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As the non-small cell lung cancer (NSCLC) adjuvant treatment landscape evolves, an evaluation of treatment patterns and outcomes of patients with early-stage, resected NSCLC eligible for adjuvant treatment in routine clinical practice is needed to better understand the unmet needs in this patient population.
Materials and Methods
Data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2019) were used to identify patients with newly diagnosed stage IB (tumor size ≥4cm)-IIIA (AJCC 7th edition) NSCLC who received primary surgery (index date). We assessed adjuvant treatment patterns, real-world disease-free survival (rwDFS; time from index date to first recurrence or death) and overall survival (OS; time from index date to death), and loco-regional recurrence pattern and treatment distribution.
Results
Among 1761 patients with primary surgery, mean age was 73.8 years; 47.9% were male; and 83.9% were white. Approximately 41% of patients received adjuvant chemotherapy; median time from surgery to adjuvant chemotherapy initiation was 48 days, and the most frequently observed adjuvant chemotherapy regimen was carboplatin+paclitaxel (24.5%). In the overall population, median rwDFS was 24.8 months and OS was 76.7 months; 5-year rwDFS and OS rates were 29.3% and 57.5%, respectively. Among 392 patients with loco-regional recurrence, the most frequently observed treatment was curative radiation monotherapy (28.2%).
Conclusion
Despite clinical guideline recommendations, rate of adjuvant chemotherapy among patients with resected early-stage NSCLC was low in clinical practice. Overall, among patients with early-stage NSCLC treated with conventional primary surgery, poor survival outcomes were observed, highlighting the need for and importance of more effective adjuvant treatments.
Lung cancer is one of the most common and deadly cancers in the United States (US). The American Cancer Society projected approximately 230,000 lung cancer diagnoses and over 130,000 deaths from the disease in 2022.
The management of NSCLC varies by disease stage. For patients with resectable stage II-IIIA (American Joint Committee on Cancer [AJCC] 7th edition) disease, the conventional primary treatment is surgery followed by up to 4 cycles of adjuvant therapy with a platinum-based doublet.
Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario clinical practice guideline update.
Patients with resectable stage IB (AJCC 7th edition) disease with tumors ≥4 cm or with other high-risk factors are generally treated similarly as patients with stage II to IIIA disease, whereas those without high-risk factors are not recommended to receive adjuvant chemotherapy after surgery.
The prognosis of patients with recurrent disease is generally poorer with higher disease stage—the 5-year overall survival (OS) rate drops from 49% for stage IB to 20% for stage IIIA disease.
The IASLC lung cancer staging project: external validation of the revision of the TNM stage groupings in the eighth edition of the TNM classification of lung cancer.
As the NSCLC adjuvant treatment landscape evolves, an evaluation of treatment patterns and outcomes of patients with early-stage, resected NSCLC who are candidates for adjuvant treatment in routine clinical practice is warranted to better understand the historical unmet needs of this population. Therefore, this study aimed to describe the adjuvant treatment patterns, real-world DFS (rwDFS) and OS, as well as loco-regional recurrence patterns and treatment distribution in patients with stage IB to IIIA NSCLC after primary lung cancer surgery using US population-based data.
Methods
Study Design and Data Source
This was a retrospective observational study using data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2019) to identify patients with newly diagnosed early-stage NSCLC who received primary surgery.
The SEER-Medicare database represents the linkage of 2 large population-based sources to provide detailed information on Medicare beneficiaries with cancer. These 2 sources include the SEER cancer registries, which collect clinical, demographic, and cause of death information for patients with cancer, and the Medicare claims for covered health care services from the time of a person's Medicare eligibility until death. Data are updated biennially. As of August 2022, the data include all Medicare eligible persons appearing in the SEER data who were diagnosed with cancer through 2017 as well as their Medicare claims through 2019. Medicare Part D data are available from 2007 onward. The data are limited and complied with the Health Insurance Portability and Accountability Act and the Declaration of Helsinki.
