Curative intent therapy of stage I-III non-small cell lung cancer: a patient-centered precision approach to assess, measure, and interpret benefits and harms.

BACKGROUND

The number of people diagnosed with stage I-III non-small cell lung cancer (NSCLC) is increasing, in part due to greater implementation of lung cancer screening and earlier detection. Definitive surgery, radiation, or chemoradiation are increasingly utilized along with adjunctive therapies that include chemotherapy, radiation, immune checkpoint inhibitors (ICIs), and receptor tyrosine kinase inhibitors (rTKIs). However, remedial and adverse effects exist for each modality that must be accounted for in individual treatment plans with curative intent. The objective of this study was to characterize the benefits and harms of curative intent therapy using a novel patient-centered precision approach.

METHODS

We incorporated a precision medicine model to evaluate the benefits and harms using data from phase III randomized controlled trials (RCTs) or individual participant data meta-analyses of RCTs. We followed standard recommendations to assess benefit and harm with the absolute risk reduction (ARR) or absolute risk increase (ARI), and number needed-to-treat (NNT) for beneficial effect (NNTB) or NNT for harmful effect (NNTH). To measure the net effect of benefit and harm, we incorporated a novel summary statistic-the NNT for net effect (NNTnet), calculated as: 1/(ARR - ARI), or 1/(1/NNTB - 1/NNTH). We referenced guideline recommendations and interpreted results from the perspective of a hypothetical patient faced with choosing between treatment options; decision-making accounted for overall survival (OS) effects, what most patients have reported as acceptable mortality risk (≤2%) to gain 1 year of life, and guideline-endorsed treatment-associated mortality risk (≤5%).

RESULTS

We illustrated the NNTnet in screening and diagnosis. In definitive treatment, we identified: (I) overtreatment with lobectomy compared to segmentectomy in peripheral stage IA1-2 NSCLC (5-year OS: ARI, 3.2%; NNTH, 32); and (II) overtreatment with definitive tri-modality treatment for stage III NSCLC (i.e., induction chemoradiation followed by surgery), compared with concurrent chemoradiation without surgery, due to an excessively high 7-10% postoperative mortality with definitive tri-modality treatment and potential subsequent increased mortality within 1-year (two RCTs). In addition, we identified overtreatment with adjuvant radiation, compared to no adjuvant radiation, following complete resection of stage I-IIIB NSCLC (5-year OS: ARI, 5%; NNTB, 20) (14 RCTs). Furthermore, the harm of adjuvant radiation more than offsets the benefit of adjuvant chemotherapy (5-year OS: ARR, 4%; NNTB, 25): 1/(1/25 - 1/20), or -100. In other words, 100 patients treated with surgery and adjuvant radiation and chemotherapy, compared with surgery only, would result in one treatment-related death by 5 years. Finally, across four RCTs evaluating neoadjuvant chemo-ICI therapy, one in five participants with resectable IB-IIIA/B NSCLC did not subsequently receive curative surgery, resulting in potential undertreatment.

CONCLUSIONS

This study has important implications in clinical decision-making and the design of future trials to prevent overtreatment or undertreatment, maximize benefits, minimize harms, and achieve net benefit over harm in beneficent care for this growing population.