Long-term results in patients with pathological complete response after induction radiochemotherapy followed by surgery for locally advanced non-small-cell lung cancer

Pathologic Processing of Lung Cancer Resection Specimens After Neoadjuvant Therapy

Neoadjuvant treatment of non-small cell lung cancer challenges the traditional processing of pathology specimens. Induction therapy before resection allows evaluation of the efficacy of neoadjuvant agents at the time of surgery. Many clinical trials use pathologic tumor response, measured as major pathologic response (MPR, ≤10% residual viable tumor [RVT]) or complete pathologic response (CPR, 0% RVT) as a surrogate of clinical efficacy. Consequently, accurate pathologic evaluation of RVT is crucial. However, pathologic assessment has not been uniform, which is particularly true for sampling of the primary tumor, which instead of the traditional processing, requires different tissue submission because the focus has shifted from tumor typing alone to RVT scoring. Using a simulation study, we analyzed the accuracy rates of %RVT, MPR, and CPR of 31 pretreated primary lung tumors using traditional grossing compared with the gold standard of submitting the entire residual primary tumor and identified the minimum number of tumor sections to be submitted to ensure the most accurate scoring of %RVT, MPR, and CPR. Accurate %RVT, MPR, and CPR calls were achieved in 52%, 87%, and 81% of cases, respectively, using the traditional grossing method. Accuracy rates of at least 90% for these parameters require either submission of all residual primary tumor or at least 20 tumor sections. Accurate %RVT, MPR, and CPR scores cannot be achieved with traditional tumor grossing. Submission of the entire primary tumor, up to a maximum of 20 sections, is required for the most accurate reads.

Role of Peripheral Blood Markers for Detecting Response and Predicting Prognosis in Patients with Non-small-cell Lung Cancer Undergoing Neoadjuvant Therapy and Surgery

INTRODUCTION

To date, no validated predictors of response before neoadjuvant therapy (NAD) are currently available in locally advanced non-small-cell lung cancer (NSCLC). In this study, different peripheral blood markers were investigated before NAD (pre-NAD) and after NAD/before surgery (post-NAD) to evaluate their influence on the treatment outcomes.

METHODS

Patients affected by locally advanced NSCLC (cT1-T4/N0-2/M0) who underwent NAD followed by surgery from January 1996 to December 2019 were considered for this retrospective analysis. The impact of peripheral blood markers on downstaging post-NAD and on overall survival (OS) was evaluated using multivariate logistic and Cox regression models. Time to event analysis was performed by means of Kaplan-Meier survival curves and Log Rank tests at 5 years from surgery.

RESULTS

Two hundred and seventy-two consecutive patients were included. Most of the patients had Stage III NSCLC (83.5%). N2 disease was reported in 188 (69.1%) patients. Surgical resection was performed in patients with stable disease or downstaging post-NAD. Nodal downstaging was observed in 80% of clinical N2 (cN2) patients. The median follow-up of the total series was 74 months (range 6-302). Five-year OS in the overall population and in N2 population was 74.6% and 73.5%, respectively. The pre-surgery platelets level (PLT) (p = 0.019) and the variation (pre-NAD/post-NAD) of the neutrophil/lymphocyte ratio (p = 0.024) were identified as independent prognostic factors of OS. The preoperative PLT value (p value = 0.031) was confirmed as the only predictor of NAD response.

CONCLUSIONS

The clinical role of peripheral blood markers in locally advanced NSCLC needs to be further investigated. Based on these preliminary results, these factors may be used as auxiliary markers for the prediction of response to neoadjuvant treatment and as prognostic factors for stratification in multimodal approaches.

Predictive factors of pathological complete response after induction (ypT0N0M0) in non-small cell lung cancer and short-term outcomes: Results of the Spanish Group of Video-assisted Thoracic Surgery (GE-VATS)

INTRODUCTION

To analyze the predictors of pCR in NSCLC patients who underwent anatomical lung resection after induction therapy and to evaluate the postoperative results of these patients.

