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Outcomes Update of North American Intergroup Trial 0139 (R9309) Conducted by:

Phase III Study of Concurrent Chemotherapy and Radiotherapy (CT/RT) versus CT/RT followed by Surgical Resection for Stage IIIA(pN2) NSCLC. Radiation Therapy Oncology Group. Outcomes Update of North American Intergroup Trial 0139 (R9309) Conducted by:

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Outcomes Update of North American Intergroup Trial 0139 (R9309) Conducted by:

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  1. Phase III Study of Concurrent Chemotherapy and Radiotherapy (CT/RT) versus CT/RT followed by Surgical Resection for Stage IIIA(pN2) NSCLC Radiation Therapy Oncology Group Outcomes Update of North American Intergroup Trial 0139 (R9309) Conducted by: RTOG (chair), SWOG, NCIC CTG, ECOG, CALGB and NCCTG

  2. Lung Intergroup Trial 0139Rationale • Patients with stage III NSCLC and clinically-evident N2 disease have poor outcomes with surgery or radiotherapy (RT) alone • Chemotherapy (CT) plus RT is standard for pathologically-confirmed N2 nodes (pN2) • Surgical resection after CT/RT, although promising in phase II trials, is controversial due to increased morbidity and mortality

  3. Lung Intergroup Trial 0139Objectives • Determine if resection after CT/RT results in improved outcome compared to CT plus full-course RT (arms based on SWOG 8805 and SWOG 9019) 2. Analyze progression-free, overall, and long-term survival; toxicity; and patterns of failure

  4. Lung Intergroup Trial 0139Eligibility Criteria • T1-3, pN2, M0 non-small cell lung cancer • Resection technically feasible • FEV1 >2.0 liters, or, predicted post-resection FEV1 800 cc • Medically fit

  5. Lung Intergroup Trial 0139 Study Design STRATIFY KPS 70-80 vs 90-100 T1 vs T2 vs T3 RANDOMIZE RE-EVALUATERE-EVALUATE 2-4 weeks after 7 days before completion of RT completion of RT Cisplatin, 50 mg/m2 IV d1, 8, 29, 36 Etoposide, 50 mg/m2 IV d1-5, 29-33 Thoracic RT, 45 Gy (1.8 Gy/d), begin d1 Induction CT/RT

  6. Lung Intergroup Trial 0139 Study Design No progression at re-evaluation Continue RT to 61 Gy without interruption Surgical Resection CONSOLIDATION cisplatin plus etoposide X 2 cycles

  7. Lung Intergroup Trial 0139 Statistical Considerations • Sample size assumed 25% 2-year survival for CT/RT and 10% absolute improvement by the addition of surgery • 80% statistical power and 0.05 significance level • Final accrual 484 eligible patients

  8. Lung Intergroup Trial 0139 Results • Opened 3/94 and closed 11/01 • Accrual longer than planned with more events, thus closure allowed at n = 429 • First analysis in 2003 reported better PFS, but not OS, for surgical arm • Second planned analysis this report: Median follow-up: 81 months All patients followed >2.5 years

  9. Randomized/Eligible CT/RT/S CT/RT Female Age median yrs/70 KPS 70-80 Weight loss  5 kg T3 tumors Squamous histology LDH abnormal 429/396 (93%) 202 194 144 (36%) 60/63 (16%) 48 (12%) 84 (21%) 48 (12%) 129 (33%) 72 (18%) Lung Intergroup Trial 0139Patient and Tumor Characteristics* *balanced in both arms

  10. Lung Intergroup Trial 0139 Treatment Delivered ARM 1 (n=202) Eligible for thoracotomy 177 (88%) Thoracotomy performed 164 (81%) Complete resection 144 (71%) Incomplete resection 11 (5.5%) No resection 9 (4.5%) Eligible for consolidation CT/RT 179 (92%) Commenced consolidation 155 (80%) ARM 2 (n=194)

