Variation in Treatment and Survival Outcomes for Non-Small Cell Lung Cancer Patients

A national study by researchers at UC Davis Comprehensive Cancer Center have reported that a significant number of lung cancer patients are not receiving treatment. A variation in treatment and survival outcomes was noted for non-small cell lung cancer (NSCLC) among stage III and IV disease. Patients with untreated NSCLC have not been critically analyzed to evaluate improvable outcomes.¹

This study was also recently reported in the Journal of Thoracic Oncology.²

This study used linear regression to calculate trends in utilization of treatment. Patients with primary NSCLC were identified from the National Cancer Database from 1998 to 2012. Twenty-one percent of patients received no treatment. For patients with stage IIIA and IV the proportion of untreated patients increased over the study period from 0.21% to 0.4%. Regardless of stage, untreated patients had significantly shorter survival.

By using propensity matching analyses, researchers attempted to assess the number of untreated patients who were statistically similar to patients who received the standard of care treatment as outlined in the National Comprehensive Care Network Guidelines. The substantial fraction of matched patients receiving no treatment is evidence that other factors are affecting decisions to forgo treatment in advanced NSCLC.

Propensity-matched analyses of 6,144 stage IIIA pairs treated with chemoradiation versus no treatment confirmed shorter overall survival for untreated patients (median 16.5 vs 6.1 months, respectively). For 19,046 stage IV patient pairs treated with chemotherapy versus no treatment, similar results were obtained (median OS 9.3 vs 2 months, respectively).

In this study, data were abstracted on key clinical and pathological characteristics and analyzed factors associated with patients who were not treated. Untreated patients tend to be older, female sex, nonwhite, lack insurance, and have a lower income. These results underscore the impact of socioeconomic, racial, and other disparities in treatment decisions. The following factors may influence the decision to undergo treatment:

• Patient and disease characteristics.
• Physician factors (i.e., primary care less likely to refer to an oncologist).
• Socioeconomic factors strongly linked with different treatment and poor outcomes.
• Survival was longest among patients in the highest economic status.
• Older patients were also less likely to undergo treatment.

This study raises the issue that a large number of untreated patients were statistically similar to patients who received standard treatment. How can healthcare professionals ensure that patients from disparate populations are evaluated and counseled thoroughly by healthcare teams before choosing to forgo treatment?

Newer therapies offer improvement in supportive care and side effect management which result in improved patient tolerance to standard cytoxic therapy such as chemotherapy and radiation. Follow up studies are needed to evaluate the impact of access to care.

References:

1. UC Davis Health. Many late-stage lung cancer patients do not get treatment. 2017 Jan 18.
2. David EA, Daly ME, Li CS, et al. Increasing Rates of No Treatment in Advanced-Stage Non–Small Cell Lung Cancer Patients: A Propensity-Matched Analysis. J Thorac Oncol. 2017 Jan 18.