Study Population
The patient selection flowchart to identify patients with newly diagnosed stage IB (tumor size ≥4 cm)-IIIA (AJCC 7th edition) NSCLC who received primary surgery for lung cancer with or without adjuvant chemotherapy and did not receive neo-adjuvant chemotherapy or neo-adjuvant/adjuvant radiation therapy is presented in Figure 1. Patients who met the following criteria were included in this study: (1) had a diagnosis of NSCLC recorded in the SEER registry between 2007 and 2017 based on the following codes from the International Classification of Diseases for Oncology, Third Edition: 340-C343, C348, and C349 with the relevant histology codes (8010, 8012, 8013, 8020, 8046, 8050-8052, 8070-8078, 8140, 8141, 8143, 8147, 8250-8255, 8260, 8310, 8430, 8480, 8481, 8490, 8560, and 8570-8575); (2) had stage IB (tumor size ≥4 cm)-IIIA disease based on the AJCC 7th edition tumor node metastasis (TNM) staging criteria,
were aged ≥66 years, and were with continuous enrollment in Medicare Parts A, B, and D ≥12 months at the initial diagnosis. For a given diagnosis, pathological information was used to derive the collaborative TNM stage if available; otherwise, clinical information was used; (3) No other cancers before the diagnosis of NSCLC, continuously enrolled in Medicare Parts A, B, and D ≥12 months after the initial diagnosis, and had received either a lobectomy, bilobectomy, or a pneumonectomy within 6 months of the initial NSCLC diagnosis; (4) had no prior neo-adjuvant chemotherapy and/or neo-adjuvant or adjuvant radiotherapy; and (5) had no diagnoses of distant secondary malignant neoplasm prior to or within 30 days of surgery.
Figure 1Patient selection flowchart.
Abbreviations: NSCLC = non-small cell lung cancer; SEER = Surveillance, Epidemiology, and End Results; TNM = tumor node metastases.
Once all eligible patients were identified, patients were assigned an index date, defined as the date of first surgery, and were followed for clinical outcomes from the index date to the earliest of end of data availability, end of enrollment, or death. To ensure a minimum of 5-year available follow-up duration from date of surgery to last date of Medicare claims through 2019, all patients were required to receive the first surgery for NSCLC prior to 2015 (Figure 1).
In order to define clinical outcomes for analysis, patients who met the eligibility criteria were assigned to 2 cohorts (i.e., the recurrence and nonrecurrence cohorts) based on whether they had experienced recurrence, including loco-regional recurrence and distant metastasis, after surgery (Figure 1). Loco-regional recurrence was defined as a new diagnosis of loco-regional disease, and/or additional surgery, curative radiation therapy, and chemoradiation following a 90-day treatment-free interval after the initial surgery. Distant metastasis was defined as a diagnosis of metastatic disease, and/or additional palliative radiation therapy, and systemic therapy for advanced NSCLC following a 90-day treatment-free interval after the initial surgery. Adjuvant treatment was allowed during the 90-day treatment-free interval and was defined as any Food and Drug Administration–approved or National Comprehensive Cancer Network (NCCN)–recommended adjuvant treatment initiated within 90 days after the surgery (Supplementary Table S1).
Patient demographic and clinical characteristics were collected during the baseline period, defined as the 12 months before the index date.
Adjuvant treatment patterns were assessed among patients who initiated adjuvant chemotherapy and included the time to adjuvant chemotherapy initiation (defined as time from index date to the date of first adjuvant chemotherapy), the proportion of patients on each adjuvant chemotherapy regimen, and adjuvant chemotherapy discontinuation (defined as the earlier of either identified disease recurrence or a treatment gap of at least 90 days for all adjuvant chemotherapy agents).
