What are the treatment options for pN2 disease with negative margins?

Postoperative radiotherapy (PORT) has been reported in a meta-analysis to have an adverse effect in patients after complete resection of clinical earlystage NSCLC with pathological N0 or N1 disease whereas for patients with stage III, N2 disease there was no clear evidence of an adverse effect. 7However the results were limited by the inclusion of small randomized studies using older radiotherapy techniques and dosing regimens. In a population base analysis within the Surveillance, Epidemiology, and End Results database, patients with N2 nodal disease (HR 0.855; 95% CI, 0.762- 0.959; P = 0.0077).8The Adjuvant Navelbine International Trialist Association (ANITA) study also reported postoperative radiotherapy improved survival in patients with N2 disease following adjuvant chemotherapy.9Guidelines on treatment options for pN2 disease with negative margins are summarised in Supplemental Table 1.

Recommendations on the Treatment Options for pN2 Disease with Negative Margins

By consensus, the workgroup has adopted the CCCALCGWP Guidelines.

Recommendations are as follows:

1.Patients who have a good performance status and completely resected stage III NSCLC should be offered adjuvant platinum-based chemotherapy (A).

2.PORT in patients with pN2 disease is not recommended for routine use because of the lack of prospective randomised clinical trial data demonstrating an improvement in survival. PORT could be considered in selected patients with pN2 disease (C).

Cost-effectiveness

The cost-effectiveness of adjuvant chemotherapy has been addressed in one study of patients.10In this study, a cost-effectiveness analysis of adjuvant chemotherapy from the perspective of Canada's public healthcare system was performed based on the study population derived from the landmark National Cancer Institute of Canada Clinical Trials Group JBR.10 adjuvant cisplatin-vinorelbinestudy.6Ng and colleagues found the mean costs of treatment per patient in the observation and adjuvant chemotherapy arms were USD $19,149 and $25,110, respectively, with an incremental cost effectiveness ratio of USD $5754 per life-year gained. The authors concluded adjuvant cisplatin and vinorelbine was a highly cost-effective treatment that compared favourably with other standard health care interventions.10No cost-benefit/cost-effectiveness analyses have been published locally.