Overall survival according to immunotherapy and radiation treatment for metastatic non-small-cell lung cancer: A National Cancer Database analysis

Corey C. Foster, David J. Sher, Chad G. Rusthoven, Vivek Verma, Michael T. Spiotto, Ralph R. Weichselbaum, Matthew Koshy

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32 Scopus citations


Background: Preclinical studies suggest enhanced anti-tumor activity with combined radioimmunotherapy. We hypothesized that radiation (RT) + immunotherapy would associate with improved overall survival (OS) compared to immunotherapy or chemotherapy alone for patients with newly diagnosed metastatic non-small-cell lung cancer (NSCLC). Methods: The National Cancer Database was queried for patients with stage IV NSCLC receiving chemotherapy or immunotherapy from 2013 to 2014. RT modality was classified as stereotactic radiotherapy (SRT) to intra- and/or extracranial sites or non-SRT external beam RT (EBRT). OS was analyzed using the Kaplan-Meier method and Cox proportional hazards models. Results: In total, 44,498 patients were included (13% immunotherapy, 46.8% EBRT, and 4.7% SRT). On multivariate analysis, immunotherapy (hazard ratio [HR]:0.81, 95% confidence interval [CI]:0.78-0.83) and SRT (HR:0.78, 95%CI:0.70-0.78) independently associated with improved OS; however, the interaction term for SRT + immunotherapy was insignificant (p = 0.89). For immunotherapy patients, the median OS for no RT, EBRT, and SRT was 14.5, 10.9, and 18.2 months, respectively (p < 0.0001), and EBRT (HR:1.37, 95%CI:1.29-1.46) and SRT (HR:0.78, 95%CI:0.66-0.93) associated with OS on multivariate analysis. In the SRT subset, median OS for immunotherapy and chemotherapy was 18.2 and 14.3 months, respectively (p = 0.004), with immunotherapy (HR:0.82, 95%CI:0.69-0.98) associating with OS on multivariate analysis. Furthermore, for patients receiving SRT, biologically effective dose (BED) > 60 Gy was independently associated with improved OS (HR:0.79, 95%CI:0.70-0.90, p < 0.0001) on multivariate analysis with a significant interaction between BED and systemic treatment (p = 0.008). Conclusions: Treatment with SRT associated with improved OS for patients with metastatic NSCLC irrespective of systemic treatment. The high survival for patients receiving SRT + immunotherapy strongly argues for evaluation in randomized trials.

Original languageEnglish (US)
Article number18
JournalRadiation Oncology
Issue number1
StatePublished - Jan 28 2019


  • Immunotherapy
  • National Cancer Database
  • Non-small-cell lung cancer
  • Radioimmunotherapy
  • Stereotactic radiotherapy

ASJC Scopus subject areas

  • Oncology
  • Radiology Nuclear Medicine and imaging


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