Radiol Oncol 2020; 54(4): 447-454. doi: 10.2478/raon-2020-0058
447
research article
Treatment patterns and real-world evidence 
for stage III non-small cell lung cancer in 
Central and Eastern Europe
Milada Zemanova1, Marko Jakopovic2, Karmen Stanic3,4, Małgorzata Łazar-Poniatowska5, 
Martina Vrankar3,4, Petronela Rusu6, Tudor Ciuleanu6, Davorin Radosavljevic7, 
Krisztina Bogos8, Sergiusz Nawrocki9
1 1st Faculty of Medicine of Charles University, Prague, Czech Republic
2  Department for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, School of Medicine, 
University of Zagreb, Zagreb, Croatia
3 Institute of Oncology Ljubljana, Ljubljana, Slovenia
4 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
5 Department of Oncology and Radiotherapy, Medical University of Gdansk, Gdansk, Poland
6 Institute of Oncology “Prof. Dr. Ion Chiricuta”, Cluj-Napoca, Romania
7 Institute for Oncology and Radiology of Serbia, Belgrade, Serbia
8 National Koranyi Institute of TB and Pulmonology, Budapest, Hungary 
9 Department of Oncology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
Radiol Oncol 2020; 54(4): 447-454.
Received 9 June 2020
Accepted 10 July 2020
Correspondence to: Assist. Prof. Karmen Stanič, P.D., Ph.D., Institute of Oncology Ljubljana, Zaloška 2, 1000 Ljubljana, Slovenia. E-mail: 
kstanic@onko-i.si
Disclosure: Dr. Zemanova reports other from AstraZeneca, during the conduct of the study; grants from AstraZeneca, grants and personal 
fees from BristolMyersSquibb, personal fees from Boehrinegr Ingelheim, personal fees from MSD, personal fees from Roche, grants from 
Novartis, outside the submitted work; Dr. Jakopovic reports personal fees and non-financial support from AstraZeneca, personal fees and 
non-financial support from Roche, personal fees and non-financial support from MSD, personal fees and non-financial support from Pfizer, 
personal fees and non-financial support from Boehringer Ingelheim, outside the submitted work; Dr. Stanic reports personal fees and non-
financial support from AstraZeneca, during the conduct of the study; Dr. Vrankar reports personal fees from AstraZeneca, Roche, Boehringer 
Ingelheim, Merck Sharp & Dohme, other from AstraZeneca, Roche, Boehringer Ingelheim, outside the submitted work; Dr. Rusu reports 
personal fees from AstraZeneca, personal fees from AD-pharma, outside the submitted work; Dr. Ciuleanu reports consultancy fees from 
Astellas, Janssen, Bristol-Myers Squibb, Merck Serono, Amgen, Roche, Pfizer, Boehringer Ingelheim, Lilly, AstraZeneca, MSD, Sanofi, Novartis, 
Servier, AD Pharma; Dr. Radosavljevic reports personal fees and non-financial support from Astra Zeneca, personal fees and non-financial 
support from MSD, personal fees and non-financial support from Roche, personal fees and non-financial support from Pfizer, personal fees 
from Boerhinger Ingelheim, personal fees and non-financial support from Merck, personal fees and non-financial support from Amicus, 
outside the submitted work; other authors have nothing to disclose. 
Background. The aim of this project was to collect real-world evidence and describe treatment patterns for stage 
III non-small cell lung cancer in Central and Eastern Europe. Based on real-world evidence, an expert opinion was 
developed, and the unmet needs and quality indicators were identified.
Patients and methods. A systematic literature search and a multidisciplinary expert panel of 10 physicians from 
7 countries used a modified Delphi process to identify quality indicators and unmet needs in patients with stage III 
non-small cell lung cancer. The profound questionnaire was used to characterize treatment patterns used for stage 
III non-small cell lung cancer, and a systematic review identified patterns in Central and Eastern Europe. The first 
questionnaire was completed by a group of medical oncologists, radiation oncologists and pneumologists. The panel 
of experts attended an in-person meeting to review the results of the questionnaire and to process a second round 
Delphi. An additional survey was then compiled and completed by the panel.
