Top Line: How do you get everyone to agree on the best treatment for early-stage non-small cell lung cancer (NSCLC)? Use immunotherapy, stereotactic body radiation (SBRT), and surgery.
The Study: Phase 3 testing has already demonstrated an improvement in pathologic complete response rate (pCR) with the addition of immune checkpoint inhibition to chemotherapy prior to resection of NSCLC. This prospective randomized phase 2 trial asks if the addition of upfront SBRT can further improve pCR. Patients with resectable stage I-IIIA NSCLC all received two 3-week cycles of durvalumab pre-op with +/- the addition of SBRT (8Gyx3 over three consecutive days) immediately prior to the first durvalumab infusion. After neoadjuvant therapy, 26/30 (87%) in each arm went to surgery. The primary endpoint was rate of “major” pathologic response defined as no more than 10% viable tumor cells remaining, a validated surrogate of overall survival in this setting. Even with small numbers, there was a clear improvement with the addition of SBRT. After durvalumab alone 3/27 achieved major responses compared to 16/26 with SBRT+durvalumab, including 8 complete responses.
TBL: Larger studies with longer follow-up may prove the best outcomes are borne of combining, rather than competing, local therapies for early-stage NSCLC. | Altorki, Lancet Oncol 2021