Clinical outcomes were measured in the overall population and by disease stage using rwDFS and OS. rwDFS was defined as time from index date to first recurrence or death, whichever occurred first; OS was defined as time from index date to death. Patients were censored at the earlier of the last date of follow-up in the SEER-Medicare data and end of data availability.
The proportion of patients with loco-regional recurrence and the distribution of different loco-regional recurrence treatments used were reported. Treatments for loco-regional recurrence included additional surgery, curative radiation therapy, and chemoradiation following a 90-day treatment-free interval after the initial surgery but before the development of distant metastasis.
Statistical Analysis
Baseline characteristics, adjuvant treatment patterns, and loco-regional recurrence treatment patterns were summarized descriptively using means and standard deviations (SDs) for continuous variables and frequency counts and percentages for categorical variables. The number of patients who received at least 2 cycles and 4 cycles of adjuvant chemotherapy, respectively, was estimated by assuming adjuvant chemotherapy was administered every 21 days and proxied by the number of patients who did not discontinue adjuvant chemotherapy by 42 and 84 days after adjuvant chemotherapy initiation. rwDFS and OS were described using Kaplan-Meier (KM) curves. KM rates for rwDFS and OS as well as median survival were assessed once per year up to 8 years post resection.
Results
Overall, 1761 patients with early-stage NSCLC who received primary surgery met the eligibility criteria and were included in the study, including 1182 (67.1%) patients identified with disease recurrence anytime during follow-up (Figure 1). The median follow-up time from initial surgery to death was 55.0 months.
Baseline Characteristics
At initial diagnosis, 385, 933, and 443 patients had stage IB, II, and IIIA NSCLC, respectively (Table 1). Overall, patient's mean ± SD age at surgery was 73.8 ± 5.4 years; less than half of patients were male; and over 80% were white patients. More than half of patients had nonsquamous disease at initial diagnosis. Over 90% of patients received lobectomy as the primary surgery. Approximately 41% (715 of 1761) patients received adjuvant chemotherapy; among patients with stage IB (tumor size ≥4 cm), II, and IIIA disease, the proportion of patients receiving adjuvant chemotherapy was 21.6%, 42.6%, and 53.0%, respectively (Table 1). The use of adjuvant targeted therapy and immunotherapy was not observed in the data, as the study period preceded the approval of these therapies in the US.
Among the 715 patients who initiated adjuvant chemotherapy, the median time from surgery to adjuvant chemotherapy initiation was 48 days (Supplementary Figure 1). The majority of patients (>704 [>98.5%] patients) received platinum-based adjuvant chemotherapy, including 398 (55.7%) who received a carboplatin-based regimen and >306 (>42.8%) who received a cisplatin-based regimen. The most frequently used platinum-based adjuvant chemotherapy was carboplatin + paclitaxel (24.5%), followed by cisplatin + vinorelbine (15.2%), carboplatin + pemetrexed (14.8%), and cisplatin + pemetrexed (13.4%). A total of <11 (<1.5%) patients received nonplatinum-based adjuvant chemotherapy (Figure 2). The most common duration of adjuvant chemotherapy administered was 3 cycles (Supplemental Figure 2).
Figure 2Distribution of patients by adjuvant chemotherapy regimen.
Note: Among patients who used platinum-based adjuvant chemotherapy, 28 had switched from one platinum agent to another during adjuvant treatment. The number and proportion of patients using nonplatinum-based chemotherapy were not presented because the sample size <11.
In the overall population, the median rwDFS was 24.8 months, and the 5-year rwDFS rate was 29.3%. Patients with more advanced disease stage at initial diagnosis had shorter rwDFS (Figure 3). Among patients with stage IB (tumor size ≥4 cm), II, and IIIA disease, respectively, the median rwDFS was 40.9, 24.4, and 13.8 months; and the 5-year rwDFS rate postresection was 38.9%, 29.1%, and 21.5%.
Figure 3Kaplan-Meier Analysis of real-world disease-free survival stratified by disease stage.
