Focusing our work on innovation

In October 2017, we established a governance team lead by the two co-ordinating editors Pr. Virginie Westeel and Dr. Fergus Macbeth, and the managing editor Corynne Marchal. We undertook a priority setting exercise and came to the conclusion that we needed to focus our work on immunotherapy.

Lung cancer is one of the leading causes of cancer death worldwide and until recently, platinum-based chemotherapy with or without bevacizumab, an antiangiogenic agent, represented the standard first-line treatment in non-oncogene-addicted non-small cell lung cancer. The arrival of immune checkpoint inhibitors has dramatically changed the treatment paradigm.

There has not been such an important development and such promising results in lung cancer treatment for decades.

However, the immunotherapy drugs are very expensive and their use will have a significant impact on healthcare budgets. So it is very important to thoroughly evaluate the actual benefit provided by these innovative therapies.  Also, it is a fast-changing field and some questions remain unanswered, such as:

·         the best treatment strategy (monotherapy or combination therapy),

·         the respective roles of different biomarkers (such as PD-L1, TPS and TMB) for patient selection,

·         their use in the management of small-cell lung cancer,

·         their use in  the treatment of malignant pleural mesothelioma,

·         their use in the perioperative setting.

In November 2017, we submitted our proposal to our funder, the French National cancer Institute (INCa). A commission of experts studied it and fully validated our approach and proposed titles. We signed a three-year convention with the aim of focussing on these questions.

At present, a substantial number of ongoing trials is evaluating immune checkpoints inhibitors in different clinical situations worldwide.  It is essential that the Lung Cancer Group publishes systematic reviews that highlight the results of these trials because they may significantly change clinical practice.

In order to do so, we intend to use Cochrane’s new and challenging ‘living systematic review’ approach to provide up-to-date evidence-based summaries of the benefits and risks associated with use of immune check point inhibitors in the management of lung cancer.

Here is a list of reviews in progress in that field:

-          Immune checkpoint inhibitors (anti PD-1 or anti PD-L1) versus chemotherapy for second- or third-line treatment of metastatic non-small cell lung cancer

-          Checkpoint inhibitors for stage I to III non-small cell lung cancer treated with surgery or radiotherapy with curative intent

-          PD1 / PD-L1 inhibitors plus chemotherapy versus chemotherapy or immunotherapy for first-line treatment of advanced non-small cell lung cancer

-          CTLA4 inhibitors plus chemotherapy versus chemotherapy or immunotherapy for first-line treatment of advanced non-small cell lung cancer

-          Single or combined immune checkpoint inhibitors compared to first-line chemotherapy with or without bevacizumab for people with advanced non-small cell lung cancer (living review)

Already published reviews that will be updated soon

-          Immunotherapy (excluding checkpoint inhibitors) for stage I to III non-small cell lung cancer treated with surgery or radiotherapy with curative intent

Possible titles:

-          Immunotherapy for small cell lung cancer

-          Immunotherapy for malignant pleural mesothelioma.

INCa also made a special request on another priority topic : screening. Indeed, despite multiple international guidelines recommending low-dose computed tomography screening for high risk ex and current smokers, and calls for the implementation of screening, to our knowledge nationally co-ordinated screening programs have not been broadly adopted apart from Korea. However, in the absence of a co-ordinated program, there have been concerns about the low up take of screening and considerable variability in false positive rates between different providers.

There is an urgent need for a contemporaneous systematic evidence synthesis that incorporates the growing evidence base from randomized-controlled trials on both benefits and harms of screening in order to better understand the potential magnitude of any benefit and to understand in which groups any benefits might outweigh the harms. In order to do so, we intend to update our existing review Screening for lung cancer as soon as the NELSON trial will be published.