Pattern of care in locally advanced non-small cell lung cancer: A tertiary care experience from India

Heterogeneity in locally advanced (LA) Non-Small Cell Lung Cancer (NSCLC) group necessitates a multi-disciplinary approach to its management. Surgery is the standard of care treatment if resectable; otherwise, concurrent chemo-radiation (CCRT) is preferred. This audit aims to analyse various treatment strategies in real-world settings and their resultant outcomes.

Medical records of patients presented to the lung cancer clinic at our centre from January 2014 to December 2018 were retrieved. Cases with stage III NSCLC were included in this retrospective analysis. Demographic and clinical data, treatments offered with associated outcomes and side effects were analysed. The progression-free survival (PFS), and overall survival (OS) were computed using Kaplan-Meier survival curves. Cox proportional hazard model (univariate and multivariate) was used to assess factors affecting PFS and OS.

A total of 396 patients of LA NSCLC were eligible for descriptive demography; 53% of them were >60 years of age and male-to-female ratio was 4:1. The proportion of squamous cell carcinoma and adenocarcinoma were 55.8% and 31.3%, respectively. Survival analysis was limited to 310 patients who received any form of cancer treatment. Following multi-disciplinary discussions, the intent of treatment was decided to be curative in 240 of them. Upfront surgical resection was performed in 28 patients (11.6%) with 22 receiving adjuvant chemotherapy. Pre-operative chemotherapy followed by surgery was offered to 20 patients (8.3%). The majority of patients taken for definitive chemo-radiation (CTRT) were treated by induction chemotherapy followed by concurrent CTRT (46 patients = 19.2%). Sequential CTRT (SCRT) was opted for 30 patients (12.5%). Concurrent CTRT (CCRT) was received by only 12 patients (5%). Neoadjuvant chemotherapy (NACT-including preoperative and induction chemotherapy before definitive radiotherapy or CTRT) was administered to 200 patients (83.3%). Of these, 104 patients (43.3%) of NACT were not amenable to curative local treatment later on due to poor performance status (PS), comorbidities, poor cardiopulmonary reserve or logistic issues. The median follow-up was 30.7 months. Survival was assessed by intention to treat analysis. The median PFS and median OS of the curative intent group were 11.9 months (95%CI = 8.99-14.81), and 30.7 months (95%CI = 24.42-36.98), respectively. Upfront resectable patients had longer survival when compared to NACT followed by surgery. Survival outcomes for NACT followed by CCRT were superior to CCRT or SCRT. Both median OS and PFS were found to be superior with surgery plus adjuvant therapy in comparison to definitive CTRT. Long-term survival outcomes were also better with surgical resection. No significant differences in survival outcomes were observed between CCRT and SCRT approaches, likely due to the limited number of patients in the CCRT group. Overall adherence to treatment protocols was 56.7% and adherence to chemotherapy protocols was 50.4%. PS and reception of intended treatment were significant prognostic factors in multivariate analysis for survival. The median PFS and OS of the patients treated with palliative intent were 6.5 months (95% CI: 4.2-12.7), and 9.1 months (95% CI: 3.1-15.7), respectively.

Whenever feasible, curative intent treatment should be offered to fit LA-NSCLC patients. Although stage-wise comparison was not performed, it was seen that survival is longer when tumour is resectable. Homogenous treatment protocols and well-equipped cancer facilities must be in place to avoid deviations from standard recommendations.