Management and treatment of patients with stage III unresected NSCLC at UPMC: A quality initiative by Integra Connect Precision Q.
Authors: Petro Daniel P. , Gart Mike , Blanc Simon , Vasudevan Anupama , Li John , Fares Marielle , Choksi Rushir J. 
Published: June 2023

e20588

Background: The PACIFIC trial led to improved OS in patients (pts) with unresectable stage 3 NSCLC who received durvalumab (durva) post chemoradiation (CRT).1 In 2019, the University of Pittsburgh Medical Center (UPMC) and IC initiated a QI to improve immunotherapy (IO) use post CRT. A baseline analysis was done to assess scanning and treatment patterns post-CRT, and duration of treatment (DOT) with durva. Drawing on this analysis, IC and UPMC conducted a focus group to address gaps in care and initiated improvements. This real-world study aims to assess the change in IO use post-CRT, the time to scan (TTS), time to treatment (TTT), and duration of treatment (DOT) compared to baseline. The DOT of durva was compared between pts initiated <14 days of CRT and those who started ≥14 days. Methods: From the UPMC and IC Precision Q real-world databases, we identified 555 pts with stage 3 unresectable NSCLC for manual chart abstraction. Pts received CRT between 2/16/2018 and 12/31/2021. TTS was calculated from the last day of CRT to the 1st scan and the TTT obtained from the last day of CRT to the 1st durva dose. The baseline period was from 2/16/2018 to 8/31/2020 and the post-intervention stage from 9/1/2020 to 12/31/2021 based on CRT start date. Pts were excluded if they had no scan data, a 1st scan ≥90 days post CRT (TTS analyses), a duration of zero days (DOT analyses) or a TTT >120 days (TTT analyses). At least 1 yr of follow up was required for DOT comparisons. Descriptive analyses were used. A two-tailed 2 sample z-test was used for proportions and the nonparametric Wilcoxon rank sum test was used for TTS, TTT and DOT comparisons. Results: The baseline pts were 46% female with an average age of 67.7 years and the post-intervention were 47% female with an average age of 69.4 years. The rate of durva use post CRT in pts who did not progress increased from 66% (n =128/194) at baseline to 83% (n =96/116) post intervention (p < 0.01). The baseline median TTS decreased from 22.5 days (n=174) to 20 days (n=121) post intervention (p <0.05), and median TTT decreased from 35 days (n=121) to 28 days (n=90) (p < 0.05). The median DOT increased from 6 (n=127) to 8.2 months (n=76) (p >0.05). During the study period, 8% (n =17/223) of pts started durva < 14 days post CRT and 92% started ≥14 days (n =206/223). The median DOT in the < 14 days group was 10.8 months versus 6.2 months in ≥14 days (p >0.05). The median overall survival (OS) was 36.5 months in the < 14 days vs. 27.8 months in the ≥14 days group (p > 0.05). Conclusions: QIs in NSCLC are effective tools that can improve appropriate durva utilization, TTT and DOT in eligible pts. Practices that assess their clinical performance can identify gaps in care and act. In this study, a superior OS, though lacking statistical significance, was seen in the group that started IO <14 days post CRT compared to ≥14 days. Further studies with larger sample size, are needed to validate these findings.