METHODS

All patients prospectively registered in the database of the GE-VATS working group undergone anatomic lung resection by NSCLC after induction treatment and recruited between 12/20/2016 and 3/20/2018 were included in the study. The population was divided into two groups: patients who obtained a complete pathological response after induction (pCR) and patients who did not obtain a complete pathological response after induction (non-pCR). A multivariate analysis was performed using a binary logistic regression to determine the predictors of pCR and the postoperative results of patients were analyzed.

RESULTS

Of the 241 patients analyzed, 36 patients (14.9%) achieved pCR. Predictive factors for pCR are male sex (OR: 2.814, 95% CI: 1.015-7.806), histology of squamous carcinoma (OR: 3.065, 95% CI: 1.233-7.619) or other than adenocarcinoma (OR: 5.788, 95% CI: 1.878-17.733) and induction therapy that includes radiation therapy (OR: 4.096, 95% CI: 1.785-9.401) and targeted therapies (OR: 7.625, 95% CI: 2.147-27.077). Prevalence of postoperative pulmonary complications was higher in patients treated with neoadjuvant chemo-radiotherapy (p = 0.032).

CONCLUSIONS

Male sex, histology of squamous carcinoma or other than ADC, and induction therapy that includes radiotherapy or targeted therapy are positive predictors for obtaining pCR. Induction chemo-radiotherapy is associated with a higher risk of postoperative pulmonary complications.

Evaluation of prognostic factors in lung cancers with surgical complete response after induction treatment

Background

This study aims to evaluate long-term results of induction treatment and to investigate prognostic factors affecting survival in non-small cell lung cancer patients with a pathological complete response.

Methods

Between January 2010 and December 2017, a total of 39 patients (38 males, 1 female; mean age: 56.2±8.3 years; range, 38 to 77 years) having locally advanced (IIIA-IIIB) non-small cell lung cancer who were given induction treatment and underwent surgery after induction treatment and had a pathological complete response were retrospectively analyzed. Survival rates of the patients and prognostic factors of survival were analyzed.

Results

Clinical staging before induction treatment revealed Stage IIB, IIIA, and IIIB disease in three (7.7%), 26 (66.7%), and 10 (25.6%) patients, respectively. The five-year overall survival rate was 61.2%, and the disease-free survival rate was 55.1%. In nine (23.1%) patients, local and distant recurrences were detected in the postoperative period.

Conclusion

In patients with locally advanced non-small cell lung cancer undergoing surgery after induction treatment, the rates of pathological complete response are at considerable levels. In these patients, the five-year overall survival is quite satisfactory and the most important prognostic factor affecting overall survival is the presence of single-station N2.

Predictive factors of pathological complete response after induction (ypT0N0M0) in non-small cell lung cancer and short-term outcomes: results of the Spanish Group of Video-assisted Thoracic Surgery (GE-VATS)

INTRODUCTION

To analyze the predictors of pathological complete response (pCR) in not small cells lung carcinoma (NSCLC) patients who underwent anatomical lung resection after induction therapy and to evaluate the postoperative results of these patients.

METHODS

All patients prospectively registered in the database of the GE-VATS working group undergone anatomic lung resection by NSCLC after induction treatment and recruited between December 20th 2016, and March 20th 2018, were included in the study. The population was divided into two groups: patients who obtained a complete pathological response after induction (pCR) and patients who did not obtain a complete pathological response after induction (non-pCR). A multivariate analysis was performed using a binary logistic regression to determine the predictors of pCR and the postoperative results of patients were analyzed.