Note: Patients with stage IB disease were required to be with tumor size ≥4 cm.
In the overall population, the median OS was 76.7 months, and the 5-year OS rate was 57.5%. Patients with more advanced disease stage at initial diagnosis had shorter OS (Figure 4). Among patients with stage IB, II, and IIIA disease, respectively, the median OS was 97.9, 75.5, and 66.2 months; and the 5-year OS rate postresection was 66.0%, 55.6%, and 54.0%.
Figure 4Kaplan-Meier analysis of overall survival stratified by disease stage.
Note: Patients with stage IB disease were required to be with tumor size ≥4 cm.
Recurrence Pattern and Treatment Distribution for Loco-regional Recurrence
Among the 1,182 patients in the recurrence cohort, 392 (33.2%) had loco-regional recurrence as the first recurrence event, and the remaining had distant metastasis as the first recurrence event. The most frequently observed treatment for loco-regional recurrent NSCLC was curative radiation monotherapy (28.2%), followed by wedge resection (12.2%), chemoradiation therapy (4.8%), and lobectomy or pneumonectomy (4.6%). Approximately half (50.1%) of the patients did not receive any NSCLC treatment for loco-regional recurrence (Figure 5).
Figure 5Distribution of patients by treatment for loco-regional recurrent NSCLC.
Note: Among patients who received curative radio monotherapy, 18% (N = 20) received stereotactic body radiation therapy.
This retrospective observational study among patients with early-stage, resected stage IB to IIIA NSCLC with or without adjuvant chemotherapy in the US found that in the overall population, the median rwDFS and OS was 24.8 months and 76.7 months, respectively, with the 5-year rwDFS and OS rates being 29.3% and 57.5%, respectively. Additionally, patients with more advanced disease stage at initial diagnosis had shorter median rwDFS and OS as well as lower 5-year rwDFS and OS rates. Over half of the patients who experienced loco-regional recurrence did not receive any treatment for the recurrent disease. These findings highlight the poor survival outcomes of patients with early-stage, resected NSCLC and the importance of more effective adjuvant treatment options.
The findings from this study are largely aligned with previous studies assessing OS among patients with resected NSCLC and clinical trials in the adjuvant NSCLC setting in routine clinical practice. For instance, Cai and colleagues reported OS and rwDFS among patients with completely resected stage II-IIIB (AJCC 6th and 7th editions) NSCLC who received adjuvant treatment between 2008 and 2017 within the US Oncology Network clinics and found a median OS of 82.4 months and a median rwDFS of 42.9 months.
Clinical outcomes and resource utilization after surgical resection with curative intent among patients with non-small cell lung cancer treated with adjuvant therapies in a community oncology setting: A real-world retrospective observational study.
Lee and colleagues evaluated OS among patients diagnosed with stage IA to IIIB (AJCC 7th edition) NSCLC between 2010 and 2015 who received primary surgery and adjuvant treatment from the linked SEER-Medicare data and found an overall 5-year OS rate of 55.9% (ranged from 68.3% for patients with stage IA disease to 40.3% for patients with stage IIIB disease).
Despite several methodological differences between the current and the Cai and Lee studies, including the inclusion of patients with stage IIIB NSCLC in their studies who typically receive chemoradiation as a primary treatment as opposed to radical surgery with or without adjuvant chemotherapy as for stage IB to IIIA NSCLC,
Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario clinical practice guideline update.
these studies have consistently demonstrated the poor survival outcomes of patients with resected NSCLC who are candidates for adjuvant treatment in routine clinical practice.