Results. A complete consensus was reached by the panel of experts on a set of evidence-based clinical recommen-
dations. The experience-based questionnaire generated a highly variable map of treatment patterns within the region. 
A list of unmet needs and barriers to quality care were developed with near-unanimous consent of the panel of experts.
Conclusions. The current landscape of diagnostic and therapeutic approaches in Central and Eastern European 
countries is highly variable. We identified several significant barriers, mainly related to the availability of diagnostic and 
imaging methods and low rates of chemoradiotherapy with curative intention as initial treatment for unresectable 
stage III NSCLC.
Key words: stage III non-small cell lung cancer; treatment patterns; Delphi method; quality of care; expert panel; 
real-world evidence
Radiol Oncol 2020; 54(4): 447-454.
Zemanova M et al. / Stage III non-small cell lung cancer in Central and Eastern Europe448
Introduction
Lung cancer is the leading cause of cancer mortality 
worldwide, with over 2 million newly diagnosed 
cases annually. Lung cancer constituted 11.6% of 
all cancer cases diagnosed in 2018, according to the 
International Agency for Research on Cancer and 
worldwide numbers are still rising.1 There were 
over 1.8 million deaths caused by lung cancer in 
2018.1 In Central and Eastern Europe (CEE)2, the 
lung cancer incidence was almost 150,000 newly 
diagnosed cases in 2018, with over 131,000 deaths 
caused by lung cancer in the region.3
The most common form of lung cancer is non-
small cell lung cancer (NSCLC), accounting for 
80%–85% of all cases.4 Stage III non-small cell 
lung cancer comprises approximately one-third of 
NSCLC patients and is very heterogeneous with a 
variable, although mostly poor, prognosis.4 Due to 
its heterogeneity, a general schematic management 
approach is not appropriate and is recommended 
that the decision about the treatment is reached 
through multidisciplinary tumor board. Usually, 
a combination of local therapy with systemic plat-
inum-based doublet chemotherapy and, recently 
added, immune therapy is used.4 
According to the TNM 8 staging system, stage 
III NSCLC is subclassified into stage IIIA, IIIB, and 
IIIC.5,6 Lung cancer symptoms occur mostly late in 
the disease, so the majority of patients with NSCLC 
present with advanced metastatic disease that is in-
curable with currently available therapy, therefore, 
patient prognosis is critically dependent on early 
diagnosis and early treatment.
European Society for Medical Oncology 
(ESMO) guidelines, which were updated in 2017, 
directs the treatment of locally advanced NSCLC 
as follows: concurrent chemoradiotherapy is con-
sidered the preferred treatment for patients who 
are in good condition in stage IIIA, IIIB and IIIC. 
If chemoradiotherapy is not possible, then se-
quential chemotherapy followed by definitive 
radiotherapy represents a valid and effective al-
ternative.7 Results from the PACIFIC trial show 
improvement in overall survival (OS) and pro-
gression-free survival (PFS) using a combination 
of chemoradiotherapy and immunotherapy (rep-
resented by durvalumab in this case).8,9 In this ran-
domized trial, the 36-month OS rate was 57.0% in 
the durvalumab group and 43.5% in the placebo 
group.10 PFS was reported as a median duration 
of 17.2 months in the durvalumab group and 5.6 
months in the placebo group (p < 0.001) according 
to the study report from 2018.9 
Real-world data on treatment patterns of locally 
advanced NSCLC in CEE are limited. Therefore, 
we aimed to:
1.  Generate a real-world matrix on treatment 
patterns in CEE based on an extensive litera-
ture search.
2.  Generate a summary of treatment patterns 
used in stage III NSCLC in CEE based on clin-
ical practice, find the main barriers to treat-
ments, and formulate a set of quality of care 
indicators.
3.  Develop a consensus on evidence-based clini-
cal recommendations for Stage III NSCLC in 
CEE in cooperation with a panel of experts 
(henceforth referred to as the expert panel 
[EP]) from the region. 
