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The Dutch Lung Cancer Audit-Radiotherapy (DLCA-R): real-world data on stage III non-small cell lung cancer patients treated with curative chemoradiation

Open AccessPublished:November 24, 2022DOI:https://doi.org/10.1016/j.cllc.2022.11.008

      Abstract

      Introduction

      Chemoradiotherapy (CRT) is the standard of care in inoperable non-small cell lung cancer (NSCLC) patients, favoring concurrent (cCRT) over sequential CRT (seqCRT), with adjuvant immunotherapy in responders. Elderly and frail NSCLC patients have generally been excluded from trials in the past. In elderly patients however, the higher treatment related morbidity of cCRT, may outweigh the possible lower tumor control of seqCRT. For elderly patients with locally advanced NSCLC real-world data is essential to be able to balance treatment toxicity and treatment outcome. The aim of this study is to analyze acute toxicity and 3-month mortality of curative chemoradiation (CRT) in patients with stage III NSCLC and to analyze whether cCRT for elderly stage III NSCLC patients is safe.

      Methods

      The Dutch Lung Cancer Audit-Radiotherapy (DLCA-R) is a national lung cancer audit that started in 2013 for patients treated with curative intent radiotherapy. All Dutch patients treated for stage III NSCLC between 2015 and 2018 with seqCRT or cCRT for (primary or recurrent) stage III lung cancer are included in this population-based study. Information was collected on patient, tumor- and treatment characteristics and the incidence and severity of acute non-hematological toxicity (CTCAE-4 version 4.03) and mortality within three months after the end of radiotherapy. To evaluate the association between prognostic factors and outcome (acute toxicity and mortality within 3 months), an univariable and multivariable analysis was performed. The definition of cCRT was:radiotherapy started within 30 days after the start of chemotherapy.

      Results

      Out of all 20 Dutch departments of radiation oncology, 19 centers participated in the registry. A total of 2942 NSCLC stage III patients were treated with CRT. Of these 67.2% (n= 1977) were treated with cCRT (median age 66 years) and 32.8% (n=965) were treated with seqCRT (median age 69 years). Good performance status (WHO 0-1) was scored in 88.6% for patients treated with cCRT and in 71.0% in the patients treated with seqCRT. Acute non-hematological 3-month toxicity (CTCAE grade ≥3 or radiation pneumonitis grade ≥2) was scored in 21.9% of the patients treated with cCRT and in 17.7% of the patients treated with seqCRT. The univariable analysis for acute toxicity showed significantly increased toxicity for cCRT (p=0.008), WHO ≥2 (p=0.006), and TNM IIIC (p=0.031). The multivariable analysis for acute toxicity was significant for cCRT (p=0.015), WHO ≥2 (p=0.001) and TNM IIIC (p=0.016). The univariable analysis for 3-month mortality showed significance for seqCRT (p=0.025), WHO ≥2 (p<0.001), higher cumulative radiotherapy dose (p<0.001), higher gross tumor volume (GTV)total (p=0.020) and male patients (p<0.001). None of these variables reached significance in the multivariable analysis for 3-month mortality.

      Conclusions

      In this national lung cancer audit of inoperable NSCLC patients, 3-month toxicity was significantly higher in patients treated with cCRT (21.9% versus 17.7% for seqCRT) higher TNM stage IIIC, and poor performance (WHO≥2) patients.The 3-months mortality was not significantly different for tested parameters. Age was not a risk factor for acute toxicity, nor 3 months mortality.

