The development of novel immunotherapeutic and molecular targeted treatments for patients with early-stage non-small cell lung cancer has rapidly amplified over the past several years, signaling an imminent shift in treatment paradigms. While these changes offer new hope, they also raise questions about cost and accessibility. Two collaborative publications, led by Cancer Center Amsterdam researchers and recently published in The Lancet Regional Health Europe, examine this shifting medical landscape, and identify an urgent need for a collective approach to ensure that all patients across Europe have access to the best possible care.

The treatment landscape for early-stage non-small cell lung cancer (NSCLC) in Europe is set to undergo a significant transformation due to the development and integration of novel immunotherapeutic and molecular targeted therapies into standard care. Recent regulatory approvals by the European Medicines Agency (EMA) have introduced new treatment options, such as adjuvant osimertinib, adjuvant atezolizumab, adjuvant pembrolizumab, and neoadjuvant nivolumab plus chemotherapy.

While offering hope for improved survival and quality of life for patients with resectable NSCLC, this wave of innovation brings its own set of challenges, particularly in terms of discrepancies in access to these advanced therapies across different European countries.

"The differences in healthcare systems and reimbursement structures between European countries threaten to exacerbate healthcare inequalities at both the European and national level," says Idris Bahce, a Thoracic Oncologist and Associate Professor of the Multidisciplinary Thoracic Oncology Research Group at Amsterdam UMC.

The urgency for a unified European strategy

The efforts of Cancer Center Amsterdam researchers, alongside collaborators from seven European nations, have shed light on the inconsistencies in treatment access and reimbursement across Europe, as well as the discrepancies between EMA and the United States Food and Drug Administration (FDA) in terms of approval timings and the specific conditions or diseases for which a drug is approved to be used.

“Our findings reveal unequal patient access to these innovative therapies across Europe and disparities that are expected to worsen due to timing of drug approval and reimbursement,” says Ilias Houda, first author and PhD Candidate in Thoracic Oncology at Cancer Center Amsterdam.

The findings underscored the urgent need for unified strategies and collaborative efforts to ensure that all patients across Europe have timely access to the best possible care. The authors explored potential strategies and formulated a detailed set of recommendations to address discrepancies in care and access (see text box).

“Steps to reduce inequalities such as strengthening the multidisciplinary tumor board infrastructure, seeking partnerships with international regulatory bodies, and harmonizing health policies across Europe should be prioritized,” adds Ilias.

Recommendations

Despite the potential of new immuno-oncology and targeted therapies, there are still many questions and concerns. The authors identify these uncertainties and address the challenges in healthcare access in these recommendations:

Research Design

  • Define resectability criteria for stage III NSCLC.
  • Align studies with current care standards, particularly for stage III's radiotherapy aspects.
  • Include ctDNA clearance and pCR in designs to guide adjuvant therapy decisions.
  • Integrate surgical quality metrics to assess and improve surgical methods and outcomes.

Treatment Protocols:

  • Use neoadjuvant immunotherapy plus chemotherapy for stage III without driver mutations; evaluate the benefit of additional adjuvant immunotherapy.
  • Maintain adjuvant chemotherapy for stage IB to II; consider neoadjuvant/adjunct immunotherapy based on PD-L1 expression.
  • Stage II and III EGFR mutation-positive patients should receive adjuvant chemotherapy and osimertinib but not neoadjuvant chemoimmunotherapy.

Molecular Testing:

  • Conduct pre-treatment molecular tests for EGFR, ALK, and PD-L1.
  • Prefer comprehensive over single-gene testing.
  • Align reimbursement for diagnostic tests with the medicines they support.

Data Collection and Health Infrastructure:

  • Enhance or create registries for mapping NSCLC epidemiology and treatment impacts.
  • Highlight and support the role of multidisciplinary teams in treatment strategy evolution.
  • Standardize MDT advice, improve access to new treatments, and strengthen MDT frameworks.

Policy Harmonization and Access:

  • Foster partnerships for simultaneous reviews with international bodies to expedite access.
  • Harmonize health policies across Europe to streamline procedures and speed up insurance approvals.

For more information, contact Idris Bahce, or read the publications here:

Houda, Ilias et al. (2024) New systemic treatment paradigms in resectable non-small cell lung cancer and variations in patient access across Europe. The Lancet Regional Health – Europe, 38, 100840. https://doi.org/10.1016/j.lanepe.2024.100840

Houda, Ilias et al. (2024) Challenges and controversies in resectable non-small cell lung cancer: a clinician’s perspective. The Lancet Regional Health – Europe, 38, 100841. https://doi.org/10.1016/j.lanepe.2024.100841

Researchers involved at Cancer Center Amsterdam

Ilias Houda, MD

Chris Dickhoff, MD, PhD

Suresh Senan, MD, PhD (Professor)

Idris Bahce, MD, PhD

Text by Laura Roy.

This article was created for Cancer Center Amsterdam.

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