The Delphi method was used as a technique for 
consensus development.
Patients and methods
Study design
The study consisted of five parts: (1) an extensive 
literature search with a focus on real-world evi-
dence (RWE); (2) development of a questionnaire; 
(3) selection of an expert panel; (4) an online sur-
vey; and (5) analyzing and discussing the results 
during the expert panel meeting. This study con-
sisted of a survey of expert opinions, and no pa-
tient data were collected, so no specific independ-
ent ethical approval was necessary.
Expert panel
The expert panel was composed of 10 members 
from CEE countries, including Croatia, Czech 
Republic, Hungary, Poland, Romania, Serbia, and 
Slovenia. Due to the multidisciplinary nature of 
NSCLC therapy, representatives from a variety 
of disciplines were nominated to be on the expert 
panel, which ultimately consisted of medical on-
cology, radiation oncology and pneumology. Each 
of the panelists was an authority in the particular 
area of expertise in her or his country.
Literature search
Web of Science, PubMed, and the Cochrane li-
brary were thoroughly searched. A total of ten hits 
was considered relevant, and from those, a map 
of treatment patterns in CEE was generated. The 
goal was to identify synthesized research evidence 
Radiol Oncol 2020; 54(4): 447-454.
Zemanova M et al. / Stage III non-small cell lung cancer in Central and Eastern Europe 449
including clinical practice, systematic reviews, me-
ta-analyses, and conference proceedings. Articles 
were included in the RWE map if they were fully 
published in English.
Online survey
The online expert questionnaire was divided into 
three parts. These parts covered expert experienc-
es in diagnosis, therapy, and organization of the 
care of patients with stage III NSCLC. The expert 
panel members entered the rates of utilization in 
each category or other specific counts according to 
clinical practice in their medical center. Some of the 
outcomes, e.g. the number of specialized oncology 
centers in the country, were determined as counts 
in the country of panelists.
Delphi panel
The Delphi technique is a method for collecting 
data from respondents within their domain of ex-
pertise.11 The aim is to achieve a convergence of 
opinion on a specific medical issue (in this case, 
NSCLC stage III therapy). There have been sev-
eral published cases using the Delphi method to 
study lung cancer.12–17 The consensus part of the 
study was carried out using a modified Delphi 
method. The first round of the Delphi consensus 
was built as a set of 12 evidence-based recommen-
dations extracted from ESMO clinical guidelines.7 
Responses were collected on a 5-point Likert scale. 
In the 1st round, each panelist responded using the 
following answers: (1) strongly disagree; (2) basi-
cally disagree; (3) doubtful; (4) basically agree; 
or (5) strongly agree. A Delphi consensus was 
reached when the mean of all values was > 4.0. If 
the mean of all values was 5.0, the consensus was 
considered unanimous. All statements then under-
went a second Delphi round. The second Delphi 
round was held as an in-person meeting, and all 12 
statements were discussed. In the meeting, it was 
possible to vote for or against each statement. A 
consensus was defined as > 80% of the responses 
were in favor of the statement. The overall deci-
sion was then distributed via email for any sub-
sequent comments by the expert panel. A total of 
nine panelists responded to the first round and ten 
panelists responded to the second round. The first 
round took place from November 11–23, 2019 and 
TABLE 1. List of real-world evidence literature from the Central and Eastern Europe region
Authors Type of study,country Treatment
Stages of
NSCLC Type of cancer Population
Zemanová et al., 
202018
Registry, Czechia, 
Austria, Latvia, Serbia, 
Hungary, Poland
Surgery 23%, 
RT 55%, 
CT 80%
IIIA 55%,
IIIB 45%
Squamous 53%, 
adenoc. 38%, 
not specified 6%, 
other 3%
583 p., 78% males
Vrankar et al., 
201822 Observational, Slovenia
Induction CT in 
3 cycles, + CCRT, 
2 cycles
IIIA 57%, 
IIIB 43%
Squamous 58%, 
adenoc. 22%, 
large cell 6%, 
other 14%
102 p., 79% males
Ramlau et al., 
201723 Registry, Poland
Surgery 27%, 
14% RT, 
80% systemic therapy
IIIA 12%, 
IIIB 15% Adenoc. 37%, 696 p., 60% males
Podmaniczky et 
al., 201524 Observational, Hungary
Platinum-based 
neoadjuvant CT
IIIA 60%, 
IIIB 20%
Squamous 59%, 
adenoc. 41% 46 p., 63% males
Jeremic,
201525 Review, Serbia
Standard treatment 
options NA NA NA
Georgieva el at., 
201426 Observational, Bulgaria NA
III 2.4%, 
IIIA 12%, 
IIIB 2.4%
Squamous 22%, 
adenoc. 55%, non-
small 14%, other 10%
42 p., 57% males
Zielinski et al., 
201327
Retrospective 
observational study, 
Poland
Staging NA NA 899 p.