  11. Lung Intergroup Trial 0139 Treatment Delivered* Treatment CT/RT/S CT/RT p-value (n=202) (n=194) Induction 191 (95%) 177 (92%) NS chemotherapy Consolidation 112 (56%) 144 (75%) p<0.0001 chemotherapy Radiotherapy 193 (96%) 154 (79%) p<0.0001 *Per protocol or with an acceptable variation (study chair review)

  12. INT 0139 Grade 3/4 Toxicity from CT/RT 50 CT/RT/S (n=202) 80 77 40 CT/RT (n=194) 30 Percent (%) 44 20 29 26 24 20 18 10 0 Neutropenia Esophagitis* Nausea/ emesis Pneumonia/ respiratory *p=0.0006

  13. Lung Intergroup Trial 0139 Treatment-Related Mortality • During induction none, either arm • CT/RT/S total 16 (7.9%) 30 days postop. 10 (5.0%) misc. other 6 (2.9%) • CT/RT (during or 4 (2.1%) after consolidation)

  14. INT 0139 Treatment-Related Deaths on CT/RT/S Arm (n=16) Type of Total Deaths Surgery (of n=202) n (% total) Cause of Death None 38 1 (3%) Pneumonitis Exploration only 9 0 - Wedge 3 0 - Lobectomy 98 1 (1%) ARDS Pneumonectomy 54 14 (26%) ARDS/respiratory 11; miscellaneous, 3 (R) simple 17 5 (29%) (R) complex 12 6 (50%) (L) simple 6 0 (L) complex 19 3 (16%)

  15. Lung INT 0139: Patterns of Failure Site of First Arm 1 Arm 2 p-value Progression (CT/RT/S) (CT/RT) Local relapse only 10% 22% 0.002 primary 2% 14% nodes 7% 3% both 1% 5% Brain only 11% 15% 0.29 All distant metastases 37% 42% 0.35

  16. INT 0139 Pathologic T and N Status at Time of Surgery pT/N N % Thoracotomies % Total (n=164) (n=202) T0N0(pCR) 29 18% 15% T1N0 31 18% 15% T2-4N0 16 10% 8% Tany N0 76 46% 38% N1-3 or 88* 54% 43% unknown *3 were unknown

  17. 100 Failed/Total 75 CT/RT/S 159/202 CT/RT 172/194 / 50 % Alive without Progression / / / / / 25 / / / / / / / / / / / / / / / / Logrank p = 0.017 Hazard ratio = 0.77 (0.62, 0.96) / / / / 0 0 12 24 36 48 60 Months from Randomization Intergroup 0139/RTOG 9309Progression-Free Survival by Treatment Arms

  18. INT 0139/RTOG 9309 Survival Endpoints Endpoint CT+RT+S CT+RT Progression-Free Survival* Median 12.8 months 10.5 months 5-year ( 95% CI) 22.4% (6) 11.1% (5) Overall Survival* Median 23.6 months 22.2 months 5-year ( 95% CI) 27.2% (6) 20.3% (6) *crossing survival curves due to treatment-related deaths, 96 (24.2%) alive/censored

  19. INT 0139 Survival Data • CT/RT/S: more alive without progression (21% vs 11%, p = .008), but more died without progression (18% vs 10%, p = .02) • Survival curves indistinguishable through year 2, then separate • By year 5, absolute survival benefit of 7% favors surgical arm: odds ratio 0.63 (0.36, 1.10), p = 0.10; no other factor predicted 5-yr survival by logistic regression

  20. 100 Dead/Total CT/RT/S 145/202 CT/RT155/194 75 50 % Alive 25 Logrank p = 0.24 Hazard ratio = 0.87 (0.70, 1.10) 0 0 12 24 36 48 60 Months from Randomization Intergroup 0139/RTOG 9309Overall Survival by Treatment Arms

