Real-World Uptake of First-Line Immunotherapy in Advanced Non-Small Cell Lung Cancer in the US, 2010-2021

Introduction Immune checkpoint inhibitors are standard first-line therapy for most patients with advanced non-small cell lung cancer (NSCLC) without actionable driver alterations, but real-world uptake in routine practice remains incompletely characterized. Materials and methods We performed a retrospective cohort study using the National Cancer Database, including patients aged 18 years or older diagnosed with stage III or IV NSCLC from 2010 to 2021. The primary outcome was receipt of immunotherapy as first-course treatment. Multivariable logistic regression identified factors associated with immunotherapy receipt among patients diagnosed from 2016 to 2021. Results Among 860,556 patients, immunotherapy use increased from 0.3% in 2010 to 41.8% in 2021, plateauing near 42% by 2019. In 2021, utilization remained below 50% among both stage IV (43.3%) and stage III (38.9%) patients. Uptake converged across academic and non-academic facilities. By 2021, utilization was 43.2% among non-Hispanic White patients, 41.0% among non-Hispanic Black patients, 34.3% among Hispanic patients, and 31.8% among non-Hispanic Asian or Pacific Islander patients. In multivariable analysis of 326,227 patients, Hispanic patients (adjusted odds ratio [aOR] 0.77, 95% confidence interval [CI] 0.74-0.80), non-Hispanic Black patients (aOR 0.90, 95% CI 0.88-0.92), uninsured patients (aOR 0.73, 95% CI 0.69-0.77), and patients aged 75 years or older (aOR 0.58, 95% CI 0.55-0.61) had lower odds of immunotherapy receipt. Discussion Immunotherapy adoption for advanced NSCLC increased rapidly but plateaued below half of patients by 2021. Persistent differences in treatment receipt by race and ethnicity, insurance status, age, and comorbidity suggest ongoing inequities in real-world delivery.