      Keywords

      Introduction

      Based on randomized trials, chemoradiotherapy (CRT) is superior to radiotherapy alone in patients with stage III non-small cell lung cancer (NSCLC). Therefore, CRT is the standard of care, favoring concurrent (cCRT) over sequential (seqCRT)
      • Auperin Anne
      • Pechoux Cecile Le
      • Roland Estelle
      • et al.
      Meta-analysis of concomitant versus sequential radiochemotherapy in locally advanced non-small-cell lung cancer.
      . The Dutch Lung Cancer Audit-Radiotherapy (DLCA-R) started in 2013 for lung cancer patients irradiated with curative intent. Real-world data has become extremely important to compare treatment toxicity and treatment outcome, especially in the elderly patients. According to the Dutch national guidelines, cCRT is the preferred treatment for inoperable stage III NSCLC. As trials often excluded elderly patients in the past, there is scarce evidence regarding the optimal treatment in the elderly with stage III NSCLC
      • Dawe David E
      • Christiansen David
      • et al.
      Chemoradiotherapy versus radiotherapy alone in elderly patients with stage III non-small cell lung cancer: A systematic review and meta-analysis.
      . For inoperable stage III NSCLC patients, a large treatment variation was observed between and within the Netherlands and Belgium in an observational population-based study
      • Walraven I
      • Damhuis RA
      • Ten Berge MG
      • Rosskamp M
      • van Eycken L
      • de Ruysscher D
      • et al.
      Treatment Variation of Sequential versus Concurrent Chemoradiotherapy in Stage III Non-Small Cell Lung Cancer Patients in the Netherlands and Belgium.
      . SeqCRT was significantly more frequently prescribed than cCRT to elderly patients and to patients with a high N-stage. Treatment decisions for elderly patients with NSCLC should however not be made on the basis of age alone. Comorbidity, weight loss and performance score are generally integrated in the tumor board treatment decision for elderly patients with stage III NSCLC. The aim of this study is to compare treatment toxicity and short-term survival of all NSCLC patients treated with cCRT and seqCRT in the Netherlands.

      Methods

      Study design

      The nationwide Dutch Lung Surgery Audit (DLSA) started in 2012 to monitor the quality of lung operations in The Netherlands
      • Ten Berge M
      • Beck N
      • Heineman DJ
      • Damhuis R
      • Steup WH
      • van Huijstee PJ
      • et al.
      Dutch Lung Surgery Audit: A National Audit Comprising Lung and Thoracic Surgery Patients.
      . The audit has been extended with a radiation oncology as well as a thoracic oncology registry. The Dutch Lung Cancer Audit for Radiotherapy (DLCA-R) collects information on all lung cancer patients receiving thoracic radiation with curative intent in the Netherlands since 2013.The parties that provide the data are the data managers of the hospitals. The treating physicians, physician assistants or specialized nurses score the toxicity. The central data collection is done by a trusted third party: Medical Research Data Management (MRDM). The collected data are analyzed by the Dutch Institute for Clinical Auditing (DICA) and benchmarked indicator results on the quality of care processes and patient outcomes are provided back to the hospitals in secured web-based dashboards.
      Patients receiving curative radiotherapy for primary or recurrent stage I-III non-small cell lung cancer are included in this population-based study. From 2013 until 2018 a total of 14.426 patients were treated and registered in 19 out of the 20 radiation oncology departments in the Netherlands.

      Patient selection

      All registered patients who had curative chemoradiation for stage III A, B and C with pathologically proven or suspicion of NSCLC between January 1st, 2015 and December 31st, 2018, were evaluated. No ethical approval was required for this analysis under the Dutch law because all patient data is anonymized by MRDM. The analysis performed was approved by the scientific committee of the DLCA-R.

      Definitions

      Curative radiotherapy was defined in case a cumulative dose of 50 Gy or more was planned. cCRT was defined in case the irradiation started within 30 days after the start of the chemotherapy treatment. Non-hematologic toxicity and 3-months mortality were scored within three months after the last day of radiotherapy. Age was used as a continuous variable. Mortality and acute toxicity were measured as a dichotomous outcome. Toxicity was scored according to CTCAE-4 version 4.03 in case of non-hematological toxicity grade ≥3 or radiation pneumonitis grade ≥2

      Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0 Published: May 28, 2009 (v4.03: June 14, 2010) U.S.DEPARTMENT OF HEALTH AND HUMAN SERVICES. National Institutes of Health National Cancer Institute

      . TNM-7 was used in the database in 2015 and 2016. Since the introduction of the TNM-8 as of January 1st, 2017, the audit used the new staging system. It is important to realize that in the TNM-7 stage III C NSCLC did not yet exist. The Gross Tumor Volume (GTV) tumor and GTV total (tumor and lymph nodes) were analyzed in cubic centimeters (cc) for cCRT and seqCRT patients.

      Outcomes

      All participating centers collected information on patient, tumor and treatment characteristics, and the incidence of mortality and severity of acute toxicity within three months after the end of radiotherapy treatment. From 2017 onwards each institute decided to fill in a more detailed or less detailed information sheet (bare minimum) of their patients treated. We analyzed stage III NSCLC patients treated from 2015 until 2018 with cCRT and seqCRT.

