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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Stage III lung cancer that cannot be removed is treated with chemotherapy and radiotherapy together, aiming at cure. A year of the immunotherapy antibody durvalumab afterwards raised five-year survival from a third to over 40 percent, and for EGFR-mutated tumours osimertinib after chemoradiation holds the disease for years.
Concurrent chemoradiation, platinum-based chemotherapy given during six weeks of thoracic radiotherapy to 60 Gy, became the standard for unresectable stage III disease in the 1990s and 2000s after trials showed it beat radiotherapy alone and sequential treatment, at the cost of oesophagitis and pneumonitis. RTOG 0617 (2015) showed that raising the dose to 74 Gy shortened survival, so 60 Gy with intensity-modulated, image-guided delivery remains the norm, with proton therapy under randomised evaluation. Precise staging by PET-CT, brain MRI and mediastinal sampling matters because the group is heterogeneous: some IIIA tumours are resectable after induction therapy, while IIIB and IIIC are not.
PACIFIC (2017) changed the outcome: 713 patients without progression after chemoradiation were randomised to a year of durvalumab or placebo, and progression-free survival rose from 5.6 to 16.8 months, median overall survival from 29.1 to 47.5 months and five-year survival from 33.4 to 42.9 percent. Durvalumab consolidation was approved in February 2018 and adopted worldwide. PACIFIC-2 (2024), which gave durvalumab concurrently with chemoradiation, did not improve on the sequential approach, and trials of pembrolizumab with or without olaparib (KEYLYNK-012) and of other combinations are testing how to build on PACIFIC.
| Setting | Approach | Guideline |
|---|---|---|
| Unresectable stage III, fit, no EGFR mutation | Concurrent platinum-based chemoradiation to 60 Gy with intensity-modulated radiotherapy, then durvalumab for up to a year in patients without progression (PACIFIC). | not mapped |
| Unresectable stage III, EGFR-mutated | Concurrent chemoradiation then osimertinib until progression (LAURA). | not mapped |
| Unfit for concurrent treatment | Sequential chemotherapy then radiotherapy, or radiotherapy alone with a hypofractionated schedule; durvalumab afterwards where tolerated. | not mapped |
| Toxicity | Grading and steroid treatment of radiation and immune pneumonitis; oesophagitis supportive care; heart dose constraints in planning. | not mapped |