Background: Durvalumab is a category 1 recommendation per National Comprehensive Cancer Network (NCCN) guidelines for patients with unresectable Stage III non-small cell lung cancer (NSCLC) following concurrent platinum-based chemotherapy and radiation therapy (CRT). Evidence-based guidelines provide guidance to providers and can improve patient survival across several cancer types. Concordance rates with guidelines have been variable across health institutions. We aim to study the adherence and identify barriers to concordance with Durvalumab usage at our center (Plan).
Methods: This is a retrospective analysis using a QI framework to develop potential process changes for guidelines concordance. All veterans with newly diagnosed stage III unresectable NSCLC seen at the Birmingham VA from October 2017 to the present were reviewed. (Do) Data including demographics, dates of diagnosis and CRT completion, Durvalumab usage and reasons for not prescribing durvalumab were collected.
Results: Forty-two patients with stage III lung cancer were identified between October 2017 and April 2019. Thirty-five patients were evaluable. Twenty out of these patients received concurrent CRT. While 50% of eligible patients (those that had CRT) received Durvalumab only 28% percent of the initial cohort with stage III lung cancer got the therapy. Of the ten eligible patients that did not receive the drug, reasons cited included intolerance to CRT, progression on CRT and refusal by patient. One patient did not have a clearly documented reason for not receiving Durvalumab (Study).
Conclusion: Twenty-eight percent of all stage III lung cancer patients received Durvalumab. However, when looking at patients that completed CRT, usage improved to fifty percent. This discordancy with guidelines is likely explained by the difference between clinical trial populations and real-world populations, though we will work on more aggressive consideration of upfront CRT vs sequential therapy to improve eligibility (Act). In most cases, the reason for the patients not receiving concordant therapy was the listed performance status. Only one patient did not have clear documentation as to why Durvalumab was not given. Our next PDSA cycle will include measures to study reasons for low concordance with focus on patient and system level barriers.