Early evaluation of a new regional pathway for tri-modality treatment in stage III-N2 NSCLC in Greater Manchester

Abstract

Introduction: The 2019 NICE guidelines on the management of lung cancer recommended chemoradiotherapy (CRT) followed by surgery (termed ‘tri-modality’) treatment in patients with potentially resectable stage III-N2 NSCLC. NICE also recommends surgery should be completed within 3-5 weeks of CRT. The Greater Manchester (GM) Cancer Lung Pathway Board developed a new protocol including patient selection guidance, utilising the regional thoracic surgical centre for post-CRT imaging from brain to pelvis with hot reporting and same day clinical consultation and rapid access to surgical consultations. This study provides an early evaluation of this new protocol. Methods: A retrospective observational study of all patients commenced on the tri-modality pathway across GM. Patient-related data, adverse events, treatment compliance, pathway times and treatment-related mortality (30- and 90-day) were collected. Results: Six patients with stage III-N2 NSCLC have been referred for tri-modality treatment since the launch of the protocol in November 2020 (see Table 1). 4/6 (66%) successfully completed tri-modality treatment (CRT+Surgery). Two patients did not proceed with surgery after CRT. Both were PDL1 >1% and commenced maintenance durvalumab at 24- and 40-days post-CRT. The mean number of days from finishing CRT to re-imaging was 5.5 days (range 3-8), all CT scans were hot reported and all patients completed a same-day physician-led consultation. The mean number of days from re-imaging to surgical clinic was 3.3 days (range 1-9) and 29.8 days (range 23-33) from CRT to surgery. There were no grade 4/5 adverse events. The 30/90-day mortality was 0%. Pathological examination confirmed complete resection (R0) and residual tumour in all cases. Conclusion: Although based on small numbers, this initial analysis suggests appropriate patient selection and adherence to the required timelines through the different stages of the pathway, meeting the NICE recommendations. Ongoing quality assurance and analysis of long-term outcomes from the pathway is now required.