The current study also summarized use patterns of adjuvant chemotherapy in patients with early-stage, resected NSCLC in routine clinical practice. Although adjuvant chemotherapy is recommended for stage IB-IIIA disease,
Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario clinical practice guideline update.
the current study found that the proportion of patients with these disease stages who initiated adjuvant chemotherapy was low (∼41%); and among those who initiated, only about one-fifth completed at least 4 cycles of treatment. Buck and colleagues conducted an electronic medical record–based study using data from US community oncology sites and found that 345 of 609 (57%) patients with resected, stage IB-IIIA NSCLC had received adjuvant chemotherapy. Contrary to the current study that included older patients, the study by Buck and colleagues included younger as well as older adult patients; thus, the patient population in that study could have been more fit than those in the current cohort, partially contributing to the higher proportion of patients who initiated adjuvant chemotherapy. Nonetheless, the proportions of patients who used adjuvant chemotherapy were considered relatively low in both studies given the guideline recommendations and lack of alternative adjuvant treatment options at the time the studies were conducted. Regarding adjuvant chemotherapy regimens, the study by Buck and colleagues found that carboplatin + paclitaxel was the most commonly used regimen,
Treatment patterns and health resource utilization among patients diagnosed with early stage resected non–small cell lung cancer at US community oncology practices.
a finding consistent with the current study as well as that reported in the aforementioned study by Lee and colleagues. The study by Lee and colleagues also reported a median time from surgery to adjuvant treatment initiation to be 6.3 weeks,
which is comparable to the 6.8 weeks (48 days) observed in the current study.
Finally, this study summarized treatment patterns for patients with early-stage, resected NSCLC who had loco-regional recurrence. Nearly half of patients with identified loco-regional recurrence were not found to receive any NSCLC treatments. Among those who received NSCLC treatments, 28.2% received radiation monotherapy, 16.8% patients received surgery, and 4.8% received chemoradiation therapy. Limited evidence on the treatment pattern for this population in routine clinical practice exists. A Canadian population-based study conducted by Moore and colleagues included 179 patients with stage I-III NSCLC who received surgery or radiation therapy with or without chemotherapy between 2005 and 2012 and subsequently developed loco-regional recurrence and reported comparable proportion of patients receiving active treatment for loco-regional recurrence. That study found that 28% of patients received curative-intent salvage treatment, whereas the remaining 72% of patients received palliative treatment (eg, palliative radiation therapy) only. Among those receiving curative-intent salvage treatment, radical radiation therapy alone was the most commonly used treatment, followed by chemoradiation therapy and surgery.
Based on the study by Moore and colleagues, potential reasons for providing palliative treatment included the extent of disease, patient decision, poor performance status, and poor lung function.
Notably, our report is also limited to older patients, with a median patient age of 73.8 years old at surgery, and obviously older at the time of subsequent recurrence.
Collectively, our study supplements existing studies by assessing historical survival outcomes and treatment patterns among patients with early-stage, resected NSCLC with and without adjuvant chemotherapy in routine clinical practice using US population-based data. The findings highlight the unmet treatment needs for patients with early-stage, resected NSCLC who are candidates for adjuvant treatment and the importance of novel adjuvant treatment options to help improve the survival outcomes of this patient population.
The NSCLC treatment landscape in the adjuvant setting has recently evolved dramatically owing to the advent of novel treatments such as immunotherapy and targeted therapy. In the US, atezolizumab was approved for the adjuvant treatment for NSCLC following complete resection and platinum-based chemotherapy in patients with stage II to IIIA disease whose tumors have programmed cell death ligand-1 (PD-L1) expression on ≥1% of tumor cells.
Another immunotherapy, pembrolizumab, is undergoing regulatory assessment in the US, based on the positive findings of the phase III KEYNOTE-091 study, which demonstrated significantly improved disease-free survival (DFS) in patients with stage IB (tumor size ≥4 cm)-IIIA NSCLC receiving pembrolizumab compared with those receiving placebo (hazard ratio: 0.76; 95% confidence interval: 0.63-0.91; P = .0014).
