Real-world adoption of adjuvant molecularly targeted therapy and immunotherapy for resected stage Ib-III non-small cell lung cancer within the Veterans Health Administration.

Abstract

e20020 Background: Emerging evidence supports the use of adjuvant systemic therapies for appropriately selected patients with early-stage, resected non-small cell lung cancer (NSCLC). The real-world adoption of these therapies is unknown, although prior studies have highlighted slow implementation of other guideline-concordant treatments for NSCLC. This study aimed to evaluate trends in the real-world adoption of adjuvant molecularly targeted therapies and immunotherapies among patients with resected NSCLC. Methods: This study utilized a longitudinal dataset from the Veterans Health Administration Corporate Data Warehouse and queried for all patients with clinical stage IB-III NSCLC who underwent surgical resection from 2017-2023. Patients who received neoadjuvant systemic therapy (n=153, 6.2%) were excluded. Adjuvant therapies, including platinum-based chemotherapy (cisplatin and/or carboplatin), molecularly targeted therapies (osimertinib or alectinib), and immunotherapies (durvalumab, atezolizumab, pembrolizumab, or nivolumab), given within 6 months after surgery were assessed. We used the Cochran–Armitage test for trend analysis. Results: A total of 2297 patients were included in the analysis. Most patients were male (n=2218, 96.6%), of White race (n=1860, 81.0%), and had adenocarcinoma (n=990, 45.9%). Lobectomy (n=1603, 69.8%) was most frequently performed. Most patients had pathologic stage Ib (n=708, 30.8%) or II (n=946, 41.2%) NSCLC. Only 1025 (44.6%) patients received adjuvant systemic therapy (chemotherapy only: n=859, 37.4%; immunotherapy with or without chemotherapy: n=160, 7.0%; molecularly targeted therapy with or without chemotherapy: n=6, n=0.3%) [Table 1]. The overall rate of adjuvant therapy use remained stable between 2017 and 2023 (40.2% vs. 44.4%, p=0.089). While the use of adjuvant chemotherapy alone declined from 39.3% in 2017 to 19.5% in 2024 (p<0.001), the usage rates of adjuvant molecularly targeted therapies (0.0% vs. 1.2%, p<0.001) and immunotherapies (0.9% vs. 23.5%, p<0.001) significantly increased over the same period. Conclusions: While the overall rate of adjuvant systemic therapies for resected stage Ib-III NSCLC has remained stable in recent years, there has been a notable increase in the adoption of molecularly targeted therapies and immunotherapies into clinical practice. Further research is needed to examine patient selection using appropriate genomic and biomarker testing and to ensure that these emerging therapies are offered to patients with resected early-stage NSCLC who meet selected guideline- or clinical pathway-based criteria in the adjuvant setting. Frequencies of adjuvant systemic therapies. Drug Frequency, n=166 (%) Pembrolizumab 76 (45.8) Durvalumab 38 (22.9) Atezolizumab 37 (22.3) Nivolumab 9 (5.4) Osimertinib 6 (3.6)