Kolodziejczyk et al., 
201128
Prospective study, 
Poland
Radical RT, 
neoadjuvant CT 46%
IIIA 31%, 
IIIB 39%
Squamous 41%, 
adenoc. 8%, 
large cell 2%, 
no specification 45%, 
no histology 4%
100 p., 78% males
Jeremic et al.,
201129 Toxicity studies, Serbia CCRT NA NA 600 p.
Kepka et al.,
201130 Observational, Poland Surgery, RT, CT NA NA 291 p.
CCRT = concurrent chemoradiotherapy; CT = chemotherapy; NA = not available; NSCLC = non-small cell lung cancer; p. = patients; RT = radiotherapy 
Radiol Oncol 2020; 54(4): 447-454.
Zemanova M et al. / Stage III non-small cell lung cancer in Central and Eastern Europe450
was performed via an online survey. The second 
round took place in Prague, Czech Republic, on 
November 29, 2019.
Statistical analysis
Descriptive analytical methods were used to 
analyze continuous and categorical variables. 
Continuous variables were reported as mean, 
standard deviation, minimum, and maximum. 
Categorical variables were reported as count and 
rate. MS Excel was used for the analysis.
Manuscript preparation
Based on the input of expert panel, the draft man-
uscript was prepared by medical writing agency. 
This project began in August 2019 and ended in 
March 2020. During the drafting of the article, new-
ly published literature was reviewed to analyze the 
clinical implications of any new data in patients 
with stage III NSCLC.
Results
A literature search of RWE in CEE
There was a limited number of RWE-based litera-
ture on population diagnosed with stage III NSCLC 
from the CEE region. Table 1 presents a list of ana-
lyzed literature from 2011–2020. This includes data 
on patient registries and observational and toxicity 
studies. The only relevant literature with the texts 
written completely in English related to Bulgaria, 
Czech Republic, Hungary, Poland, Slovenia and 
Serbia. Mostly, these publications presented data 
on treatment, diagnostic methods and staging.
Treatment patterns based on clinical 
experience
Table 2 presents the data collected in the area 
of staging and diagnosis of stage III NSCLC. 
Concerning the staging of NSCLC, 32% (± 13%) of 
NSCLC patients in any particular medical center 
were diagnosed with stage III NSCLC, and most of 
those were in stage IIIB (45% ± 12%). Good consist-
ency in the field of imaging was observed. The most 
common diagnostic procedures, i.e. X-Ray, chest 
computed tomography (CT) (including the CT of 
upper abdomen area), and bronchoscopy, were 
provided to at least 93% of patients with stage III 
NSCLC. Differences in the percentages of treated 
patients who received abdominal CT, brain CT, en-
dobronchial ultrasound (EBUS), and PET-CT were 
evaluated. Bone scans and brain MRIs were pro-
vided at lower rates to patients (14%–15%). Also, 
PD-L1 was tested at various rates within the CEE. 
The mean rate of patients undergoing the PD-L1 
reflex testing was 50% (± 40%). The mean rate of 
available PD-L1 results was 56% (± 31%), as pro-
portion of patients was tested on demand. 
