

“…In that sense, reducing adverse events by lowering the dose to organs at risk while securing the radiation dose to the tumor using IMRT has gained great significance. However, there are some barriers in introducing IMRT for locally advanced lung cancer 10 . One such barrier is the complexity of treatment plan optimization.…”

Simple method for evaluating achievement degree of lung dose optimization in individual patients with locally advanced non‐small cell lung cancer treated with intensity modulated radiotherapy

“… 7 Although IMRT for LA‐NSCLC is being increasingly used worldwide, 7 , 8 , 9 , 10 , 11 the proportion of the facilities where IMRT for LA‐NSCLC is performed varies widely in each region, mainly due to limited human and machine resources. 12 One of the obstacles in performing IMRT for LA‐NSCLC is the difficulty in the treatment plan optimization process because it is more complex than for 3D‐CRT. With 3D‐CRT, lung dose distribution may not vary much once target volume is determined.…”

“…Additionally, some researchers have expressed concern that the incidence of radiation pneumonitis (RP) may be slightly higher in specific ethnic groups after CCRT followed by durvalumab. 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 Thus, it is important to create safe and reproducible IMRT plans for treating LA‐NSCLC. However, in the absence of established means of determining clinical goals for lung dose optimization in individual patients, it is difficult to be sure that adequate optimization has been achieved or not.…”

“…Therefore, IMRT has been increasingly administered to patients with LA‐NSCLC, especially in the Western world during the last decade 7 . Although IMRT for LA‐NSCLC is being increasingly used worldwide, 7–11 the proportion of the facilities where IMRT for LA‐NSCLC is performed varies widely in each region, mainly due to limited human and machine resources 12 . One of the obstacles in performing IMRT for LA‐NSCLC is the difficulty in the treatment plan optimization process because it is more complex than for 3D‐CRT.…”

“…However, with IMRT to the same target volume, lung dose optimization can vary widely because dose distribution can easily be modified by adjusting optimization settings. Additionally, some researchers have expressed concern that the incidence of radiation pneumonitis (RP) may be slightly higher in specific ethnic groups after CCRT followed by durvalumab 9–16 . Thus, it is important to create safe and reproducible IMRT plans for treating LA‐NSCLC.…”