Trends in immunotherapy use and survival impact in stage IV non-small cell lung cancer.

Abstract

e20715 Background: Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. 5-year survival rate for metastatic non-small cell lung cancer (NSCLC) is estimated at 4%. For patients who lack a driver mutation, platinum based chemotherapy had been the cornerstone treatment, but the addition of immunotherapy has altered the treatment landscape for many advanced NSCLC patients. Immunotherapy, with or without chemotherapy, has been demonstrated in many clinical trials to extend survival in both the first-line setting as well as subsequent lines of therapy. While the clinical trial data over the past several years has been robust, less is known about how these agents have fared in routine clinical practice. To understand this better, we utilized the National Cancer Data Base (NCDB) to examine the survival of patients who received immunotherapy for stage IV NSCLC. Methods: We queried the NCDB from 2004-2015 for patients with stage IV NSCLC treated with chemotherapy and at least 3 months of follow-up. Multivariable logistic regression was used to determine predictors of immunotherapy use. Multivariable cox regression was used to determine predictors of overall survival. A propensity score was calculated and used to mitigate indication bias. Results: Of 203,069 eligible patients, 5,877 received immunotherapy. The median age was 65 years (40-90). The median follow up was 10.6 months (3-154). Patients were more likely to receive immunotherapy if they were younger, had a lower comorbidity score, received treatment at an academic facility, had adenocarcinoma histology, private insurance, Caucasian race, and a more recent treatment year. The use of immunotherapy rose steadily across the dataset years, rising from 1% to 12%. Predictors of survival were younger age, lower comorbidity score, lower grade tumor, treatment at an academic facility, higher education, higher income, private insurance, metropolitan location, immunotherapy use, adenocarcinoma histology, and more recent year of treatment. On propensity-matched Kaplan-Meier analysis patients treated with immunotherapy in addition to chemotherapy had improved survival, 13.7 months compared to 11.8 months, p < 0.0001. Conclusions: This analysis demonstrates improved overall survival in stage IV NSCLC patients who received immunotherapy. There are inherent limitations of retrospective analyses of data from large databases, however the survival improvement noted in this study is concordant with the more robust prospective clinical research published to date.

Clinical Impact of the Epithelial-Mesenchymal Transition in Lung Cancer as a Biomarker Assisting in Therapeutic Decisions

“…Even in localized stages with a surgically resectable tumor, 5-year survival rates drastically drop from 60% for stage IIA disease to 36% for stage IIIA disease according to the 8th edition staging project of the International Association for the Study of Lung Cancer (IASLC) [Goldstraw et al, 2016]. Promising and innovative strategies are ongoing, especially in neoadjuvant [Uprety et al, 2020] and adjuvant [Broderick, 2020;NCT02595944;NCT02486718;NCT02504372] contexts, which could improve the dramatic landscape of NSCLCs [Otaibi et al, 2019;Kris et al, 2020]. Nevertheless, this fateful prognosis also highlights the need to further refine tumor characteristics in order to improve clinical patient management.…”

Association Between Food and Drug Administration Approval and Disparities in Immunotherapy Use Among Patients With Cancer in the US

“…In several of the scenarios assessed, socioeconomic characteristics (eg, insurance status) were associated with lower immunotherapy use before FDA approval. Insurance-associated differences in immunotherapy use have been previously described, albeit not specifically with regard to the preapproval era . Lower income has been associated with lower use of immunotherapy for melanoma but not for RCC and NSCLC.…”

“…Insurance-associated differences in immunotherapy use have been previously described, albeit not specifically with regard to the preapproval era. 13 , 25 , 36 , 37 Lower income has been associated with lower use of immunotherapy for melanoma 27 , 38 but not for RCC and NSCLC. One possible explanation could be travel burden because, particularly among patients with RCC and melanoma, fewer than one-half of the hospitals that treated patients for the 3 cancer types included in this study were administering immunotherapy before FDA approval.…”

“…Patient health, sociodemographic, and socioeconomic characteristics were selected as independent exposure variables based on exploratory analysis and existing literature. 13 , 14 , 15 The following individual-level independent variables were included: comorbidity measured by a modified Charlson-Deyo comorbidity score (0 indicates no comorbid conditions recorded; 1 and ≥2 indicate an increasing number or severity of comorbid conditions 12 ), age group (≤55 years, 56-65 years, 66-75 years, or >75 years), sex (male or female), race (Black, White, or other race), ethnicity (Hispanic or non-Hispanic), insurance status (none, private, Medicaid, Medicare, or other government insurance), and tumor histological characteristics (for NSCLC: adenocarcinoma, large cell carcinoma, NSCLC not otherwise specified, squamous cell carcinoma, and other [including NSCLC not further defined]; for RCC: clear cell carcinoma, papillary carcinoma, RCC not otherwise specified, and other [including RCC not further defined]; and for melanoma: acral lentiginous melanoma, cutaneous melanoma, melanoma not otherwise specified, and other [including melanoma of the skin not further defined]). The categorization of age was based on approximate quartiles to ensure the same category cutoffs for all 3 cancers.…”