COMMENTARY

Durvalumab After Chemoradiotherapy 'Immediately Changes Practice' in Patients With NSCLC

Mark G. Kris, MD

Disclosures

October 27, 2017

Hello. This is Mark Kris from Memorial Sloan Kettering in New York City. Today I'm speaking about an important development that was announced at this year's European Society for Medical Oncology Congress in September. This pertains to the use of durvalumab, an anti-PD-1 agent, following the completion of concurrent chemotherapy and radiation for patients with locally advanced lung cancers.

In this trial,[1] patients who received durvalumab after the completion of best therapy received a huge improvement in progression-free survival compared with patients who did not receive durvalumab. This is a very important development, primarily because it is the first time in nearly two decades that there has been a development in this field.

We know that some of these patients [with locally advanced lung cancers] can be cured and we would love to improve the cure rate in a way that would be practical. All of our efforts in recent years—adding more chemotherapy, longer chemotherapy, or higher doses of radiation—have not been successful. But in this trial, giving durvalumab after the conclusion of chemotherapy and radiation resulted in progression-free survival, the endpoint of the trial.

I believe that this is one of those trials that immediately changes practice. I think all of us should try to use this agent or a comparable one for patients with this stage of disease. Durvalumab has other advantages as well.

Many oncologists have continued chemotherapy after the conclusion of chemotherapy and radiation, despite data showing that it is ineffective and adds to toxicity. It is actually permitted in various guidelines that are available, despite the fact that there are no data suggesting that more chemotherapy [is beneficial]. Durvalumab is an alternative to that approach, and one that has been shown to work in a large randomized trial, now published in the New England Journal of Medicine.[1] I urge you to use it.

When you look at this paper in more detail, I urge you to note that about half of the patients in this trial had stage IIIA disease. I believe that there is no question that for patients with stage IIIB diseases, concurrent chemotherapy/radiation followed by durvalumab is the standard of care.

For patients with stage IIIA disease, it is a lot more complicated. In those cases, I would urge that, for every single patient, you make sure to have a multimodality discussion with all members of the care team before a final decision is made. Many of these patients can be very efficiently and effectively—and perhaps better—treated by using surgery with radiation and chemotherapy. For each of these patients, I urge you to go through the pros and cons of the different modalities for them. And once the decision is made, it needs to be followed through.

I urge you very strongly against creating a situation in which the patient may not be a good surgical candidate or not have a complete resection, or the tumor has poor operability at the beginning, [and therapy is given] in the hope that with therapy the tumors will become resectable or operable. There is no evidence to say that is true. Decisions for surgery need to be based on the physiology and the extent of disease at the time of diagnosis. However, that can be a very effective strategy—surgery following induction chemotherapy, or surgery followed by adjuvant chemotherapy or radiation.

This is excellent news about the benefits of durvalumab. There is no reason not to proceed and use durvalumab in the care of every patient who has characteristics similar to those treated in this clinical trial.

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