      Statistical analysis

      To evaluate the association between prognostic factors and outcome parameters (acute toxicity and 3-months mortality) an univariable and multivariable analysis was performed using the logistic regression method to obtain Odds Ratio's (OR) and 95% confidence intervals. We performed backward stepwise (conditional) analysis to find the optimal model based on the Log likelihood test. P-values ≤0.05 were considered statistically significant. Statistical analysis was performed with Statistical Package IBM SPSS Statistics (version 28.0.1.1(15)), R version 3.6.3 (2020-02-29) and R studio version 1.1.456.

      Results

      Baseline characteristics

      Between 2015 and 2018, 2942 patients were treated by curative chemoradiation for stage III NSCLC and registered in the DLCA-R.
      In Table 1, the baseline characteristics of all patients (n=2942) are shown. A total of 1977 patients (67.2%) were treated with cCRT with a median age of 66 years. A total of 965 (32.8%) were treated with seqCRT with a median age of 69 years. In the cCRT group 58.2% was male, comparable to 57.9% in the seqCRT group. Good performance status (WHO 0-1) was reported in 88.6% of the patients who had cCRT and 71.0% of the patients who had seqCRT. The NSCLC was pathologically proven in 98.3% of the cCRT group, compared to 96.5% of the seqCRT group. The primary tumor volumes were available for 271 patients in both groups. The median volume of the GTV (gross tumor volume) was 84 cc in the cCRT group and 50.5 cc in the seqCRT group. The median volume of the GTV total (primary tumor and lymph nodes) was 109.5 cc in the cCRT group and 75 cc in the seqCRT group. The cumulative radiotherapy dose was not given as planned in 3.6% of the cCRT group and in 1.9% of the seqCRT group.
      Table 1Patient-, tumor- and treatment characteristics of patients with non-small cell lung carcinoma stage III who had concurrent chemoradiation (cCRT) or sequential chemoradiation (seqCRT) from 2015 through 2018.
      cCRTseqCRT
      Number of patients treated1977 (67%)965 (33%)
      Variable
      Age (median [range], years)66 [31-89]69 [33-89]
       Missing31
      Year
       2015488 (24.7%)197 (20.4%)
       2016420 (21.2%)173 (17.9%)
       2017509 (25.7%)257 (26.6%)
       2018560 (28.3%)338 (35.0%)
      Gender
       Male1151 (58.2%)559 (57.9%)
       Female826 (41.8%)406 (42.1%)
      WHO
       0718 (36.3%)183 (19.0%)
       11034 (52.3%)502 (52.0%)
       ≥2113 (5.7%)164 (17.0%)
       Missing112 (5.7%)116 (12.0%)
      Primary or recurrent tumor
       Primary1914 (96.8%)921 (95.4%)
       Recurrent57 (2.9%)43 (4.5%)
       Unknown6 (0.3%)1 (0.1%)
      Tumor location
       Trachea3 (1.7%)1 (0.1%)
       Right lung1099 (55.6%)464 (48.1%)
       Left Lung606 (30.7%)254 (26.3%)
       Mediastinum36 (1.8%)11 (1.1%)
       Right and left bronchi118 (6.0%)46 (4.8%)
       Unknown115 (5.8%)189 (19.6%)
      Pathologically proven disease
       NSCLC (tissue diagnosis)1944 (98.3%)931 (96.5%)
       Suspicion NSCLC33 (1.7%)34 (3.5%)
      TNM stage
       Stage IIIA1207 (61.1%)516 (53.5%)
       Stage IIIB677 (34.2%)374 (38.8%)
       Stage IIIC93 (4.7%)75 (7.8%)
      Type of chemoradiation
       Concurrent:cCRT1977 (67%)-
       Sequential: SeqCRT-965 (33%)
      GTV tumor median, range, cc84 [0-1213]50.50 [0-614]
       Missing/unknown1762887
      GTV total (tumor, lymph nodes) median, cc [range],109.5 [7-1300]75.0 [5-614]
       Missing/unknown1773898
      Cumulative RT dose median, Gy [range], 66.0 [50.0-83.6]66.0 [50.0-93.3]
       Missing/unknown00
      Cumulative RT dose as planned
       Yes1820 (92.1%)768 (79.6%)
       No72 (3.6%)18 (1.9%)
       Missing/unknown85 (4.3%)179 (18.5%)
      GTV = gross tumor volume.
      Different fractionation schemes were given for cCRT and seqCRT. The most common fractionation schemes for cCRT were 33 × 2 Gy (31%), 24 × 2.75 Gy (22%) and 30 × 2 Gy (13%). The following fractionation schemes were used frequently in sequential chemoradiation: 24 × 2,75 Gy (26%), 25 × 2,4 Gy (18%) and 33 × 2 Gy (13%).