RESULTS

Of the 241 patients analyzed, 36 patients (14.9%) achieved pCR. Predictive factors for pCR are male sex (OR 2.814, 95% CI 1.015-7.806), histology of squamous carcinoma (OR 3.065, 95% CI 1.233-7.619) or other than adenocarcinoma (ADC) (OR 5.788, 95% CI 1.878-17.733) and induction therapy that includes radiation therapy (OR 4.096, 95% CI 1.785-9.401) and targeted therapies (OR 7.625, 95% CI 2.147-27.077). Prevalence of postoperative pulmonary complications was higher in patients treated with neoadjuvant chemo-radiotherapy (p = 0.032).

CONCLUSIONS

Male sex, histology of squamous carcinoma or other than ADC, and induction therapy that includes radiotherapy or targeted therapy are positive predictors for obtaining pCR. Induction chemo-radiotherapy is associated with a higher risk of postoperative pulmonary complications.

Radiomics in predicting treatment response in non-small-cell lung cancer: current status, challenges and future perspectives

OBJECTIVES

Radiomics is the extraction of quantitative data from medical imaging, which has the potential to characterise tumour phenotype. The radiomics approach has the capacity to construct predictive models for treatment response, essential for the pursuit of personalised medicine. In this literature review, we summarise the current status and evaluate the scientific and reporting quality of radiomics research in the prediction of treatment response in non-small-cell lung cancer (NSCLC).

METHODS

A comprehensive literature search was conducted using the PubMed database. A total of 178 articles were screened for eligibility and 14 peer-reviewed articles were included. The radiomics quality score (RQS), a radiomics-specific quality metric emulating the TRIPOD guidelines, was used to assess scientific and reporting quality.

RESULTS

Included studies reported several predictive markers including first-, second- and high-order features, such as kurtosis, grey-level uniformity and wavelet HLL mean respectively, as well as PET-based metabolic parameters. Quality assessment demonstrated a low median score of + 2.5 (range - 5 to + 9), mainly reflecting a lack of reproducibility and clinical evaluation. There was extensive heterogeneity between studies due to differences in patient population, cancer stage, treatment modality, follow-up timescales and radiomics workflow methodology.

CONCLUSIONS

Radiomics research has not yet been translated into clinical use. Efforts towards standardisation and collaboration are needed to identify reproducible radiomic predictors of response. Promising radiomic models must be externally validated and their impact evaluated within the clinical pathway before they can be implemented as a clinical decision-making tool to facilitate personalised treatment for patients with NSCLC.

KEY POINTS

• The included studies reported several promising radiomic markers of treatment response in lung cancer; however, there was a lack of reproducibility between studies. • Quality assessment using the radiomics quality score (RQS) demonstrated a low median total score of + 2.5 (range - 5 to + 9). • Future radiomics research should focus on implementation of standardised radiomics features and software, together with external validation in a prospective setting.

Survival analysis of pathological complete response of locally advanced lung cancer after neoadjuvant treatment

AIM

The first aim is to determine the clinical and pathological characteristics and factors affecting survival in patients with pathological complete response (pCR) after neoadjuvant therapy, and the secondary aim is to investigate the effect of adjuvant therapy on survival in these patients.

METHODS

Between 2003 and 2015, there was 372 patients who underwent lung resection after neoadjuvant therapy with a diagnosis of locally advanced lung cancer. Sixty-eight patients who had pCRwere retrospectively analyzed. The odds ratios (OR) were calculated in regards of recurrence.

RESULTS

Overall 5-year survival rate was 65.1%. Recurrence was the risk factor affecting survival (78.2% vs 19.3%, p = 0.001) while neoadjuvant treatment type (p = 0.766), the reason of neodjuvant treatment (p = 0.581), and the type of operation (p = 0.860) did not affect survival. Postoperative adjuvant treatment had a positive effect on survival (71.1% versus 62.7%), although this difference was not significant (p = 0.561). Local or distant recurrence was detected in 15 patients (22%). In multivariate analysis, the independent risk factors affecting the recurrence were the time from the end of the neoadjuvant therapy to the surgery being less than eight weeks (OR = 6.49, p = 0.03), the type of neoadjuvant treatment (OR = 0.203, p = 0.03). In patients with a squamous cell carcinoma, there was a decreased trend toward in terms of recurrence (p = 0.06).