The most heterogeneous set of responses was 
obtained for the descriptions of initial patient 
therapy, which reflects high variability in treat-
ment approaches across the region (Table 3). 
About two-thirds of patients initially received 
radical treatment, and a mean of 30% of patients 
were treated palliative. When looking at the initial 
radical treatment modalities, with the intention to 
cure, showed that clinical practice was heterogene-
ous from country to country, and even individual 
clinical centers within countries had their own ap-
proach. As reported, in mean, chemotherapy alone 
was administered in 13% and cumulatively, con-
current and sequential chemoradiotherapy was ad-
T ABLE 2. Patterns in stage III non-small cell lung cancer 
diagnosis in Central and Eastern Europe region; % of patients 
treated in the medical center of particular panelists
N Mean (±SD) Min-Max
Staging
 All stage III 9 32% (± 13%) 20%–65%
 Stage IIIA 9 37% (± 14%) 20%–60%
 Stage IIIB 9 45% (± 12%) 30%–60%
 Stage IIIC 9 18% (± 11%) 6%–40%
Imaging
 X-Ray 9 99% (± 3%) 90%–100%
 Chest CT 9 98% (± 4%) 90%–100%
 Abdominal CT 9 87% (± 19%) 50%–100%
 Brain CT 9 58% (± 33%) 12%–100%
 Bronchoscopy 9 93% (± 10%) 75%–100%
 EBUS 9 37% (± 29%) 9%–80%
 PET-CT 9 54% (± 30%) 20%–80%
 Bone scan 9 15% (± 16%) 0%–40%
 Brain MRI 9 14% (± 7%) 2%–20%
Biomarkers
 PD-L1 reflex testing 9 50% (±40%) 2%–100%
 PD-L1 results available* 9 56% (±31%) 2%–100%
*  Rates of PD-L1 results available of PD-L1 tests performed; 
CT = computed tomography; EBUS = endobronchial ultrasound; 
MRI = magnetic resonance imaging; PET-CT = positron emission 
tomography-computed tomography; SD = standard deviation
Radiol Oncol 2020; 54(4): 447-454.
Zemanova M et al. / Stage III non-small cell lung cancer in Central and Eastern Europe 451
ministered in more than 50% of patients in mean. 
Palliative radiotherapy was provided in 60% of pa-
tients intended for palliative treatment.
Table 4 describes how the care of patients with 
stage III NSCLC is organized. Usually, the first 
contact physician is a general practitioner (54% ± 
27%) or a pneumologist (35% ± 29%). Other, less 
common, first contact variants included other pro-
fessionals such as medical oncologists and radia-
tion oncologists. In four out of nine countries lung 
cancer patients are referred to specialized oncology 
centers, where the patient has access to innovative 
oncology treatment options, while in other five 
countries, lung cancer is treated in local hospitals. 
The number of specialized oncology centers per 
country varies from 3 to 50, according to the popu-
lation size of the particular country. Most respond-
ents (89%) reported that patients diagnosed with 
stage III of NSCLC were referred to a multidisci-
plinary team. In most cases, medical oncologist is 
supervising the follow-up after initial therapy for 
unresectable stage III patients.
Evidence-based clinical 
recommendations
Table 5 shows the level of consensus for the twelve 
evidence-based clinical recommendations relative 
to stage III NSCLC. There was a high level of con-
sensus and sometimes even unanimity with many 
of the twelve statements.
Main barriers and quality indicators
Table 6 presents the final list of the main barriers to 
treatment of stage III NSCLC identified and con-
sensually agreed on by the expert panel. Rates of 
chemoradiotherapy (CRT) are low due to the long 
waiting times for radiotherapy and especially for 
advanced radiotherapy techniques. The reason for 
the low CRT rates could also be caused by provid-
ing radiotherapy and chemotherapy in different 
institutions. Another barrier is a long referral pro-
cess among different physician specialties. Next, 
awareness of lung cancer symptoms, risk factors, 
and treatment options among patients is affected 
by health literacy and the influence of social status. 
