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WCLC 2025 | Timing & benefit of CRT-IO in black & elderly patients with stage III NSCLC
John Varlotto, MD, Marshall University, Huntington, WV, comments on outcomes in elderly and black patients with stage III non-small cell lung cancer (NSCLC) treated with chemo-radiation (CRT) and immunotherapy (IO). Overall survival benefit was maintained regardless of IO timing was reported, even when initiated 42 days post-CRT. Elderly patients benefited similarly to younger patients, and black patients derived greater benefit, despite underutilization in both groups, emphasizing the need to expand IO use in underrepresented populations. This interview took place at 2025 World Conference on Lung Cancer (WCLC) in Barcelona, Spain.
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Transcript
First of all, I’d like to credit our statistician, Dr Rick Volan, for the amazing statistical work that he did. We had basic three questions in the era of locally advanced non-small cell carcinoma lung in the durvalumab era. The PACIFIC trial was established in our country in 2018 when FDA approved it, and it’s very interesting in this world of ever-changing lung cancer therapies, it has been uncontested...
First of all, I’d like to credit our statistician, Dr Rick Volan, for the amazing statistical work that he did. We had basic three questions in the era of locally advanced non-small cell carcinoma lung in the durvalumab era. The PACIFIC trial was established in our country in 2018 when FDA approved it, and it’s very interesting in this world of ever-changing lung cancer therapies, it has been uncontested. So we have real questions about that. What is the timing of post chemo radiation therapy, durvalumab, does it matter? What is the percentage of patients that are receiving durvalumab and how are they selected and what is the overall prognostic characteristics? So what we did was we looked at the National Cancer Database, which is a large database in the US that has about 80% of our population. We looked at the years 2016 to 2021, and what we saw was the percentage of patients receiving durvalumab in the era of its approval 2018 was roughly 52%, which rose to only 63% by 2021, despite a progression-free survival benefit, despite an overall survival benefit, and despite being the biggest advance in 25 years in locally advanced non-small cell lung cancer. So we asked the question in this multivariate analysis, who is being selected for it? And what we saw was the elderly blacks and Hispanics were receiving this. They were much less likely to receive a consolidated durvalumab after concurrent chemoradiation therapy. We looked at prognosis. Prognosis for just chemoradiation therapy. And we wanted to see how durvalumab actually changed the prognosis. The prognosis that we looked at for 2016 to 2017 with just chemo radiation therapy, prognosis was worse with age, comorbidity, and squamous cell carcinoma. And we shifted over to 2018 to 2021 when Durvalumab was being given as standard of care. Those same three factors counted against survival, which was basically age, performance status, and squamous cell carcinoma. However, we now noticed that academic centers had an overall survival benefit, suggesting that when you switch to newer therapies, it may be better to go to an academic institution. The other factor which surprised us was the black population, which was about 12 to 13 percent of our population, actually had an improved survival. So we looked at the timing of post-chemoradiation therapy, durvalumab, and the hazard ratios ranged from 0.57 to 0.63. They didn’t matter that much. It looked a little better if you gave it quicker after chemoradiation, but it mattered a big deal if you gave it at all. And in fact, we looked at the time period of roughly 42 days estimated after chemoradiation to give durvalumab. And in that arm, that patient group, the median time that they received durvalumab after chemo radiation was estimated to be 61 days. And there was a 37% reduction in the hazard ratio, or basically a 37% increase in overall survival by giving durvalumab after 42 days. What we looked at was races, and basically the white non-Hispanics benefited the least. They had a 17% improvement in survival. Blacks or African Americans had a 34% improvement in overall survival. And the Hispanic population, which is quite small in this study, was 32% increase in survival. So blacks and Hispanics benefited more. What about the elderly? We saw that the elderly had a worse prognosis with or without immunotherapy, immunotherapy, but they benefited the same extent with an overall survival benefit of 26%, 29% better if they got immunotherapy. And it was the same benefit as the younger patients. So in summary, with that study, what did we show? We showed timing doesn’t matter as much as giving immunotherapy at all. And even after a two-month median time period, we estimated they seem to benefit greatly from getting immunotherapy. So by all means, if someone’s not getting it right away, give your immunotherapy. We noticed that the blacks and Hispanics received immunotherapy after radiation therapy much less often and benefited actually more than the white, non-Hispanic population. And we also noted that the elderly patient benefited just as well.
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