In unresectable stage III non-small cell lung cancer (NSCLC), the principle is straightforward: patients who can tolerate it should receive concurrent chemoradiotherapy (cCRT), followed by consolidation with durvalumab if they do not progress.
Clinical guidelines and the PACIFIC trial made that pathway the modern benchmark for unresectable disease.1,2 However, real-world practice is messier. The more challenging question is not what the standard is, but how often health systems can actually bring patients to it.
Our recent multicenter Polish study (DOI: 10.1200/GO-25-00189) offers one answer. Among 273 patients with unresectable stage III NSCLC treated with curative-intent radiotherapy between April 2021 and March 2022, cCRT and sequential chemoradiotherapy (sCRT) were administered with equal frequency to patients (37.7% each), while 16.5% received definitive radiotherapy (dRT) alone.
PET-CT was performed in 69.6% of cases overall, and only 17.6% of patients were both diagnosed and treated in the same institution. These numbers suggest that the main challenge is not simply what happens in the radiotherapy department. It involves the entire chain: diagnosis, staging, referral, multidisciplinary evaluation, and only then eligibility for the most effective treatment.
Timing is important when interpreting these data. Our cohort captured an early transition period, shortly after durvalumab reimbursement was introduced in Poland and during what the study explicitly describes as the early phase of national implementation of consolidation immunotherapy.
For this reason, these findings should not be treated as a fully mature PACIFIC-era representation of Polish practice. If anything, current cCRT rates in Poland may already be somewhat higher, particularly because reimbursement for immunotherapy remains linked to prior cCRT.
That financial and regulatory framework may encourage broader qualifications for concurrent treatment. However, whether this always translates into better outcomes for patients is a more complicated question.
This is where international comparison becomes useful. Poland does not appear to be a dramatic outlier; rather, it fits within a broader European pattern in which cCRT and sCRT continue to coexist in routine care.
In the population-based Netherlands/Belgium analysis by Walraven and colleagues, cCRT was administered to 55% of patients in the Netherlands and 35% in Belgium. In both countries, older age and more advanced nodal disease were associated with greater use of sCRT.3
UK discussions of stage III care similarly reflect a system in which both concurrent and sequential approaches remain part of everyday practice rather than cCRT being universally achievable.4 Viewed in this context, the Polish pattern is not best described as simple underuse of cCRT. Instead, it reflects the same constraints seen elsewhere: some patients are too frail for combined treatment, while others present with disease that is technically radical but already difficult to treat safely with a concurrent approach.
That distinction is especially important when interpreting radiotherapy alone. In our cohort, dRT was not primarily a shortcut or a sign of therapeutic nihilism. Rather, it was mainly the treatment option chosen for patients who were older, more fragile, and less suitable for combined-modality therapy.
Health status was the recorded reason for choosing dRT in 68.9% of cases. In contrast, sCRT was more frequently linked to disease extent, cited in 65.6% of cases; when specified further, a large tumor mass predominated. In turn, cCRT was more often chosen when tumor location—rather than sheer size—was the key issue.
In other words, the TNM stage alone did not explain the treatment patterns very well. What mattered more was whether the tumor and the patient still allowed safe and realistic radical therapy. From this perspective, dRT often functioned as a radical compromise for patients at the borderland between curative intent and a more palliative clinical reality.
These observations also matter for a question frequently asked in hindsight: how many patients treated with sCRT might have truly been candidates for cCRT? Retrospective datasets are poorly suited to answer this with confidence. While they can describe the recorded reasons behind a decision, they cannot fully reconstruct the day-by-day clinical judgment behind performance status assessment, pulmonary reserve, anticipated field size, or tolerance of combined treatment.
What our study can more reliably say is that many patients in the sCRT group were there for recognizable clinical reasons, rather than because cCRT had simply been overlooked. At the same time, newer evidence—such as PACIFIC-6—is clinically relevant here.
The final analysis of PACIFIC-6 suggests that durvalumab following sCRT is feasible and demonstrates encouraging efficacy. However, cCRT followed by durvalumab remains the established standard, and sCRT should not be viewed as equivalent by default.5 This distinction matters because the real world does not always present textbook candidates for PACIFIC-style treatment.
The Polish data also extend beyond oncology infrastructure and into health policy. Stage III NSCLC care is often discussed as a question of access to radiotherapy or multidisciplinary care, but it is also shaped upstream by population health.
In Poland, the prevalence of daily smoking remains above the OECD (Organization for Economic Co-operation and Development) average, and exposure to ambient PM2.5 is substantially higher than the OECD average. The 2025 EU Country Cancer Profile also indicates that avoidable lung cancer mortality rates are higher in Poland than the EU average for both women and men.
At the same time, the European Environment Agency continues to identify household solid-fuel heating and transportation as major contributors to particulate pollution, despite gradual improvements in air quality over the past decade. These upstream conditions do not determine individual MDT decisions, but they do influence the population that reaches definitive treatment: patients with heavier tobacco exposure, poorer respiratory health, and often a narrower therapeutic window.
The larger lesson, then, is not simply that “too few patients received cCRT.” Rather, access to the modern standard of care for stage III NSCLC depends on a chain of eligibility, and every link in that chain matters.
Prevention matters. Respiratory health matters. Staging matters. Referral speed matters. Reimbursement matters as well, as it may increase cCRT qualification rates; however, it should not push systems to pursue cCRT as an end in itself.
The goal is not to maximize cCRT at any cost. Instead, the objective is to maximize appropriate access to radical-intent multimodality care—early enough and selectively enough for patients to truly benefit. Poland’s experience suggests that if we want more patients to reach this standard, we must consider not only the treatment itself, but also the pathway that makes such treatment possible.
References
- 1. Kuncman Ł, Bilski M, Konat-Bąska K, et al. Real-World Patients Management and Referral Patterns in Patients With Stage III Unresectable Non-Small Cell Lung Cancer in Poland. JCO Glob Oncol. 2026;12:e2500189. doi:10.1200/GO-25-00189.
- 2. Spigel DR, Faivre-Finn C, Gray JE, et al. Five-Year Survival Outcomes From the PACIFIC Trial: Durvalumab After Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer. J Clin Oncol. 2022;40:1301-1311.
- 3. Walraven I, Damhuis RA, Ten Berge MG, et al. Treatment Variation of Sequential Versus Concurrent Chemoradiotherapy in Stage III Non-Small Cell Lung Cancer Patients in the Netherlands and Belgium. Clin Oncol (R Coll Radiol). 2017;29:e177-e185.
- 4. Conibear J. Rationale for Concurrent Chemoradiotherapy for Patients With Stage III Non-Small-Cell Lung Cancer. Br J Cancer. 2020;123:10-17.
- 5. Garassino MC, Khalifa J, Reck M, et al. Durvalumab After Sequential Chemoradiotherapy in Unresectable Stage III Non-Small-Cell Lung Cancer: Final Analysis From the Phase II PACIFIC-6 Trial. ESMO Open. 2025;10:105071.