Finally, late access to diagnostic and imaging pro-
cedures is also combined with long waiting times 
and low capacity. 
The list of the agreed quality of care indicators 
is presented in Table 7. The proportion of patients 
treated with chemoradiotherapeutic radical treat-
ment intention was described as the most signifi-
 TABLE 3. Patterns in stage III non-small cell lung cancer diagnosis therapy; % of 
patients treated in the medical center of the particular panelist
 N Mean (±SD) Min–Max
Initial treatment
 Radical treatment 9 70% (±20%) 30%–96%
 Palliative treatment 9 30% (±20%) 4%–70%
Radical treatment
 Surgery 9 17% (±6%) 10%–25%
 Chemotherapy 8 13% (±16%) 0%–48%
 Radiotherapy 8 15% (±9%) 5%–25%
 Concurrent chemoradiotherapy 8 21% (±12%) 0%–30%
 Sequential chemoradiotherapy 8 34% (±14%) 18%–50%
Palliative treatment
 Palliative radiotherapy 8 60% (±33%) 3%–90%
 Best supportive care 8 29% (±24%) 10%–80%
 TABLE 4. Patterns in stage III non-small cell lung cancer diagnosis organization of 
care; % of patients treated in the medical centers of particular panelists
First contact physician N Mean (±SD) Min-Max
General practitioner 9 54% (± 27%) 20%–90%
Pneumologist 9 35% (± 29%) 10%–95%
Medical oncologist 9 9% (± 13%) 0%–30%
Radiation oncologist 9 3% (± 5%) 0%–10%
Other 9 5% (± 5%) 0%–10%
cant indicator of quality of care, followed by the 
improved survival over time.
Discussion
The main scope of the project was to explore the 
treatment patterns in stage III NSCLC in the CEE 
region since the current information on this topic 
is very limited. Data were gathered through a sys-
tematic literature search, an online survey of lead-
ing experts, and a modified Delphi consensus. It 
should be noted that the abovementioned data on 
treatment patterns represent the particular medi-
cal centers associated with the respondents and 
that situations in particular countries could differ 
slightly. 
The literature search generated a limited amount 
of real-world data from the CEE region and only 
represented a subset of the countries participating 
in the study. This is mainly because most of the 
Radiol Oncol 2020; 54(4): 447-454.
Zemanova M et al. / Stage III non-small cell lung cancer in Central and Eastern Europe452
 TABLE 5. Evidence based clinical recommendations consensus 
Statement
1st round
average
N = 9
Final 
consensus
1.
All patients planned for stage III NSCLC treatment should undergo a diagnostic contrast-enhanced CT scan of 
the chest and upper abdomen followed by a PET or a combined PET-CT using a CT technique with adequately 
high resolution for initial staging purposes.
4.8 Consensus
2. All patients planned for curative stage III NSCLC treatment should receive brain imaging for initial staging. 4.8 Consensus
3. Concurrent CRT is the treatment of choice in patients evaluated as unresectable in stage IIIa, IIIb, and IIIc. 4.6 Consensus
4. If concurrent CRT is not possible - for any reason - sequential ChT followed by definitive RT represents a valid and effective alternative. 4.8 Consensus
5. An experienced multidisciplinary team is of paramount importance in any complex multimodality treatment strategy decision. 4.9 Consensus
6. In the absence of contraindications, the optimal ChT to be combined with radiation in stage III NSCLC should be platinum-based therapy. 4.3 Consensus
7. When delivered perioperatively, platinum-based combinations are considered the treatment of choice, in the absence of contraindications. 4.6 Consensus
8. In the stage III disease CRT strategy, two to four cycles of concomitant ChT should be delivered. 4.9 Consensus
9. In the perioperative setting, three to four cycles of platinum-based ChT are recommended. 4.8 Consensus
10. 60–66 Gy in 30–33 daily fractions is recommended for concurrent CRT. The maximum overall treatment time should not exceed 7 weeks. 5.0 Unanimity
11. In sequential approaches, RT delivered over a short overall treatment time is recommended. 4.3 Consensus
12. Adjuvant anti PD-L1 checkpoint inhibitor durvalumab is indicated for unresectable NSCLC with PD-L1 ≥ 1% without progression after chemoradiotherapy with a platinum-based regime. 5.0 Unanimity
ChT = chemotherapy; CRT = chemoradiotherapy; CT = computed tomography; NSCLC = non-small cell lung cancer; PET-CT = positron emission tomography-computed 
tomography; RT = radiotherapy
TABLE 6. Main barriers in the treatment of stage III non-small cell 
lung cancer found by our panel of experts
Main barriers
1.
