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Pooling 4,584 patients from the five big trials of chemotherapy after lung cancer surgery gave a clear answer: it helps, by about 5 percent at five years, and the benefit is in stage II and III rather than stage IA.
Pignon, Tribodet, Scagliotti, Douillard, Shepherd and colleagues pooled individual patient data from the five largest trials of cisplatin-based chemotherapy after complete resection conducted after the 1995 meta-analysis: 4,584 patients, median follow-up 5.2 years.
The stage gradient is the operational result. Chemotherapy after surgery is worth giving in stage II and III disease, is marginal in stage IB and looks actively harmful in stage IA, and no drug partner, patient sex, age, histology or type of surgery changed that. It is the evidence base that adjuvant targeted therapy (ADAURA, ALINA) and adjuvant immunotherapy (IMpower010) were later added to.
The rule that a patient with a resected stage II or III lung cancer is offered chemotherapy and a patient with a small stage I tumour is not. Everything added to adjuvant treatment since has had to beat, or be added to, this 5 percent.
Adjuvant treatment for lung cancer is now chosen by genotype. A resected ALK-positive tumour is treated with two years of a tablet instead of four cycles of platinum, which is a different life as well as a different outcome.
Adjuvant immunotherapy entered lung cancer here, and with it the question that still divides practice: whether it is better given before the operation, after it, or on both sides.
Every resected non-squamous lung cancer should be tested for EGFR mutations, because patients who carry one live longer if they take osimertinib for three years after surgery. The trial does not tell us whether adjuvant chemotherapy can be omitted, nor what happens on relapse after osimertinib, and the three-year duration was chosen empirically.
The foundation of minimal residual disease testing in lung cancer: a blood test that says a patient will relapse months before a scan does, and says which part of the tumour is doing it. Whether acting on that signal changes outcome is what the ctDNA-guided trials are for.
The paper that ended therapeutic nihilism in lung cancer. The effect was small, and saying so honestly is what made it credible; every later trial in advanced disease is measured against the platinum doublet this analysis justified.
Shares Adjuvant atezolizumab after adjuvant chemotherapy in resected stage IB-IIIA non-small-cell lung cancer (IMpower010), Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Dormant cells and minimal residual disease, Neoadjuvant / adjuvant / perioperative and the tag lung-evidence.
Shares Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials, Performance status (ECOG, Karnofsky), Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Trial design, endpoints and cost and the tag lung-evidence.
Shares Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Neoadjuvant / adjuvant / perioperative, Resectable stage I to III non-small-cell lung cancer, Trial design, endpoints and cost and the tag lung-evidence.
Shares Alectinib in resected ALK-positive non-small-cell lung cancer, Radiotherapy, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Trial design, endpoints and cost and the tag lung-evidence.
Shares Radiotherapy, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Etoposide, Cisplatin and the tag lung-evidence.
Shares ADAURA: three years of osimertinib after surgery for EGFR-mutated lung cancer, Radiotherapy, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Lung cancer (all types) and the tag lung-evidence.
Shares Phylogenetic ctDNA analysis depicts early-stage lung cancer evolution, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Resectable stage I to III non-small-cell lung cancer, Lung cancer (all types) and the tag lung-evidence.
Shares Radiotherapy, Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch, Dormant cells and minimal residual disease, Lung cancer (all types) and the tag lung-evidence.