      Toxicity

      Table 2 shows acute 3-month toxicity (grade ≥3) in 21.9% of the patients treated with cCRT and in 17.7% of the patients treated with seqCRT. In Table 3, the univariable analysis for acute toxicity showed significance for cCRT (p=0.008) (OR 0.78, CI 0.65-0.94), WHO PS ≥2 (p=0.006) (OR 1.56, CI: 1.13-2.14), and TNM stage IIIC (p=0.031) (OR 1.50, CI 1.04-2.16). The multivariable analysis for acute toxicity showed significance for cCRT (p=0.015) (OR 0.7, CI 0.62-0.95), WHO≥2 (p=0.001) (OR 1.73, CI 1.25-2.41) and TNM stage IIIC (p=0.016) (OR 1.59, CI 1.09-2,31). No influence of age was observed (p=0.331) for acute toxicity.
      Table 2Summary of patient outcomes of concurrent chemoradiation (cCRT) and sequential chemoradiation (seqCRT) in patients with stage III lung cancer.
      cCRTseqCRT
      Number of patients treated1977 (67%)965 (33%)
      Variable
      Acute toxicity
       <3 or none (radiation pneumonitis < grade 2)1424 (72%)704 (73.0%)
       ≥3432 (21.9%)171 (17.7%)
       Missing/unknown121 (6.1%)90 (9.3%)
      3-month mortality
       No1851 (93.6%)879 (91.0%)
       Yes68 (7.0%)
       Missing/unknown72 (3.6%)

      54 (2.7%)
      18 (1.0%)
      Table 3Univariable and multivariable analysis of acute toxicity.
      Univariable analysis of non-hematological acute toxicity
      VariableOR95% CI
      LowHighp-value
      Age0.9960.9891.0040.331
      Gender
       Male1.0---
       Female1.0110.8421.2140.905
      WHO
       0 (ref)1.0---
       11.1300.9161.3930.254
       >=21.5571.1332.1400.006
      TNM
       IIIA (ref)1.0---
       IIIB1.1000.9071.3330.332
       IIIC1.4971.0392.1580.031
      Cum dose0.9820.9601.0050.133
      GTV tumor1.0000.9991.0010.822
      GTV total1.0010.9991.0030.157
      Treatment
       cCRT1.0---
       seqCRT0.7800.6500.9370.008
      Multivariable analysis of non-hematological acute toxicity
      VariableOR95% CI
      LowHighp-value
      WHO
       0 (ref)1.0---
       11.1570.9361.4300.179
       >=21.7331.2452.4120.001
      TNM
       IIIA (ref)1.0---
       IIIB1.0670.8731.3050.525
       IIIC1.5851.0892.3080.016
      Treatment
       cCRT1.0---
       seqCRT0.7650.6170.9500.015
      NSCLC patiënts treated with chemoradiation in the Netherlands between 2015-2018.

      Mortality

      Three-months mortality was scored in 3.6% of the patients treated with cCRT and in 7.0% of the patients treated with seqCRT (Table 2). In Table 4, the univariable analysis for 3-month mortality showed significance for seqCRT (p=0.025) (OR 1.22, CI 1.03-1.45) WHO ≥2 (p<0.001) (OR 3.87, CI 2.28-6.58), higher cumulative dosis (p<0.001) (OR 0.92, CI 0.88-0.95) higher GTV total (p=0.020) (OR 1.00CI 1.00-1.01) and male patients (p<0.001) (OR 0.43, CI 0.29-0.64). In the multivariable analysis for 3-month mortality these variables were not significant anymore.
      Table 4Univariable and multivariable analysis of 3-month mortality.
      Univariable analysis of 3-month mortality
      VariableOR95% CI
      LowHighp-value
      Age1.0010.9981.0040.604
      Gender
       Male1.0--
       Female0.4290.2900.637<0.001
      WHO
       0 (ref)1.0---
       11.4690.9392.2970.092
       ≥ 23.8702.2776.579<0.001
      TNM
       IIIA (ref)1.0---
       IIIB1.2970.9081.8540.153
       IIIC1.6130.8383.1060.153
      Cumulative dose0.9170.8840.951<0.001
      GTV tumor1.0000.9991.0020.492
      GTV total1.0031.0001.0060.020
      Treatment
       cCRT1.0---
       seqCRT1.2201.0261.4520.025
      Multivariable analysis of 3-month mortality
      VariableOR95% CI
      lowhighp-value
      Gender
       Male1.0---
       Female0.8840.5001.5630.672
      WHO
       0 (ref)1.0---
       10.6280.3481.1330.123
       ≥ 21.1580.4043.3140.785
      Cumulative dose1.0180.9421.1020.648
      GTV total1.0010.9991.0030.212
      Treatment
       cCRT1.0---
       seqCRT0.8550.4361.6760.648
      NSCLC patiënts treated with chemoradiation in the Netherlands between 2015-2018.