CONCLUSIONS

pCR after neoadjuvant therapy positively affects survival. Better survival may be detected in patients receiving adjuvant therapy. Due to unexpected the high recurrence rate, patients should be followed in the postoperative period closely.

Prognostic Factors and Long-Term Survival in Locally Advanced NSCLC with Pathological Complete Response after Surgical Resection Following Neoadjuvant Therapy

Simple Summary

Higher response may be achieved with induction therapy (IT) and better survival results could be expected after complete surgical resection for non-small-cell lung cancer (NSCLC) patients. Thus, locally advanced (LA)-NSCLC patients with pathological complete response (pCR) are optimal candidates to undergo surgery after IT, achieving good to very good long-term survival. Herein, we performed a retrospective analysis on a large cohort of locally advanced NSCLC patients who achieved pCR after IT and surgery, exploring long-term survival and factors affecting prognosis. We observed a rewarding 5-year overall survival (56%) with baseline N2 single-station disease and adjuvant therapy after surgery associated with better prognosis. These findings may be useful to better define the strategy of care in this highly selected subset of NSCLC patients.

Abstract

Background: Outcomes for locally advanced NSCLC with pathological complete response (pCR), i.e., pT0N0 after induction chemoradiotherapy (IT), have been seldom investigated. Herein, long-term results, in this highly selected group of patients, have been evaluated with the aim to identify prognostic predictive factors. Methods: Patients affected by locally advanced NSCLC (cT1-T4/N0-2/M0) who underwent IT, possibly following surgery, from January 1992 to December 2019, were considered for this retrospective analysis. Survival rates and prognostic factors have been studied with Kaplan-Meier analysis, log-rank and Cox regression analysis. Results: Three-hundred and forty-three consecutive patients underwent IT in the considered period. Out of them, 279 were addressed to surgery; among them, pCR has been observed in 62 patients (18% of the total and 22% of the operated patients). In the pCR-group, clinical staging was IIb in 3 (5%) patients, IIIa in 28 (45%) patients and IIIb in 31 (50%). Surgery consisted of (bi)lobectomy in the majority of cases (80.7%), followed by pneumonectomy (19.3%). Adjuvant therapy was administered in 33 (53.2%) patients. Five-year overall survival and disease-free survival have been respectively 56.18% and 48.84%. The relative risk of death, observed with the Cox regression analysis, was 4.4 times higher (95% confidence interval (CI): 1.632–11.695, p = 0.03) for patients with N2 multi-station disease, 2.6 times higher (95% CI: 1.066–6.407, p = 0.036) for patients treated with pneumonectomy and 3 times higher (95% CI: 1.302–6.809, p = 0.01) for patients who did not receive adjuvant therapy. Conclusions: Rewarding long-term results could be expected in locally advanced NSCLC patients with pCR after IT followed by surgery. Baseline N2 single-station disease and adjuvant therapy after surgery seem to be associated with better prognosis, while pneumonectomy is associated with poorer outcomes.

Neoadjuvant Treatment Is Associated With Superior Outcomes in T4 Lung Cancers With Local Extension

BACKGROUND

Neoadjuvant chemoradiation is associated with improved survival of superior sulcus cancers, but little data exists regarding clinical T4 lung cancers with mediastinal invasion. We hypothesized that neoadjuvant treatment would be associated with improved survival in T4 lung cancer patients with mediastinal invasion.

METHODS

Clinical T4-N0/1-M0 non-small cell lung cancers from 2006-2015 were identified in the National Cancer Database. Patients with T4 extension to mediastinal structures undergoing lobectomy, bilobectomy, or pneumonectomy were included. Neoadjuvant treatment was defined as preoperative chemotherapy and/or radiation. Patients receiving surgery >120 days after radiation were excluded. Study endpoints were pathologic margin status and overall survival. To adjust for heterogeneity, a 1:1 propensity match analysis was performed.

