Sheneka Bothwell is a Clinical Nurse Educator, and Devika Das is the Section Chief of Oncology, both at Birmingham Veterans Affairs Medical Center in Alabama. Nabiel Mir was an Internal Medicine Resident in the Department of Medicine at the time the article was written; Olivia Hull is a Fellow in the Division of Hematology and Oncology, and Devika Das is Clinical Assistant Professor of Hematology and Oncology, all at University of Alabama at Birmingham. Correspondence: Nabiel Mir (nabiel.mir@uchospitals.edu)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
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Background: Durvalumab is recommended by national guidelines for patients with unresectable stage III non-small cell lung cancer (NSCLC) following concurrent chemoradiation therapy (CRT). Nonadherence to guidelines is associated with adverse outcomes. We studied the adherence and identified barriers to durvalumab usage at the Birmingham Veterans Affairs Medical Center (VAMC) Oncology Clinic in Alabama.
Methods: Using retrospective analysis, we assessed the use of consolidative durvalumab among veterans at Birmingham VAMC. The health records of all veterans with stage III unresectable NSCLC from October 2017 to August 2019 were reviewed. Data collected included demographics, barriers to CRT initiation and completion, durvalumab usage, and reasons for not prescribing durvalumab.
Results: In our data review, 34 patients were found to have stage III unresectable NSCLC. Twenty (58.8%) of those 34 initiated CRT, but only 16 (47.1%) completed CRT treatment and 7 (20.6%) underwent further treatment with durvalumab. Of the 14 patients who did not initiate CRT, the most common reasons were poor performance status and/or the presence of comorbidities. Of the evaluable cohort of 34, 11 (32.4%) patients with stage III NSCLC received durvalumab. Of the 9 eligible patients who did not receive durvalumab, the most common reasons cited were toxicities experienced during or following CRT (11.8%).
Conclusions: Just one-third of patients were eligible to receive durvalumab at Birmingham VAMC. This was likely due to the difference between clinical trial and real-world patient populations. Interventions to address socioeconomic and system level barriers to improve our center’s delivery of lung cancer treatment are planned.
The US Food and Drug Administration (FDA) approved the use of durvalumab for patients with unresectable stage III non-small cell lung cancer (NSCLC) whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy (CRT).1 After 2 randomized phase 3 studies in 2017 and 2018 showed significant progression-free and overall survival respectively,2,3 durvalumab became a category 1 recommendation for the above indication per National Comprehensive Cancer Network (NCCN) guidelines.4 Adherence to guidelines have been shown to improve patient survival across several cancer types.5-7 However, guideline adherence rates have been variable across health institutions. Therefore, further study is warranted to evaluate nonadherent practices with the goal of improving the quality of cancer care delivery.8,9
Stage III NSCLC is associated with poor survival rates.10 Concurrent CRT remains the standard of care in patients with good performance status based on clinical trial populations.4 Lung cancer remains a disease of the elderly, with a median age at diagnosis of 70 years.11 Discrepancies in the treatment of lung cancer in older adults can vary widely due to a lack of evidence surrounding the treatment in those who have comorbidities and poor performance status, widening the gap between clinical trial and real-world populations.11
A recent review by Passaro and colleagues revealed that at least 11 pivotal randomized controlled trials have shown the activity of immune checkpoint inhibitors (ICI) in locally advanced and metastatic lung cancer. However, these studies have mostly excluded patients with a performance status of the Eastern Cooperative Oncology Group (ECOG) level ≥ 2.11
Durvalumab is one of many new therapies to enter clinical practice to demonstrate survival benefit, but its use among veterans with stage III NSCLC in adherence with National Comprehensive Cancer Network (NCCN) guidelines was not robust at the Birmingham Veterans Affairs Medical Center (VAMC) in Alabama. Therefore, we decided to study the level of adherence and to identify barriers to conformity to the category 1 NCCN recommendations.