      Discussion

      Our study shows higher risk of 3-month toxicity in patients treated with concurrent chemoradiotherapy in real world, with worse performance status and higher TNM stage. Higher age did not increase the risk on 3 month toxicity or 3 month mortality.
      In a recent Belgium nationwide analysis, 34% of all the patients with stage III NSCLC disease received chemoradiation, and 17% of those patients with stage IIIA disease had surgery
      • Ocak S
      • Tournoy K
      • Berghmans T
      • Demedts I
      • Durieux R
      • Janssens A
      • et al.
      Lung cancer in Belgium.
      . Moderate variability between centres was observed. It is hard to do a comparison with our data from the DLCA-R. We analysed the patients with inoperable stage III NSCLC treated with cCRT or seqCRT. In our results age did not increase the risk on 3-month toxicity nor 3-month mortality. cCRT should therefore not be dispensed on the basis of age alone
      • Salama JK
      • Vokes E.
      New radiotherapy and chemoradiotherapy approaches for non-small-cell lung cancer.
      .
      In a large meta-analysis for NSCLC patients treated with cCRT based on individual patient data, risk factors for symptomatic pneumonitis were examined. Elderly patients receiving cCRT with carboplatin-paclitaxel were at greatest risk of lung toxicity (pneumonitis up to 77% in ages 61-70)
      • Palma David A
      • Senan Suresh
      • Tsujino Kayoko
      • et al.
      Predicting radiation pneumonitis after chemoradiation therapy for lung cancer: an international individual patient data meta-analysis.
      . Unfortunately we have no information on the type of chemotherapy administered in our study. Almost all patients were treated before adjuvant durvalumab became standard of care, so it is important to know if toxicity increased after the introduction of adjuvant durvalumab. This will be subject of future DLCA-R analysis. The consensus based Dutch guideline for stage III NSCLC concludes that older NSCLC patients do not necessarily show a higher incidence of toxicity after chemoradiotherapy.This is supported by our data.
      In a Japanese trial, 200 patients older than 70 years, with unresectable stage III NSCLC were randomly assigned to cCRT or radiotherapy alone showed increased hematological toxicity (grade 3 and 4) in older patients (>70 years) by the addition of carboplatin to radiotherapy
      • Ocak S
      • Tournoy K
      • Berghmans T
      • Demedts I
      • Durieux R
      • Janssens A
      • et al.
      Lung cancer in Belgium.
      . The DLCA-R does not register hematologic toxicity. It is Important to note is that a significantly prolonged survival was seen in the cCRT arm
      • Atagi S
      • Kawahara M
      • Yokoyama A
      • Okamoto H
      • Yamamoto N
      • Ohe Y
      • et al.
      Thoracic radiotherapy with or without daily low-dose carboplatin in elderly patients with non-small-cell lung cancer: a randomised, controlled, phase 3 trial by the Japan Clinical Oncology Group (JCOG0301).
      . In our study, we only can make conclusions on the 3-month mortality, because follow up after 3 months is not scored. Most patients are followed by the thoracic oncologists in the Netherlands. Driessen et al studied patient characteristics predictive for tolerance and survival of chemoradiation in daily clinical practice. In a cohort of 216 patients they found that although relatively fit elderly were assigned to cCRT, treatment tolerance was worse especially for those with severe comorbidity when treated with cCRT and seqCRT with a Odds Ratio (OR) 6.2 (95%CI 1.6-24) and OR 6.4 (95%CI 1.8-22), respectively
      • Driessen EJ
      • Bootsma GP
      • Hendriks LE
      • van den Berkmortel FW
      • Bogaarts BA
      • van Loon JG
      • et al.
      Stage III Non-Small Cell Lung Cancer in the elderly: Patient characteristics predictive for tolerance and survival of chemoradiation in daily clinical practice.
      . Atagi et al. concluded in a randomized, controlled, phase 3 trial, that for a select group of elderly patients with locally advanced NSCLC, combination chemoradiotherapy provides a clinically significant benefit over radiotherapy alone
      • Atagi S
      • Kawahara M
      • Yokoyama A
      • Okamoto H
      • Yamamoto N
      • Ohe Y
      • et al.
      Thoracic radiotherapy with or without daily low-dose carboplatin in elderly patients with non-small-cell lung cancer: a randomised, controlled, phase 3 trial by the Japan Clinical Oncology Group (JCOG0301).
      ,
      • Dawe David E
      • Christiansen David
      • et al.
      Chemoradiotherapy versus radiotherapy alone in elderly patients with stage III non-small cell lung cancer: A systematic review and meta-analysis.