Low chemoradiotherapy rates due to long waiting 
times for radiotherapy, especially for advanced RT 
techniques and/or radiotherapy and chemotherapy 
performed by different institutions.
2.
Long referral process among different specialities 
(general practitioner, pneumologist, medical 
oncologist, radiotherapist).
3.
Poor health literacy and social status of patients 
influence awareness of lung cancer symptoms, risk 
factors and treatment.
4. Late access to imaging and diagnostic procedures, especially PET-CT – long waiting times, low capacity.
5. Barriers to implementing targeted population screening programs.
PET-CT = positron emission tomography-computed tomography; 
RT = radiotherapy
TABLE 7. Quality of care indicators in stage III non-small cell 
lung cancer found by our panel of experts
Quality of care indicators
1. The proportion of patients treated with chemoradiotherapy in radical treatment intention.
2. Improved survival (median OS, 5 years survival) over time.
3.
Time from first symptoms to first contact with a lung 
cancer specialist, time from first contact with a lung 
cancer specialist to first treatment. 
4.
The proportion of patients with full histopathological/
molecular confirmation of the diagnosis – PET-CT, 
brain imaging, PD-L1.
5. The proportion of treatment decisions confirmed by a multidisciplinary team. 
OS = overall survival; PET-CT = positron emission tomography-computed 
tomography
published data were not published in English or in 
the indexed literature. It is worth noting that much 
of the literature was published in recent years, 
which may reflect the availability of new therapeu-
tic modalities.
A comparison of the expert panel consensus 
with the ESMO guidelines and the current prac-
tice in staging, diagnosis, and treatment of stage 
III NSCLC revealed differences.7 This fact was 
well described in the survey of the main barri-
ers and quality of care indicators among the pan-
elists. There was great agreement regarding the 
evidence-based recommendations extracted from 
ESMO clinical guidelines in the treatment of stage 
III NSCLC, even though the experience-based 
survey revealed considerable differences in cur-
rent treatment patterns. The list of quality of care 
indicators produced by the expert panel agreed in 
part with the list produced in other countries (e.g., 
the United Kingdom and China), especially with 
Radiol Oncol 2020; 54(4): 447-454.
Zemanova M et al. / Stage III non-small cell lung cancer in Central and Eastern Europe 453
regard to the proportions of patients intended to 
various treatments or histopathological diagnostic 
procedures, but our list also proposed several new 
indicators relative to the decision making role of 
multidisciplinary teams.14,16 Expert panel agreed 
a new era for unresectable stage III NSCLC pa-
tients in CEE is coming and expert panel agreed to 
reevaluate the 1–2 year the treatment improvement 
based on the indicators. 
Significantly, our survey found a great deal of 
heterogeneity in therapy organization and treat-
ment modalities offered (available) in different 
medical centers within CEE. The heterogeneity was 
found in almost all parts of the survey, excluding 
consent rates of patients in long-term established 
diagnostic procedures such as X-Ray and CT. The 
more specific the procedure, e.g., histopathologi-
cal diagnostic procedures, the greater the variance 
in rates of utilization in patients. It is agreed, that 
reflex PD-L1 testing and brain MRI rates should 
be improved. Moreover, patterns of initial radi-
cal treatment showed great variability among the 
panelists. This fact was also observed in a recent 
publication by Zemanová et al., which mapped 
these patterns in the same region.18 It is important 
to focus on improving the rates of chemoradio-
therapy provided to patients. Yet in 2007, the posi-
tive impact of concurrent chemoradiotherapy with 
vinorelbine and platinum based compounds fol-
lowed by consolidation chemotherapy was proven 
by Rusu et al.19 This study reported a 15 months 
median OS in patients with stage III NSCLC and 
well tolerability of the treatment. 
