Late-stage lung cancer is often over-treated with radiation

Almost half of patients with advanced lung cancer receive more than the recommended number of radiation treatments to reduce their pain, according to a new study published in the Journal of the National Cancer Institute.

Radiation therapy that is palliative, or not intended to cure, can reduce the pain from lung tumors and improve quality of life. But unnecessary treatments add to costs and require needless trips to the hospital – and can lead to radiation toxicity and difficulty in swallowing.

Guidelines developed from clinical trials recommend no more than 15 radiation treatments be given for pain in stage 4 lung cancer. The guidelines recommend that patients not receive chemotherapy at the same time, to reduce the risk of toxicity.

The new analysis looked at 47,000 patients who received palliative radiation for stage 4 lung cancer in the U.S. between 2004 and 2012 and found that about one in five had received chemotherapy at the same time. Nearly a third of patients received more than 25 radiation treatments — 10 above the recommended maximum.

This study uncovered that there’s a lot of treatment of late-stage lung cancer with palliative radiation that goes beyond what is recommended by several national guidelines and multiple clinical trials,” said the study’s lead author, Dr. Matthew Koshy, a radiation oncologist at the University of Illinois Hospital & Health Sciences System.

More education is needed for radiation oncologists, to prevent over-treatment — which has not been proven to further improve symptoms or quality of life, and can have some significant side effects,” Koshy said.

The researchers also looked for any particular type of patient more likely to be overtreated.

Having private insurance was the number-one predictor of being overtreated,” Koshy said. Privately insured patients were 40 percent more likely than others to receive more than the recommended 15 treatments. Patients treated in community cancer centers – clinics without ties to an academic institution – were also more likely to be over-treated.

Koshy said physicians might tend to overtreat privately insured patients because services are billed per-treatment, creating a financial incentive. However, he said, “it could also be because these patients may be perceived to have better potential for a more positive outcome.”

Koshy et al. Prevalence and predictors of inappropriate delivery of palliative thoracic radiotherapy for metastatic lung cancer. J Natl Cancer Inst. 2015; 107 (12): djv278 doi: 10.1093/jnci/djv278 [Abstract]

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Physical activity benefits lung cancer patients and survivors

Exercise and physical activity should be considered as therapeutic options for lung cancer as they have been shown to reduce symptoms, increase exercise tolerance, improve quality of life, and potentially reduce length of hospital stay and complications following surgery for lung cancer.

Lung cancer is the leading cause of cancer deaths in the United States with an estimated 160,000 deaths each year and worldwide there are 1.4 million deaths. In the last two decades lung cancer therapy has improved, but the overall 5-year survival rate is still quite low at 17%. Lung cancer patients experience many debilitating symptoms including difficulty breathing, cough, fatigue, anxiety, depression, insomnia, and pain. A third of long term survivors, those >5 years from diagnosis, experience reduced quality of life and report lower physical and health scores compared to healthy patients. Given the incidence of lung cancer and the associated costs An inexpensive and relatively easy cancer therapy to reduce symptoms and improve quality of life, like physical activity, could be beneficial, especially for therapy, but clinicians underutilize exercise as a therapy, in part due to the lack of evidence-based consensus as to how and when to implement increasing physical activity.

Dr. Gerard A. Silvestri, Dr. Brett Bade, and colleagues at Medical University of South Carolina have reviewed the safety, benefits, and application of increasing physical activity and exercise in lung cancer with the goal to summarize the effect on improved lung cancer outcomes. Their results are published in the Journal of Thoracic Oncology, the official journal of the International Association for the Study of Lung Cancer (IASLC).

The authors found that most lung cancer patients (regardless of stage) want physical activity advice directly from a physician at a cancer center before cancer treatment and exercise guidance may increase compliance with a dedicated program.

Physical activity reduces risk of cancer development in multiple cancer types including lung. Large trials showed exercise’s association with reduced all-cause mortality and that self-reported moderately vigorous physical activity led to lower risk of all-cause and cancer-specific mortality. Multiple trials have shown that increased activity reduces symptom burden and that exercise interventions may have beneficial effects on quality of life, physical function, social function, and fatigue.

Perioperative exercise in lung cancer patients appears to be safe with improvement in operability, operative risk, post-operative complications, as well as increase exercise capacity. Preoperative interventions may be more beneficial than post. Non-surgical advanced-stage lung cancer patients may benefit from increased physical activity by improving exercise tolerance and symptom burden, though the location, duration, and intensity to be recommended is not clear.