      .
      Three months mortality was scored in 3.6% of the patients treated with cCRT and in 7.0% of the patients treated with seqCRT. We did however not register the cause of death. In the Belgian lung cancer registry, the proportion of patients with stage III NSCLC who died within 60 days after end of primary (chemo)RT with curative intent was higher: 9.3%
      • Ocak S
      • Tournoy K
      • Berghmans T
      • Demedts I
      • Durieux R
      • Janssens A
      • et al.
      Lung cancer in Belgium.
      . Miller et al found that sequential chemotherapy and radiation was superior to concurrent chemoradiation in the elderly (≥ 70 years old)
      • Miller ED
      • et al.
      The addition of chemotherapy to radiation therapy improves survival in elderly patients with stage III non-small cell lung cancer.
      . They reported that sequential chemoradiation compared to concurrent chemoradiation, was associated with a 9% reduction in the risk of death in the elderly patients. We did not observe a significant difference in 3 months mortality in the elderly between patients treated with cCRT versus seqCRT. A possible explanation could be that for our elderly patients in the tumor board meeting a strict selection was applied for cCRT. .
      This Dutch audit on lung cancer treatment provides the health professional with real-world data for patients stage III NSCLC treated with CRT. Very often elderly patients were excluded from trials studying chemoradiation. It is extremely important to analyze real world data of patients treated with curative chemoradiation in daily practice in the Netherlands. This study may help to gain insight in patient selection: in case of bad performance patients should be informed about some increased toxicity with cCRT, which could be a factor to consider seqCRT. For elderly patients in a good WHO PS, cCRT should however certainly be the primary choice of treatment.
      Our study has several limitations. The DLCA-R does not register hematologic toxicity, cause of death, late toxicity or chemotherapy regimen administered. In the future, details of chemotherapy regimen and adjuvant immunotherapy will become transparent because the registrations aim to be connected on a patient level.
      Another limitation is that scoring of co-morbidity and tumor volumes is not mandatory for the participating institutions that fill in the ’bare minimum’ patient data. This resulted in a lot of missing GTV data. Nevertheless, due to the relatively large numbers, GTV was included in our analysis and a higher GTV total was a significant factor in the univariable analysis for 3 month mortality.
      Furthermore, our data was scored by the treating physician, specialized nurse or physician assistant and entered in the registry by a data manager. Prior external data verification showed high levels of patient inclusion and good quality of the registered data
      • van der Werf LR
      • Voeten SC
      • van Loe CMM
      • Karthaus EG
      • Wouters M
      • Prins HA.
      Data verification of nationwide clinical quality registries.
      .
      Whether a stage III patient will be treated with cCRT or seqCRT remains a multidisciplinary tumor board decision. In the Netherlands 95% of all lung cancer patients are discussed in a specialized tumor board
      • Ronde Merle I
      • Bahce Idris
      • Hashemi Sayed
      • Dickhoff Chris
      • de Haan Patricia F
      • et al.
      Factors influencing multi-disciplinary tumor board recommendations in stage III non-small cell lung cancer.
      . Despite the limitations, this nation-wide study included large numbers of patients treated in real life, reflecting current daily practice.
      In the near future we will repeat the analyses in more recent years and report the results after the nationwide introduction of adjuvant immunotherapy .

      Conclusions

      This national lung cancer audit provides real-world outcome data for stage III NSCLC patients treated between 2015 and 2018 with CRT. In conclusion, this study shows higher risk of 3-month toxicity in patients with concurrent chemoradiotherapy, worse performance status and higher TNM stage. Age did not increase the acute toxicity risk. The multivariable analysis for 3-month mortality did not show significant differences in the variables tested. The data supports earlier studies and current clinical practice that cCRT is the preferred treatment for the young and fit elderly. SeqCRT is advised in the elderly and frail patients (WHO PS ≥2) because of reduced toxicity. Future research should focus on predicting prognostic factors for curative chemoradiation in the era of adjuvant immunotherapy.

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