Does nivolumab for progressed metastatic lung cancer fulfill its promises? An efficacy and safety analysis in 20 general hospitals.

OBJECTIVES: In patients with refractory or recurrent non-small-cell lung cancer (NSCLC) after first line chemotherapy, phase III trials showed superiority of nivolumab, an IgG4 programmed death-1 immune-checkpoint-inhibitor antibody, over docetaxel. We evaluated case mix, effectiveness and safety of nivolumab upon implementation in general practice. MATERIALS AND METHODS: In 20 general hospitals, all consecutive NSCLC patients treated with nivolumab within the medical need program (inclusion period 12 months) in Flanders - Belgium were evaluated. RESULTS: There were 267 patients, Eastern Cooperative Oncology Group (ECOG) score was 2 in 24% and 0-1 in 76%. In 48%, two or more systemic regimens were given before nivolumab. The median overall survival was 7.8 months (95% confidence interval (CI) 6.3-9.3). At one year, the overall survival rate was 36.5±0.34%. Median progression-free survival was 3.7 months (95% CI 2.9-4.5). An objective response was obtained in 23.2%. ECOG score 2 and presence of liver metastasis strongly correlated with worse survival (p<0.00001). Treatment related adverse events grade 3 or 4 were reported in 21%, colitis (4%) and pneumonitis (7%) were most frequent. CONCLUSION: Upon implementation of nivolumab therapy in general hospitals, the case mix was characterized by a more heavily pretreated population with a substantial fraction of patients with ECOG score 2. The median overall survival is slightly inferior to what was published in the randomized phase III trials. An ECOG score 2 and the presence of liver metastasis correlated strongly with a worse survival. We report a high prevalence of serious adverse events.

Generalized or personalized treatment for stage IIIA-N2 non-small-cell lung cancer?

The optimal approach to and the role of surgery in stage IIIA-N2 (ipsilateral lymph node metastases) non-small-cell lung cancer (NSCLC) remains a challenge for many clinical oncologists. Much of the question relates to the choice between a generalized or personalized approach. We should realize that a generalized approach--'chemoradiotherapy fits all'--as advocated by some based on Phase III trials--is not optimal for these patients, just as 'any platinum doublet fits all' is no longer the best choice in stage IV NSCLC. While chemoradiotherapy may be the choice for patients with bulky or multilevel N2-disease, for others surgery will be an important part of the multimodality treatment. To make this distinction, 'personalization factors' should be considered: complete resectability, downstaging of mediastinal nodes and favorable clinical and pathological response of the primary tumor. A personalized approach making the appropriate choice based on multidisciplinary assessment of stage, resectability and cardiopulmonary fitness is in the interest of each of our individual stage IIIA-N2 patients.