Durvalumab as neoadjuvant (with chemotherapy) and adjuvant (as monotherapy) treatment for resectable non-small-cell lung cancer ID6220

Lung cancer is the third most common cancer and the most common cause of cancer death in the UK accounting for 13% of all new cancer cases and 21% of all cancer deaths between 2017 and 2019.(1) Most lung cancers are diagnosed at an advanced stage when the cancer has spread to lymph nodes and other organs in the chest (locally advanced disease; stage 3) or to other parts of the body (metastatic disease; stage 4).

Less than 30% of lung cancers are diagnosed at an early stage (stage 1 or 2).(2)In 2021 91% (31374) of people diagnosed with lung cancer in England had NSCLC.(2) Of these people 17% (5333) had surgical treatment for their cancer.(2) Despite the curative intent of treatment for early-stage lung cancer survival is poor with only about 57% people with stage 1 34% with stage 2 and 13% with stage 3 surviving for 5-years after diagnosis.(3) It is estimated that over half of all NSCLCs express the programmed cell death ligand-1 (PD-L1) biomarker.(4) Cancer cells expressing PD-L1 are believed to suppress certain immune responses which results in a weaker anti-tumour response.(45)The treatment pathway for NSCLC can be divided into interconnected decision points based on the number staging system and line of therapy.

Treatment choices are influenced by the presence of biological markers (including programmed cell death 1 ligand PD-L1 status) oncogenic driver genetic alterations histology (squamous or non-squamous) and previous treatment.

NICE’s Technology Appraisal Pathway Pilot scope for treatments for non-small-cell lung cancer outlines in more detail the NSCLC treatment pathway.NICE guideline 122 (NG122) ‘Lung cancer: diagnosis and management’ recommends surgery radiotherapy chemoradiotherapy or a combination of these for stage 1 to 2 NSCLC.

People may be offered a neo-adjuvant (before surgical removal of cancerous tumour) treatment which could be platinum based chemotherapy or nivolumab with chemotherapy as recommended by NICE TA876.

Neoadjuvant chemotherapy has shown equivalent outcomes in terms of survival to adjuvant chemotherapy.(6)For stage 3 NSCLC surgery is carried out if the surgeon deems the tumour to be resectable.

Before surgery chemoradiotherapy (chemotherapy with radiotherapy) may be used or surgery may potentially be followed by chemotherapy.

If well enough people may be offered a cisplatin-based chemotherapy (adjuvant treatment) after surgery.People who have had surgery may have an adjuvant treatment.

NICE TA761 recommends osimertinib in the Cancer Drugs Fund as adjuvant treatment for people whose cancer has an EGFR exon 19 deletion or an exon 21 (L858R) substitution mutation. For people whose cancer does not have an EGFR mutation platinum chemotherapy may be offered as adjuvant treatment.

NICE TA823 recommends atezolizumab in the Cancer Drugs Fund as an option for maintenance treatment after complete tumour resection in adults with stage 2 to 3a NSCLC and adjuvant chemotherapy. References1. Cancer Research UK (2023). Lung cancer statistics. Accessed October 20232. Royal College of Surgeons of England (2023).

National Lung Cancer Audit: State of the Nation Report 2023. Accessed November 20233. Office for National Statistics. Cancer Survival in England: adults diagnosed between 2013 and 2017 and followed up to 2018. 2019.

Available from:https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/ conditionsanddiseases/datasets/cancersurvivalratescancersurvivalinenglanda dultsdiagnosed. Accessed October 20234. Skov B. Rørvig S.

Jensen T. et al. (2020) The prevalence of programmed death ligand-1 (PD-L1) expression in non-small cell lung cancer in an unselected consecutive population. Mod Pathol 33 109–1175. Han Y Liu D Li L. PD-1/PD-L1 pathway: current researches in cancer. Am J Cancer Res. 2020 Mar 1;10(3):727-742. PMID: 32266087; PMCID:PMC7136921.6.

European Society for Medical Oncology (ESMO).

Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis treatment and follow-up. Annals of Oncology. 2017;28(Supplement 4):iv1–iv21. Available from: https://www.esmo.org/Guidelines/Lung-andChest-Tumours/. Accessed October 2023