VP3-2022: Pembrolizumab (pembro) versus placebo for early-stage non-small cell lung cancer (NSCLC) following complete resection and adjuvant chemotherapy (chemo) when indicated: Randomized, triple-blind, phase III EORTC-1416-LCG/ETOP 8-15–PEARLS/KEYNOTE-091 study.
For patients with epidermal growth factor receptor–mutated NSCLC, the targeted therapy osimertinib was approved as adjuvant treatment after resection in patients with NSCLC whose tumors have epidermal growth factor receptor exon 19 deletions or exon 21 L858R mutations.
With additional data availability, further research is needed to understand the utilization and clinical outcomes with immunotherapy and targeted therapies in routine clinical practice.
The current study is subject to certain limitations. The linked SEER-Medicare database only includes Medicare patients aged ≥65 years; therefore, the results from this study may not reflect outcomes among a younger patient population with NSCLC. However, in the US, over 70% of patients with lung cancer between 2015 and 2019 were diagnosed at the age of 65 or above, with the median age at diagnosis being 71 years.
Therefore, patients from the SEER-Medicare data may be representative of the general patient with NSCLC in the US. Additionally, the data used in this study ranged from 2007 to 2019, which was prior to any approval of targeted therapy and immunotherapy for NSCLC in the US; thus, findings from this study are not generalizable to patients with NSCLC who received targeted therapy or immunotherapy. Due to the nature of administrative claims data, NSCLC recurrence cannot be identified directly; therefore, an algorithm that relied on various procedure codes, diagnosis codes, drug codes, and assumptions was used. Coding inaccuracies may have led to misclassification bias and misidentification of patients with NSCLC recurrence. Lastly, because information on both adjuvant treatment and loco-regional recurrence treatment was identified from the Medicare claims data, clinical information on treatment decision-making, including treatment initiation and treatment discontinuation, is limited. As such, future studies with data sources that have more detailed clinical information available are warranted to better understand the observed adjuvant and loco-regional recurrence treatment patterns in the current study.
Conclusion
This retrospective US population-based study found that approximately 41% of patients ≥65 with early-stage, resected NSCLC received adjuvant chemotherapy. The overall median rwDFS and OS was 24.8 and 76.7 months, respectively, with poorer survival outcomes observed among patients with more advanced disease stage at initial diagnosis. Approximately two-thirds of patients experienced disease recurrence during 4.5 years of follow-up. Approximately a third of patients with disease recurrence had loco-regional recurrence as the first recurrence, but less than half of patients with loco-regional recurrent NSCLC were identified to receive active treatment. These findings highlight the importance of more effective adjuvant treatment options for patients with early-stage, resected NSCLC to improve survival outcomes.
Clinical Practice Points
•
Early-stage NSCLC, typically refers to stage IB-IIIA (AJCC 7th edition) disease, is conventionally treated with radical surgery with or without adjuvant chemotherapy. However, Up to 70% of patients with resected NSCLC tumor developed recurrence.
•
An evaluation of historical treatment patterns and outcomes of patients with early-stage, resected NSCLC who are generally considered candidates for adjuvant treatment in routine clinical practice is warranted to better understand the unmet needs of this population.
•
This retrospective observational study using data from the SEER-Medicare database (2007-2019) found that among 1761 patients with newly diagnosed stage IB (tumor size ≥4 cm)-IIIA (AJCC 7th edition) NSCLC who received primary surgery for lung cancer, a relatively small proportion of patients (40.6%) received adjuvant chemotherapy despite guideline recommendations; and 67.1% experienced disease recurrence during the course of follow-up (median 4.5 years). The median rwDFS and OS were 2.1 years (ie, 24.8 months) and 6.4 years (ie, 76.7 months), respectively, and the 5-year rwDFS and OS rates were 29.3% and 57.5%, respectively.
•
Poorer survival outcomes were observed among patients with more advanced disease stage at initial diagnosis. Approximately a third of patients with disease recurrence had loco-regional recurrence as the first recurrence, but less than half of patients with loco-regional recurrent NSCLC were identified to receive active treatment.
