Do you offer adjuvant durvalumab for stage I small cell lung cancer following SBRT or surgery?

Obviously, there are no direct data, and the standard is EP chemotherapy. The cure rate in this situation is still suboptimal, but the majority of patients are cured. Adding IO might improve survival, but will most certainly increase cost and toxicity. I would discuss with patients, and I often tell them not only the pros and cons but also what I would do, I would add IO, myself.

Yes I would, and this is an appropriate question because only about 13% of patients in ADRIATIC were stage I/II, raising concerns about their representation. The forest plot, unlike in stage III, showed a confidence interval crossing 1, suggesting less clear benefit. However, SCLC is a systemic disease at any stage, with high metastatic potential (42-55% of stage I relapse despite such early stage disease Robinson et al., PMID 38926078). Given durvalumab’s favorable toxicity profile, its use remains warranted. All evidence (Moreno and Lin, PMID 30788238) shows that even in stage I, adding full systemic therapy improves DFS and DM and these patients benefit from aggressive attempts at distant control (see the table with study summaries). NCC...

Great question and a common scenario! A clinical trial would be most appropriate, but I agree with Dr. @Dr. First Last that the data is just not there. Extrapolating from ADRIATIC and from NSCLC studies, the case for adjuvant immunotherapy after chemo is strong. I would consider the two options presented in the questions somewhat differently, though the final answer may be the same. In surgically treated stage I with proper lymph node assessments etc., adjuvant chemo (EP) is standard; adjuvant IO post-chemo would be an extrapolation from NSCLC studies. I discuss this with my patients and advocate for it based on theoretical benefit, (insurance reviewers do not agree with me often). For stage I treated with SBRT, the data supporting SBRT its...