RESULTS

A total of 1101 patients with cT4N0/1M0 cancers were analyzed; 595 (54.0%) received primary surgery and 506 (46.0%) received neoadjuvant treatment. Neoadjuvant therapy was associated with fewer positive surgical margins (46 of 506 [9.3%] vs 186 of 595 [33.1%], P < .001). Multivariate analysis showed an association of neoadjuvant therapy with a lower rate of positive margin (odds ratio 0.220, P < .001). Overall survival was longer among patients receiving neoadjuvant treatment (65.9 vs 27.5 months, P < .001). Propensity matching identified 331 matched pairs of patients. Among these, positive margins were less likely after receiving neoadjuvant treatment (10.5% vs 31.3%, P < .001). Overall survival among the matched pairs was improved in those receiving neoadjuvant treatment (57.0 vs 27.5 months, P < .001).

CONCLUSIONS

In the NCDB, T4N0/1 mediastinal invasion patients who receive neoadjuvant treatment have decreased rates of positive surgical margins and improved overall survival. The use of neoadjuvant treatment should be considered in these patients.

Factors Associated With Survival in Complete Pathologic Response Non-Small Cell Lung Cancer

OBJECTIVES

There is a strong association with improved survival for patients with non-small cell lung cancer (NSCLC) who have developed a pathological complete response (pCR) after neoadjuvant therapy. A national database was used to investigate factors associated with long-term survival in this cohort of patients.

PATIENTS

Retrospective review was completed of the National Cancer Database of patients who obtained pCR and had neoadjuvant therapy for stage I to stage III NSCLC between 2004 and 2014. All patients had neoadjuvant chemotherapy with or without radiation therapy.

METHODS

Univariate and multivariable analysis was performed on factors associated with overall survival (OS), including gender, clinical stage, and nodal count. Patients were divided into 2 groups based on the Commission on Cancer-recommended median number of lymph nodes (LNs) examined: 0 to 9 LNs and ≥10 LNs. Chi-square and Wilcoxon rank-sum tests were used to compare patient, hospital, and clinical variables between groups.

RESULTS

Increased age (hazard ratio [HR] 1.02, 95% confidence interval [CI], 1.00-1.03), neoadjuvant radiation therapy (HR 1.48, 95% CI, 1.10-2.00), and pneumonectomy (HR 1.64, 95% CI, 1.22-2.22) were associated with worse survival in the 759-patient cohort. Multivariable regression demonstrated having ≥10 nodes harvested (HR 0.71, 95% CI, 0.56-0.89) was associated with improved survival as was every increase in LN harvest up to 17 LNs. No significant differences in 5-year OS were found between clinical stage I, II, and III, respectively (66.1% vs. 60.9% vs. 58.6%, P = .288).

CONCLUSION

This study shows that younger age, increasing LN harvest, female sex, the absence of neoadjuvant radiation therapy and non-pneumonectomy resections are all associated with improved OS in patients with NSCLC who have developed pCR.

Major Pathologic Response after Induction Therapy Has a Long-Term Impact on Survival and Tumor Recurrence in Stage IIIA/B Locally Advanced NSCLC

BACKGROUND

Major pathologic response (MPR) determines favorable outcome in locally advanced non-small cell lung cancer after induction therapy (IT) followed by lung resection. The aim of this retrospective study was to identify the prognostic relevance of MPR in long-term interval.

METHODS

In 55 patients, the survival rate according to MPR and non-MPR was estimated by Kaplan-Meier method and compared using log-rank, Breslow, and Tarone-Ware tests.

RESULTS

The IT included chemoradiation with 50.4 Gy (range: 45-56.4 Gy) combined with platinum-based chemotherapy in 52 patients (94.5%) and platinum-based chemotherapy in 3 patients (5.5%). Perioperative morbidity and 30-day mortality were 36 and 3.6%, respectively. The estimated 5-year postoperative and progressive-free survivals were statistically significantly improved in MPR versus non-MPR with 53.5 versus 18% and 49.4 versus 18.5%, respectively. According to the log-rank, Breslow, and Tarone-Ware tests, the MPR demonstrates prognostic significance in early, long-term, and whole postoperative interval.