  21. INT 0139 Cox Stepwise Selection Model for Overall Survival Variable* Hazard Ratio p-value (95% CI) Weight loss 1.54 (1.16, 2.05) 0.003 <5 kg vs 5 kg Female vs male 1.42 (1.09, 1.84) 0.009 1 N2 station 1.38 (1.04, 1.83) 0.024 positive vs 2 CT/RT/S vs CT/RT 1.07 (0.84, 1.36) 0.61 *Not significant: age, KPS, T stage, LDH, histology

  22. INT 0139 Trimodality Arm (n=202) Survival by Pathologic Status at Surgery T/N Median Survival Subset (months) 5-year Tany N0* 34 41% Tany N1-3 26 24% or unknown No surgery 8 8% *29 of these = T0N0 (pCR): MS, 40 months; 5-year, 42%

  23. Intergroup 0139 Trimodality ArmOverall Survival by Pathologic Nodal Status 100 Pathologic N0 (n=76) Pathologic N1-3, unknown (n=88) 75 No surgery (n=38) p < 0.0001 % Alive 50 25 0 0 20 40 60 80 100 120 Months from Randomization

  24. INT 0139 Exploratory Survival Analysis • All but 1 postoperative death followed a pneumonectomy • Hypothesized survival advantage for CT/RT/S if lobectomy performed and for CT/RT if pneumonectomy • Patients on CT/RT/S were matched with those on CT/RT arm on 4 prestudy factors (KPS, age, sex, T stage); match feasible for 90/98 lobectomies and 51/54 pneumonectomies

  25. INT0139 Overall Survival of the Lobectomy Subset versus Matched CT/RT Subset 100 Dead/Total CT/RT/S 57/90 CT/RT74/90 75 Logrankp = 0.002 % Alive / / / 50 / / / / / / / / / / / / / / / 25 / / / / / CT/RT CT/RT/S MS 34 mos. 22 mos. 5 yr OS 36% 18% 0 0 12 24 36 48 60 Months from Randomization

  26. Lung Intergroup Trial 0139/RTOG 9309 Conclusions • Both approaches have median and 5-year survivals better than predicted from phase II data in stage IIIA(pN2) NSCLC • Longer follow-up confirms significantly improved PFS, but not OS, when surgery follows CT/RT • There is a trend for increased 5-year survival with trimodality therapy

  27. Lung Intergroup Trial 0139/RTOG 9309 Conclusions • N0 status at surgery significantly predicts greater 5-year survival • The trimodality approach is not optimal when a pneumonectomy is required due to high mortality risk • Surgical resection after CT/RT can be considered for fit patients if lobectomy is feasible

  28. INT 0139 Acknowledgements Radiation Therapy Oncology Group Study Chairs: Kathy S. Albain, M.D. – Medical Oncology Valerie R. Rusch, M.D. – Thoracic Surgery Andrew T. Turrisi, III, M.D. – Radiation Oncology Biostatisticians: R. Suzanne Swann, Ph.D. Rebecca Paulus, B.S.

  29. INT 0139 Acknowledgements Radiation Therapy Oncology Group Other Coauthors: Frances A. Shepherd, M.D. Colum Smith, M.D. David R. Gandara, M.D. David H. Johnson, M.D. Mark R. Green, M.D. Robert C. Miller, M.D. Yuhchyau Chen, M.D., Ph.D. Robert B. Livingston, M.D. Gail Darling, M.D. William T. Sause, M.D. James D. Cox, M.D.

  30. INT 0139 Other Acknowledgements Radiation Therapy Oncology Group Additional Protocol Discipline Chairs: Yvon Cormier, M.D. Mark Krasna, M.D. Claude Deschamps, M.D. Randolph Marks, M.D. Bahman Emami, M.D. Tom Rice, M.D. David Ettinger, M.D. Stephen Seagren, M.D. Richard Feins, M.D. Henry Wagner, M.D. Daniel Ihde, M.D. Major Thoracic Surgical Support: Willard Fry, M.D. RTOG Headquarters: Joanne Ley, R.N., C.C.R.P.

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