Adjuvant Chemotherapy for Lung Cancer and Real-world Practice

The data from a wide range of prospective, randomized phase 3 trials are clear: There is a significant survival benefit from adjuvant cisplatin-based chemotherapy for patients with resected higher-risk non–small-cell lung cancer (NSCLC), often defined as node-positive and/or with the primary tumor measuring 4 cm or greater in diameter. As in many clinical settings, however, patients in real-world practice are not well represented by those on the relevant clinical trials, as those in the pivotal adjuvant trials are approximately a decade younger and with a near uniformly good performance status. A clinical trial directly comparing preoperative with postoperative chemotherapy for early-stage NSCLC also demonstrated an attrition rate of 34% for postoperative chemotherapy within the protocol-defined window of 6 to 7 weeks owing to a wide range of complicating factors. In practice, this means that many patients who would otherwise be appropriate candidates for adjuvant chemotherapy do not present for consideration of treatment until later than best practices would recommend. Should an intervention with an established survival benefit be deferred in this setting? While we do not have prospective evidence to speak to this, absence of proof is not proof of absence.

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