Importantly, the expert panel unanimously 
agreed that adjuvant anti PD-L1 checkpoint in-
hibitor durvalumab is indicated for unresectable 
NSCLC with PD-L1 ≥ 1% without progression after 
chemoradiotherapy with a platinum-based regime 
(Table 5). Chemoradiotherapy followed by the im-
munotherapy is new standard of care according 
to the National Comprehensive Cancer Network 
(NCCN) guidelines and The National Institute for 
Health and Care Excellence (NICE) guidance.20,21 
Improving the chemoradiotherapy rates, PD-L1 
testing and gaining access to durvalumab are the 
next needed steps to be implemented in CEE in or-
der to treat the stage III unresectable patients ac-
cording to new standard of care.
Conclusions
The current landscape of diagnostic and therapeu-
tic approaches in CEE countries is highly variable, 
and relevant real-world data are missing. We iden-
tified several significant barriers, mainly related to 
the availability of diagnostic and imaging methods 
and low rates of chemoradiotherapy with curative 
intention as initial treatment for unresectable stage 
III NSCLC. Improving CRT rates will also enable 
consolidative treatment with durvalumab to fur-
ther improve the OS of stage III unresectable pa-
tient population.
The way forward will involve an agreement to 
establish a set of quality of care indicators with rou-
tine monitoring and assessment within the clinical 
practice framework. The panel of experts agreed 
on future monitoring of improvement in the stand-
ards of care for stage III unresectable NSCLC.
Acknowledgem ents
This manuscript presents independent work of the 
expert panel. The views and opinions expressed by 
authors in this publication are those of the authors 
and do not necessarily reflect the overall situation 
in specific country. 
The project was funded by AstraZeneca for lo-
gistical and medical writing support. 
Tina Jerič, M. Pharm. and Lenka Mikasová, Ph. 
D. of AstraZeneca contributed to the project design 
and participated at the expert panel meeting.
Medical writing support, which was in accord-
ance with good publication practice guidelines, was 
provided by Tomaš Doležal and Tereza Tumova, of 
Value outcomes (Prague, Czech Republic).
References
1. International Agency for Research on Cancer. World Health Organization. 
Press release N. 263. [cited 2020 Feb 13]. Available at: https://www.who.
int/cancer/PRGlobocanFinal.pdf
2. Publications Office of the EU. Central and Eastern Europe. [cited 2020 
Feb 14]. Available at: https://op.europa.eu/en/web/eu-vocabularies/th-
concept/-/resource/eurovoc/914
3. International Agency for Research on Cancer. World Health Organization. 
Lung cancer. [cited 2020 Feb 15]. Available at: https://gco.iarc.fr/today/
data/factsheets/cancers/15-Lung-fact-sheet.pdf
4. Huber RM, Ruysscher DD, Hoffmann H, Reu S, Tufman A. Interdisciplinary 
multimodality management of stage III nonsmall cell lung cancer. Eur Respir 
Rev 2019; 28: 190024. doi: 10.1183/16000617.0024-2019 
5. Detterbeck FC, Boffa DJ, Kim AW, Tanoue LT. The eighth edition lung 
cancer stage classification. Chest 2017; 151: 193-203. doi: 10.1016/j.
chest.2016.10.010 
6. Goldstraw P, Chansky K, Crowley J, Rami-Porta R, Asamura H, Eberhardt 
WEE, et al. The IASLC Lung Cancer Staging Project: proposals for revision of 
the TNM stage groupings in the forthcoming (eighth) edition of the TNM 
classification for lung cancer. J Thorac Oncol 2016; 11: 39-51. doi: 10.1016/j.
jtho.2015.09.009