CONCLUSION

MPR is associated with a robust correlation to long-term postoperative and recurrence-free survival improvement, and can potentially simplify the multidisciplinary debate and allow further stratification of adjuvant treatment in multimodality therapy.

Pathologic complete response after induction therapy-the role of surgery in stage IIIA/B locally advanced non-small cell lung cancer

Background

Pathologic complete response (pCR) is dominant prognostic factor determining favorable outcome in locally advanced non-small cell lung cancer (NSCLC) after induction therapy (IT). There is no non-operative diagnostics that adequately estimates the pCR. Aim of this retrospective study was to assess the correlation between clinical and pathological factors in patients with pCR.

Methods

Twenty-five patients with pCR after curative lung resection following IT were assessed using univariate and multivariate Cox regression and descriptive analysis. The survival rate was estimated by Kaplan-Meier method.

Results

The IT included chemoradiation with median doses of 50.4 Gy (range, 45-59.4 Gy) combined with platinum-based chemotherapy in 23 patients (92%) and induction platinum-based chemotherapy in 2 patients (8%). Clinical tumor stage before IT was IIIA in 21, IIIB in 4 patients. Mean interval between IT and surgery was 8.1±3.0 weeks. Perioperative morbidity and 30-day mortality was 32% and 4%, respectively. There was no significant correlation of pCR and different clinical and pathological factors. The estimated 5-year long-term survival (LTS) and progressive-free survival (PFS) was 57% and 54%, respectively. The median LTS and PFS was not reached.

Conclusions

pCR in patients with locally advanced NSCLC following IT is an independent prognostic factor, without correlation with pathological and clinical factors. Non-operative accurate assessment of pCR is currently impossible. Surgical resection enables secure identification of pCR and might improve the patient stratification for additive therapy.

Induction chemoradiotherapy using docetaxel and cisplatin with definitive-dose radiation followed by surgery for locally advanced non-small cell lung cancer

Background

Induction chemoradiotherapy (CRT) followed by surgery is a therapeutic option for locally advanced non-small cell lung cancer (LA-NSCLC). Typically, around 40-50 Gy of radiation is applied as the induction-dose; however, a definitive-dose (DD) of radiation (60 Gy or higher) is occasionally applied to increase local control. We investigated the impact of induction CRT with DD radiation in LA-NSCLC patients treated with a single regimen of docetaxel and cisplatin.

Methods

We reviewed 110 patients with LA-NSCLC who underwent induction CRT followed by surgery using a single regimen (docetaxel and cisplatin) between January 1999 and December 2014 at our hospital. The clinical outcomes of a DD group (60 Gy or higher, n=11) and a non-DD group (less than 60 Gy, n=99) were investigated using a propensity score (PS)-matched analysis.

Results

An advanced clinical stage was significantly more common in the DD group than in the non-DD group (P=0.033). Before and after the PS-matching based on seven factors including clinical stage, there was no significant difference in the rates of postoperative (PO) complication, mortality, 5-year overall survival (OS), or 5-year recurrence-free survival (RFS) between the two groups. After the PS-matching, the pathological complete response (CR) rate was significantly higher in the DD group than in the non-DD group [50% (n=5/10) vs. 0% (n=0/10), P=0.033].

Conclusions

Induction CRT followed by surgery using docetaxel and cisplatin with DD radiation can be performed safely and is associated with a higher pathological CR rate than that attained using non-DD radiation in LA-NSCLC patients.

