乌鸦传媒

Neoadjuvant chemoimmunotherapy has recently been approved in the United States for resectable non-small cell lung cancer (NSCLC). Given the historically limited use of neoadjuvant therapy (NT), a team of researchers recently analyzed data from the U.S. National Cancer Database to identify potential barriers, as well as sociodemographic and clinical factors that predict therapy in the neoadjuvant setting among patients with NSCLC.¹

Their retrospective analysis, published online ahead of print in The Journal of Thoracic and Cardiovascular Surgery, found that lower rates of neoadjuvant treatment were associated with a number of socioeconomic variables, such as Black race, older age, receipt of Medicaid/Medicare insurance, lower income level, and treatment in community centers, as well as with several clinical variables, including a Charlson Comorbidity Index 鈮�2.¹

鈥淥ur findings identify populations who may be at risk of not receiving NT,鈥� the authors concluded in their report, 鈥渁nd steps should be taken to ensure accessibility to all patients eligible for NT.鈥�

Predicting neoadjuvant therapy use

The researchers used data from 2006 to 2019 from the U.S. National Cancer Database, which contains hospital-based tumor registries for approximately 1500 U.S. hospitals. They identified 80,707 patients who had undergone surgery for clinical stage II and III NSCLC. The study population was divided into 2 groups according to whether they had received upfront surgery or neoadjuvant therapy, defined as any type of systemic chemotherapy, radiation treatment, or immunotherapy prior to surgery. 

The research team evaluated various sociodemographic and clinical characteristics and conducted univariable and multivariable analyses to determine any associations with the use of neoadjuvant therapy. In an exploratory analysis, survival differences between propensity-matched groups were calculated using the Kaplan-Meier Method.

Socioeconomic factors linked to less neoadjuvant therapy use

The use of neoadjuvant treatment remained low throughout the study period, the authors noted, with 7.5% and 28.6% of patients with clinical stage II and III NSCLC, respectively, receiving treatment in the neoadjuvant setting. Overall, 21.4% of patients had received neoadjuvant therapy.

According to a multivariable analysis, lower rates of neoadjuvant therapy were significantly associated with:

• Black race (OR 0.78; 95% CI 0.67-0.90; P<.001)
• Older age (OR 0.95; 95% CI 0.95-0.96; P<.001) 
• Medicaid/Medicare insurance (OR 0.82; 95% CI 0.75-0.90; P<.001)
• Low median income level (OR 0.79; 95% CI 0.71-0.87; P<.001)
• Treatment in community cancer centers (OR 0.81; 95% CI 0.67-0.96; P=.02) or in comprehensive community cancer centers (OR 0.72; 95% CI 0.66-0.79; P<.001)
• Facility location in the South (OR 0.79; 95% CI 0.71-0.89; P<.001), Midwest (OR 0.72; 95% CI 0.65-0.80; P<.001), and West (OR 0.81; 95% CI 0.71-0.93; P=.003)

Many of these socioeconomic factors have been linked to undertreatment and poorer survival outcomes among patients with lung cancer in previous investigations, the authors noted in their report.

Charlson Comorbidity Index 鈮�2 was also associated with a lower use of neoadjuvant therapy (OR 0.75; 95% CI 0.67-0.85; P<.001). No significant associations were evident between the use of neoadjuvant therapy and sex, education level, or metropolitan setting.

A significantly higher proportion of patients were treated with neoadjuvant therapy if they had clinically positive lymph nodes (25.5%) vs clinically negative lymph nodes (14.1%; P<.001) and AJCC clinical stage III NSCLC (28.6%) vs AJCC clinical stage II NSCLC (7.5%; P<.001). Moreover, use of neoadjuvant therapy varied by clinical T stage and histology, with a significantly greater percentage of patients with T4 tumors and with adenocarcinoma or squamous cell carcinoma receiving this treatment (P<.001). 

Exploring perioperative and survival outcomes

Compared to those with upfront surgery, patients receiving neoadjuvant therapy prior to their surgery had significantly lower 30-day readmission rates (3.7% vs 4.1%; P<.001), 30-day mortality (2.3 vs 2.9%; P<.001), and 90-day mortality (4.9% vs 5.8%; P<.001). The median length of hospital stay was 5 days for patients undergoing upfront surgery as well as for those receiving neoadjuvant therapy.

In an exploratory analysis, 5-year overall survival rate was comparable for patients with clinical stage II NSCLC receiving neoadjuvant therapy and those undergoing upfront surgery (52% vs 50.6%; P=.08), but was significantly better for patients with clinical stage III NSCLC receiving neoadjuvant therapy (47.8% vs 45.3%; P<.001).

鈥淸W]hile we did note a significant but small survival benefit in patients who received neoadjuvant therapy, there is a possibility that selection bias may also have contributed to this finding,鈥� the authors commented. They did conclude, however, that overall the improvements in perioperative and survival outcomes observed in their study are 鈥渃onsistent with previous studies and supports the neoadjuvant treatment paradigm.鈥�

鈥淎s we move into the neoadjuvant chemoimmunotherapy era,鈥� the researchers added, 鈥渆nsuring that such treatment is available to all patients regardless of socioeconomic status is critical. Barriers to care must be overcome, and local interventions must be developed.鈥�

Published: November 08, 2023