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]

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Increased overall survival for advanced stage non-small cell lung cancer patients is associated with availability of less toxic chemotherapy

A 10-year population-based study shows that increased availability of better systemic chemo- and targeted-therapies for patients with advanced non-small cell lung cancer (NSCLC) coincides with increased usage of these therapies. This in turn leads to a significant increase in overall survival.

Researchers from the British Columbia Cancer Agency, Vancouver, Canada, performed a retrospective chart review of all patients referred to the agency with advanced stage (IIIB or IV) lung cancer and grouped the patients into 4 one-year time frame cohorts; one termed “baseline” and three other groups that each started 6-months after a new second-line agent (docetaxel, erlotinib and pemetrexed) was made commercially available and put into practice. In British Columbia, Canada, the implementation of the second-line agents docetaxel, erlotinib and pemetrexed occurred in December 2000, October 2005 and June 2007, respectively. Cohort 1 (January to December 1998) with 555 patients was the baseline and cohort 2 (May 2001-April 2002) had 613 patients, cohort 3 (March 2006-February 2007) had 688 patients and Cohort 4 (November 2007-Ocotober 2008) had 750 patients.

The results published in the August Issue of the Journal of Thoracic Oncology, the official journal of the International Association for the Study of Lung Cancer, show that the usage of second-line therapy increased significantly over time. At baseline only 21% of the patients received second-line therapy but in Cohorts 2 and 3 this increased to 27% and 37% respectively, and by Cohort 4 more than half, 55%, received second-line therapy. The most common agent in Cohort 1 was docetaxel (48%) but by Cohort 4 erlotinib (EGFR TKIs) and pemetrexed were used 50% and 26% of the time. The research also found that the proportion of patients who received at least first-line systemic chemotherapy also increased over the four time points from 16% in Cohort 1 to 23%, 34% and 33% for Cohorts 2-4, respectively.

The median overall survival of the patients who did not receive any chemotherapy did not change over the four time points; 3.9, 4.0, 3.1 and 3.2 months (p=0.136), however for those that did receive chemotherapy survival increased significantly, 9.4. 9.8 11.0 and 11.8 months (p=0.023). Examination of the entire population showed that the median overall survival of those not receiving chemotherapy was 3.51 months, whereas those receiving first-line therapy was 7.9 months and for those receiving second-line or beyond therapy the survival was 17 months (p<0.001).

The authors note that “The benefits of chemotherapy and specifically second-line treatment on patient outcomes are substantial, even in a widely mixed population of patients, which confirms the advances seen in clinical trial populations over the past decade“. Likewise, “As the options for treatment of NSCLC expand we anticipate that the outlook for lung cancer will continue to improve.”

Ho et al., (2014). Less Toxic Chemotherapy Improves Uptake of All Lines of Chemotherapy in Advanced Non–Small-Cell Lung Cancer: A 10-Year Retrospective Population-Based Review. J. Thoracic Oncol., 9: 1180-1186, doi: 10.1097/JTO.0000000000000225 [Abstract]

Survey sheds light on common clinical practice for incompletely resected lung cancer

A landmark survey of more than 700 specialists provides crucial real-world insight into the treatments most oncologists choose for lung cancer patients whose tumour has been incompletely resected, an expert from the European Society for Medical Oncology (ESMO) says.

Jean Yves Douillard, from the ICO Institut de Cancerologie de l’Ouest René Gauducheau, France, Chair of the ESMO Educational Committee, was commenting on a paper published in the journal Lung Cancer. In the study, researchers led by Raffaele Califano of The Christie NHS Foundation Trust, Manchester, UK, surveyed 768 oncologists from 41 European countries about the treatments they offered patients who had “R1 resected” non-small-cell lung cancer.

R1 resection is a term used by oncologists to indicate that it is possible to find microscopic evidence of cancer cells remaining after a cancer has been surgically removed.

We know that incomplete resection, or R1 resection, is associated with a higher risk of relapse but there are currently no strong evidence-based recommendations on how to treat these patients after surgery,” Douillard says.

This study is important since it provides a good overview on how the problem is handled in clinical practice all over Europe by practitioners who treat lung cancer.”

