Big and small.

Top Line: For the past year, patients with extensive-stage small cell lung cancer (ES-SCLC) have been benefiting from the addition of atezolizumab to carboplatin and etoposide.

The Study: In IMpower133, concurrent and adjuvant atezo improved median overall survival from 10 → 12 months and 1-year overall survival from 38→ 52%. Well, make way for durvalumab. In the CASPIAN trial, over 800 patients with newly diagnosed ES-SCLC were randomized to first-line treatment with one of three arms: [1] standard platinum + etoposide chemo for 4-6 cycles, [2] arm 1 plus concurrent and maintenance durvalumab, or [3] arm 2 plus the anti-CTLA-4 antibody tremelimumab. Interestingly, only patients in arm 1 could receive prophylactic cranial irradiation. This initial report addresses only the interim survival analysis of arms 1 versus 2. Here the addition of durvalumab resulted in a significant increase in median survival from 10→ 13 months and 1-year overall survival from 40→ 54% (look familiar?), a benefit seen across all subsets. While this feels like continued progress, the 2-month absolute improvement in survival barely puts a dent in the natural course of this disease. We’re left wondering a couple of things. First, when will small cell follow suit with a mono-immunotherapy arm? More importantly, with a streak of durvalumab trials named after large bodies of water, what poor investigator is going to be left accruing patients to the DEAD trial?

TBL: Concurrent and maintenance durvalumab with platinum + etoposide chemo improves survival in patients with extensive-stage small cell lung cancer. | Paz-Ares, Lancet 2019