Chronically-ill cancer patients have different exercise limitations than their healthy counterparts and other concurrent diseases and high symptom burden add challenges in how best to study and implement physical activity programs in lung cancer patients. Low-intensity regimens such as daily walking or step-counting may provide a safe mechanism to increase physical activity while identifying an individual patient’s activity limits. Both supervised and self-directed programs have potential benefit, though how to choose one versus the other is not yet clear.

The same benefits of increased activity observed in lung cancer patients, especially improved symptoms and quality of life, appear to apply to lung cancer survivors as well.

The authors conclude “clinicians should (at minimum) consider physical activity early, counsel against inactivity, and encourage physical activity in all stages of lung cancer patients and lung cancer survivors. This review shows uniform recognition that exercise and physical activity are safe for those with lung cancer, patients are requesting increased activity counseling, and multiple studies and reviews show potential clinical benefit in quality of life, exercise tolerance, and post-operative complications. Further, we know that inactivity in cancer patients is associated with worse outcomes.” However, “there are still large gaps in the published literature to be addressed and these could be filled with large definitive prospective trials that evaluate the benefit of exercise in lung cancer patients”.

Bade et al. Increasing physical activity and exercise in lung cancer: Reviewing safety, benefits, and application. J Thorac Oncol. 2015. doi:10.1097/JTO.0000000000000536 [Abstract]

Race, hospital, insurance status all factors in how lung cancer is treated

African Americans, Hispanics, and those who receive care at a community hospital are all significantly less likely than other patients to receive treatment for early stage non-small cell lung cancer, according to a report in the Journal of Thoracic Oncology.

We found significant disparities for treatment of a curable cancer based on race, insurance status, and whether or not treatment was at an academic or community hospital,” said Dr. Matthew Koshy, a physician in the department of radiation oncology at the University of Illinois at Chicago College of Medicine, and lead author of the study. “Reducing these disparities could lead to significant improvements in survival for many people with inoperable early stage lung cancer.

The study is the largest to date looking at treatment received by patients with stage I non-small cell lung cancer, an early stage of lung cancer that has not spread to the lymph nodes and is characterized by a small nodules in the lung tissue. Treatment during this early stage offers the best chance for long-term survival.

Surgery to remove cancerous nodules in the lungs is the standard treatment for patients with stage I NSCLC. But many patients cannot undergo surgery, due to complicating medical conditions such as poor lung function or heart disease.

For those patients, radiation therapy has been the standard treatment, but outcomes are much poorer than for surgical treatment. Many patients deemed inoperable are only monitored, because the benefits of conventional radiation are regarded as minimal.

Over the last 10 years, a new radiation technology called stereotactic body radiotherapy, or SBRT, has replaced conventional radiation as the standard treatment for inoperable stage I NSCLC. It delivers much higher doses of radiation, requires fewer treatments, is better tolerated, and has survival outcomes comparable to surgery.

Koshy and his colleagues wanted to know if any factors predicted whether a patient was more likely to be observed, treated with conventional radiation, or treated with SBRT — and if there were any disparities in the use of those treatments.

They looked at data from nearly 40,000 patients with inoperable stage I NSCLC added to the National Cancer Database between 2003 and 2011. The hospital-based cancer registry collects information on patient demographics, insurance status, diagnosis, treatment and outcome.

The analysis showed that African Americans were 40 percent less likely, and Hispanics 60 percent less likely, to be treated with radiation — either conventional radiation or SBRT. Of patients who did receive radiation, African Americans and those with no insurance were less likely to receive SBRT.

Patients were two-and-a-half times more likely to receive SBRT in academic hospitals than in community hospitals, and seven times more likely to receive SBRT at a high-volume medical center than at a low-volume center.

The researchers found that in 2011, 46 percent of patients receiving care in community care centers were only observed, compared to 21 percent of patients at academic medical centers. Sixty-eight percent of patients at academic medical centers received SBRT compared to 25 percent of patients at community hospitals.

Koshy suggests that all patients with early stage inoperable lung cancer be evaluated by a radiation oncologist, and that more radiation oncologists trained in SBRT are needed. Better access to facilities that offer SBRT could help reduce the disparities the study uncovered, he said.

Koshy et al. Disparities in Treatment of Patients with Inoperable Stage I Non-Small Cell Lung Cancer: A Population-Based Analysis. J Thorac Oncol. 2014; EPub Ahead of Print. doi: 10.1097/JTO.0000000000000418 [Abstract]