Prognostic model for long-term survival of locally advanced non-small-cell lung cancer patients after neoadjuvant radiochemotherapy and resection integrating clinical and histopathologic factors

Background

Outcome of consecutive patients with locally advanced non-small cell lung cancer and histopathologically proven mediastional lymph node metastases treated with induction chemotherapy, neoadjuvant radiochemotherapy and thoracotomy at the West German Cancer Center between 08/2000 and 06/2012 was analysed. A clinico-pathological prognostic model for survival was built including partial or complete response according to computed tomography imaging (CT) as clinical parameters as well as pathologic complete remission (pCR) and mediastinal nodal clearance (MNC) as histopathologic factors.

Methods

Proportional hazard analysis (PHA) and recursive partitioning analysis (RPA) were used to identify prognostic factors for survival. Long-term survival was defined as survival ≥ 36 months.

Results

A total of 157 patients were treated, median follow-up was 97 months. Among these patients, pCR and MNC were observed in 41 and 85 patients, respectively. Overall survival was 56 ± 4% and 36 ± 4% at 24 and 60 months, respectively. Sensitivities of pCR and MNC to detect long-term survivors were 38% and 61%, specificities were 84% and 52%, respectively.

Multivariable survival analysis revealed pCR, cN3 category, and gender, as prognostic factors at a level of α < 0.05. Considering only preoperative available parameters, CT response became significant. Classifying patients with a predicted hazard above the median as high risk group and the remaining as low risk patients yielded better separation of the survival curves by the inclusion of histopathologic factors than by preoperative factors alone (p < 0.0001, log rank test). Using RPA, pCR was identified as the top prognostic factor above clinical factors (p = 0.0006). No long term survivors were observed in patients with cT3-4 cN3 tumors without pCR.

Conclusions

pCR is the dominant histopathologic response parameter and improves prognostic classifiers, based on clinical parameters. The validated prognostic model can be used to estimate individual prognosis and forms a basis for patient selection for treatment intensification.

Anti-epidermal-growth-factor-receptor agents and complete responses in the treatment of advanced non-small-cell lung cancer: a meta-analysis of 17 phase III randomized controlled trials

PURPOSE

Currently, the anti-epidermal-growth-factor-receptor (EGFR) agents have shown encouraging treatment benefits in patients with various types of solid tumors including non-small-cell lung cancer (NSCLC). Despite these advances, radiological complete response to these therapies is rare. We meta-analyze the incidence of complete response (CR) in advanced NSCLC patients treated with anti-EGFR agents and controls in randomized controlled trials (RCTs).

METHODS

PubMed, Web of Science, Embase and Cochrane library databases were reviewed for phase III RCTs with EGFR-targeted agents vs. non-EGFR-targeted agents in patients with advanced NSCLC. We calculated the odds ratio of CR in patients assigned to anti-EGFR agents compared to controls.

RESULTS

A total of 11,568 patients from 17 RCTs were included for analysis. The incidence of CR in patients treated with anti-EGFR agents was 1.1% (95% CI, 0.7-1.7%) compared to 0.6% (95% CI, 0.4-0.9%) in control arms. Comparing the different types of anti-EGFR agents, the incidence of CR was 1.9% for gefitinib (95% CI: 1.4-2.6%), 1.4% for cetuximab (95% CI: 0.8-2.7%) and 0.9% for erlotinib (95% CI: 0.6-1.5%), respectively. The use of anti-EGFR agents significantly increased the odds ratio of obtaining a CR (OR 2.12, 95% CI: 1.28-3.49, p = 0.003) compared to controls. This was found to be higher in treatment arms involving more than 50% of: female patients, patients who had never smoked tobacco, patients of Asian descent or patients with adenocarcinoma or EGFR mutation. No significant differences in ORs were observed in any prespecified sub-groups.

CONCLUSION

Although a CR is rare in advanced NSCLC patients receiving anti-EGFR agents, these drugs significantly increase the OR of a CR compared to controls, especially for patients with EGFR mutations. Further studies are needed to investigate whether the increase of CR with anti-EGFR therapy would be translated into survival benefits.