Inadequate staging and excessive surveillance imaging: Evaluating the magnitude of benefit of targeted therapies in lung cancer

Several phase III trials have altered the management of oncogenic driven non-small cell lung cancer (NSCLC) including those harboring EGFR and ALK mutations. However, several of these pivotal trials deviated from standard-of-care practices for either baseline imaging or surveillance imaging. This occurred despite sponsor acknowledgement in a clinical trial protocol that historical trials utilized imaging modalities that potentially under-staged patients. Inadequate baseline imaging for adjuvant trials instead of PET/CT may not identify individuals with metastatic disease, and thereby subject such individuals with metastatic disease to inferior treatment if randomized to the control arm. Similarly, more frequent surveillance imaging than what is considered standard-of-care may identify disease progression earlier than what is expected in real-world clinical practice and therefore embellish the magnitude of benefit between a targeted therapy and the control arm. While targeted therapies have provided clinical benefit for individuals with oncogenic driven NSCLC, physicians and patients must be cognizant that clinical trial deviations from standard-of-care imaging practices may have embellished the magnitude of benefit for several of these therapies. •LAURA trial deviated from standard practices for baseline and surveillance imaging.•Other NSCLC trials also have deviated from standard of care practices in imaging.•Deviations in imaging can embellish the magnitude of benefit of therapies.