Atezolizumab for adjuvant treatment of resected non-small-cell lung cancer (MA review of TA823) [ID6324]

Lung cancer is the third most common cancer and the most common cause of cancer death in the UK accounting for 10% of all new cancer cases and 20% of all cancer deaths in 2020.(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).In 2022 92% (around 34000) of people diagnosed with lung cancer in England had NSCLC.(2) Of these people 18% (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 NSCLCsexpress 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 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 in the form of 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. 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 and is currently being reviewed by NICE. 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.References:1. NHS England. Cancer Registration Statistics England 2020. Accessed March 20242. Royal College of Surgeons of England (2024).

National Lung Cancer Audit: State of the Nation Report 2024. Accessed May 20243. 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/cancersurvivalratescancersurvivalinenglandadultsdiagnosed. 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 33 109–117.5. 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