•
As novel adjuvant treatments for NSCLC such as immunotherapy and targeted therapy are emerging, the suboptimal treatment patterns and outcomes observed highlight the importance of more effective treatment options for patients with early-stage, resected NSCLC to improve survival outcomes.
Author Contributions
Su Zhang, Yan Song, Chi Gao, Ariel Lerner, Anya Jiang, and James Signorovitch contributed to study conception and design, collection and assembly of data, and data analysis and interpretation. Howard West, Diana Chirovsky, Ayman Samkari, and Xiaohan Hu contributed to study conception and design, data analysis and interpretation. All authors reviewed and approved the final content of this manuscript.
Authorship
All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.
Medical Writing, Editorial, and Other Assistance
Medical writing assistance was provided by professional medical writer, Flora Chik, PhD, MWC, an employee of Analysis Group, Inc., a consulting company that has provided paid consulting services to Merck Sharp & Dohme LLC., a subsidiary of Merck & Co., Inc., Rahway, NJ.
Data Statement
This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services , Inc.; and the SEER Program tumor registries in the creation of the SEER-Medicare database.
The collection of cancer incidence data used in this study was supported by the California Department of Public Health pursuant to California Health and Safety Code Section 103885; Centers for Disease Control and Prevention's National Program of Cancer Registries, under cooperative agreement 5NU58DP006344; the National Cancer Institute's Surveillance, Epidemiology and End Results Program under contract HHSN261201800032I awarded to the University of California, San Francisco, contract HHSN261201800015I awarded to the University of Southern California, and contract HHSN261201800009I awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and do not necessarily reflect the opinions of the State of California, Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors.
Ethics Statement
The data are limited and complied with the Health Insurance Portability and Accountability Act and the Declaration of Helsinki.
Acknowledgments
This study was supported by Merck Sharp & Dohme LLC., a subsidiary of Merck & Co., Inc., Rahway, NJ, USA. Authors had full control of the content and made the final decision on all aspects of this article. The sponsor commissioned the study but had no role in the decision to publish the final paper.
Disclosure
Howard West is Clinical Executive Director at AccessHope and an Associate Professor at City of Hope. He also serves on advisory board for Amgen, AstraZeneca, Genentech/Roche, Merck, Mirati Therapeutics, Regeneron, and Takeda and as a Speaker for AstraZeneca and Merck. Xiaohan Hu, Diana Chirovsky, and Ayman Samkari are employees of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ and own stock/stock options in Merck & Co., Inc., Rahway, NJ. Su Zhang, Yan Song, Chi Gao, Ariel Lerner, Anya Jiang, and James Signorovitch are employees of Analysis Group, Inc., a consulting company that has provided paid consulting services to Merck Sharp & Dohme LLC., a subsidiary of Merck & Co., Inc., Rahway, NJ, which funded the development and conduct of this study and manuscript.
Adjuvant systemic therapy and adjuvant radiation therapy for stage I to IIIA completely resected non-small-cell lung cancers: American Society of Clinical Oncology/Cancer Care Ontario clinical practice guideline update.
The IASLC lung cancer staging project: external validation of the revision of the TNM stage groupings in the eighth edition of the TNM classification of lung cancer.
Clinical outcomes and resource utilization after surgical resection with curative intent among patients with non-small cell lung cancer treated with adjuvant therapies in a community oncology setting: A real-world retrospective observational study.
Treatment patterns and health resource utilization among patients diagnosed with early stage resected non–small cell lung cancer at US community oncology practices.
VP3-2022: Pembrolizumab (pembro) versus placebo for early-stage non-small cell lung cancer (NSCLC) following complete resection and adjuvant chemotherapy (chemo) when indicated: Randomized, triple-blind, phase III EORTC-1416-LCG/ETOP 8-15–PEARLS/KEYNOTE-091 study.
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