Negative Predictors for Surgery Following Induction Chemo-Immunotherapy in Patients with Stage IB-III NSCLC between 2017-2021.

The CheckMate 816 trial established a new standard of care for patients with resectable stage IB-IIIA NSCLC with the use of induction chemo-immunotherapy followed by surgery. However, only 83% of patients who received induction chemo-immunotherapy ultimately underwent surgery. Despite this, several case reports have suggested using induction chemo-immunotherapy to convert initially unresectable disease (cN3 or stage IIIB-C) to be resectable. The purpose of this study was to determine the relative likelihood of receiving post-induction surgery based on patient demographics and initial extent of disease. Retrospective data was obtained from the National Cancer Database (NCDB) for patients diagnosed with NSCLC between 2017 (FDA approval of immune checkpoint inhibitors for NSCLC) to 2021. Patients were included if they had clinical stage IB-III disease and received upfront chemo and immunotherapy simultaneously <90 days from diagnosis. Patients were classified to have received post-induction surgery if they received radical surgery >90 days from diagnosis. Linear regression was used to examine temporal trends in induction chemo-immunotherapy usage. Binary logistic regression was used to examine predictors for not receiving surgery in this population. Out of 88656 patients with stage IB-III NSCLC, only 2136 (2.4%) patients received induction chemo-immunotherapy between 2017-2021. Usage of Induction chemo-immunotherapy increased significantly from 2017 (0.7%, N = 151/20028) to 2021 (5.3%, N = 842/15962) (slope = 1.02%/year, R2 = 0.87, p = 0.02). Out of the 2136 patients who received induction chemo-immunotherapy, only 584 (27.3%) patients ultimately underwent surgery. On univariate analysis, age ≥65 (p = 0.10), higher clinical N stage (p<0.01), and higher clinical group stage (p<0.01) were negatively associated with receiving surgery. Gender, race, Charlson Deyo comorbidity index, tumor histology, and clinical T stage were not significantly associated with receipt of surgery. On multivariate analysis, factors associated with not receiving surgery included age ≥65 vs. <65 (OR 0.60, 95% CI 0.40-0.90, p = 0.01), cN3 vs. cN0 (OR 0.15, 95% CI 0.04-0.52, p<0.01), clinical stage IIIA vs. IB-IIA (OR 0.41, 95% CI 0.18-0.92, p = 0.03), and clinical stage IIIB-C vs. IB-IIA (OR 0.14, 95% CI 0.05-0.38, p<0.01). Age ≥65, cN3, and stage III disease were all negative predictors for receiving surgery following induction chemo-immunotherapy. Patients with cN3 and stage IIIB-C disease had the lowest likelihood of receiving surgery afterwards (OR <0.15), suggesting induction chemo-immunotherapy should not be used to try to convert initially unresectable disease to be resectable. For patients ≥65 years old or with stage IIIA disease, more scrutiny should be used when deciding between the CheckMate vs. PACIFIC regimen since these patients also have a lower likelihood of receiving surgery after induction chemo-immunotherapy. [ABSTRACT FROM AUTHOR]