Overall, 83% of experts surveyed were medical oncologists –specialists trained to treat cancer using chemotherapy, targeted therapies, immunotherapy and other medications.

Of the respondents, 91.4% prescribed chemotherapy, mostly cisplatin/vinorelbine or cisplatin/gemcitabine. The survey showed that the majority of doctors (85%) discussed with the patient the fact that there was limited clinical evidence to guide treatment options. Almost 50% of participants prescribed radiotherapy, with radiation oncologists most likely to offer this treatment approach.

Treating physicians clearly believe in what they do, and try to provide the best for their patients,” says Douillard. “According to the survey, however, practice is heterogeneous and varies according to the specialty of the treating physician—whether they are radiation oncologists or medical oncologists. This is why treatment decisions are best made by multidisciplinary teams.”

The evidence gathered in this survey is supported by the recommendations of the 2nd ESMO Consensus Conference on Lung Cancer held in 2013, Douillard notes. That group of worldwide recognised experts recommended adjuvant chemotherapy and adjuvant radiation in R1 resected patients.

The authors of the latest paper call for prospective trials to be undertaken to provide stronger evidence to guide post-surgery treatment in this situation. Douillard agrees that such trials would be informative.

However, trials of adjuvant treatment in R1 resected lung cancer would be very difficult to design and perform, as this is fortunately an infrequent occurrence. R1 resection would also need to be clearly defined in such studies, as it actually represents a quite heterogeneous group.”

Based on evidence from clinical trials in resected patients in whom all tumour cells have been completely removed, there is a rationale for using both chemotherapy and radiotherapy in R1-resected non-small-cell lung cancer,” Douillard says.

As the authors of this survey state, definitive proof would come from a randomised clinical trial, although such studies would be difficult to perform.”

Additional Information:

Califano et al., (2014). Use of adjuvant chemotherapy (CT) and radiotherapy (RT) in incompletely resected (R1) early stage Non-Small Cell Lung Cancer (NSCLC): A European survey conducted by the European Society for Medical Oncology (ESMO) Young Oncologists Committee. Lung Cancer85(1):74–80 [Abstract][pdf]

Hormone therapy linked to better survival after lung cancer diagnosis in women

Survival among people with lung cancer has been better for women than men, and the findings of a recent study indicate that female hormones may be a factor in this difference. The combination of estrogen plus progesterone and the use of long-term hormone therapy were associated with the most significant improvements in survival.

The study was designed to explore the influence of several reproductive and hormonal factors on overall survival of women with non-small cell lung cancer (NSCLC). After adjusting for stage of disease at diagnosis, treatment type (surgery or radiation), smoking status, age, race, and education level, the only factor studied that predicted survival after a diagnosis of NSCLC was use of hormone therapy.

Among the 485 women, the median survival time was 80 months for women receiving hormone therapy and 37.5 months for women not receiving hormone therapy. Combined estrogen and progesterone was associated with a slightly higher median survival time (87.0 months) than estrogen alone (83.0 months). The findings of the study are published in the March issue of the International Association for the Study of Lung Cancer’s journal, the Journal of Thoracic Oncology (JTO).

The use of hormone therapy for 11 years or more was associated with significantly improved survival, and this finding remained significant among women who took either estrogen alone or estrogen plus progesterone and among women who had never smoked or were smokers.

What has emerged from this study and other published findings is a complex relationship between hormone use and lung cancer outcomes, with variation in results based on years of use,” says lead author Ann G. Schwartz, PhD, MPH, of Karmanos Cancer Institute, Detroit, MI, and an IASLC member.

Studies on the effect of hormone use on lung cancer survival have been limited, and the results have been inconsistent. Because of this, additional research is needed to evaluate the significance of long-term use of hormone therapy on outcomes in lung cancer, with better characterization of tumors in terms of expression of estrogen and progesterone receptors.

Dr. Schwartz adds, “There is more to learn about survival differences between men and women; hormone use may contribute to those differences. The largest impact on lung cancer outcomes will come from successful early detection and treatment.”

Katcoff et al., (2014). Survival in women with NSCLC: The role of reproductive history and hormone use.J.Thorac.Oncol.9:355-361 [Abstract]