Quality initiative (QI) in unresectable stage III non-small cell lung cancer (NCSLC): Impact on time-to-treatment (TTT) for immunotherapy post chemoradiation (CRT).
Authors: Gart Mike , Gierman Hinco J. , Petro Daniel P. , Choksi Rushir J. , Varughese Prateesh , Labrador Monica , Tarlazzi Rebecca , English Sandy , Brown Greg , Botts Elizabeth , Quatela Sarah , Marshall Elvis , Scott Jeffrey A. , Smith Robert E. 
Published: June 2021

e18780

Background:In August 2019 Integra Connect (IC) partnered on a QI with University of Pittsburgh Medical Center (UPMC) to improve outcomes in patients with stage 3 and 4 NSCLC. This report details the findings and interventions in the unresectable stage 3 cohort of the QI. The addition of durvalumab (D) in the PACIFIC trial (Antonia et al. NEJM 2017) after completion of CRT in stage 3 patients who had not progressed showed significant Progression Free Survival and Overall Survival (OS) benefit with Food and Drug Administration approval on 2/16/2018 in this setting. An update (Gray et al. Thoracic Oncol 2020) on 10/14/2019 noted superior OS in patients in whom randomization to D occurred 1-14 days post CRT vs. those with interval 15-42 days (HR 0.43 vs. 0.79). Data suggest that CRT renders tumors more responsive to immunotherapy (McCall et al. Clin Can Res 2018). As part of the QI, we explored the question whether time from CRT to D (TTT) could be shortened. Methods:From the UPMC and IC real-world-data (RWD) databases, we identified 182 patients with Stage 3 unresectable NSCLC treated with CRT between 2/16/18 (D approval) and 11/16/20 for manual chart abstraction. We calculated the TTT from the latest day of radiation or chemotherapy to the first D dose. Time-to-scan (TTS) used a similar methodology. If post-CRT scan data was not found, those patients were excluded from TTS analysis. We captured caregiver perception with surveys and used RWD to determine the proportion of eligible patients treated with D, categorizing the data into 3 successive time periods: Phase 1 (240 days): 2/16/18 approval of D to Gray update 10/14/19, Phase 2 (321 days): 10/15/19 to physician leadership intervention 8/31/20, Phase 3 (76 days): 9/1/20 to 11/16/20. Patients were excluded in phase 3 who started CRT after 11/16/20 to allow for up to 2 months to start D. Our plan included baseline and ongoing monitoring of metrics complemented with physician leadership intervention to address identified gaps in care. Results: Median age of the 182 patients was 68 (range 46-87) with 60% male. Of eligible patients, 121 (66.5%) received at least 1 dose of D. Median TTS improved 16 days from Phase 1 to Phase 3 while TTT concomitantly improved 17 days (Table ). Conclusions: This QI resulted in simultaneous shortening of TTS and TTT following physician intervention with establishment of TTS as a key potential driver of TTT which ultimately may result in improved OS. To do so required overcoming the traditional paradigm of imaging 4-6 weeks post-CRT to capture maximal response with that of early imaging aimed at assuring no progression had occurred. This, as well as proportion treated with D and its resulting duration, plus any subsequent treatments that might indicate relapse, continue to be monitored in a real-time dashboard.[Table: see text]