Meeting NewsPerspective

Chemotherapy, radiation underused in initial treatment of limited-stage small-cell lung cancer

CHICAGO — Initial treatment with chemotherapy and radiation appeared underused among patients with limited-stage small-cell lung cancer, according to study results presented at the International Association for the Study of Lung Cancer Multidisciplinary Symposium in Thoracic Oncology.

In turn, these patients demonstrated worse survival outcomes.

Combined modality treatment using chemotherapy and radiation plays a role in the initial treatment of limited-stage small-cell lung cancer.

“Despite being the long-held standard of care, we hypothesize there are significant socioeconomic barriers to standard-of-care chemoradiation delivery in this patient population,” Stephen G. Chun, MD, assistant professor in the department of radiation oncology at The University of Texas MD Anderson Cancer Center, said during the presentation. “The purpose of this study was to understand patterns of care in this population and find avenues to improve quality care delivery to limited-stage small-cell lung cancer.”

Chun and colleagues analyzed the initial management of 70,247 patients in the National Cancer Data Base with International Association for the Study of Lung Cancer-defined limited-stage small-cell lung cancer from 2004 to 2013 to determine rates of chemotherapy and radiation delivery, as well as factors associated with utilization and survival.

Median follow-up was 62.3 months.

Initial treatment options included chemotherapy plus radiation (55%), chemotherapy only (20%), radiation only (3%), or neither treatment option (20%).

Patients treated with chemotherapy and radiation demonstrated the longest median OS at 18.2 months, compared with 10.5 months in those who received chemotherapy, 8.3 months in those who received radiation, and 3.7 months for those who received neither treatment (P < .001).

According to multivariable analysis, Medicaid and Medicare insurance yielded no impact on chemotherapy delivery.

However, Medicaid (OR = 0.79; 95% CI, 0.72-0.87) and Medicare (OR = .86; 95% CI, 0.82-0.91) insurance appeared independently associated with a lower likelihood of radiation delivery.

Adjusted analysis showed nonacademic programs, uninsured status, Medicaid and Medicare independently worsened survival (HR > 1; P < .001), whereas chemotherapy and radiation improved survival (HR < 1; P < .001).

These findings are relevant to the ongoing debate in the United States regarding access to health care and programs specifically designed to address access to care, Chun said.

“Regarding chemotherapy, there are targeted action programs such as 340b and the Medicaid Drug Discount Program that allow hospitals to administer chemotherapy at competitive reimbursements, whereas, with federal insurance, hospitals are not reimbursed competitively for administering radiation,” he said. “These data suggest the need for targeted access improvement for this patient population.”

Chun also noted these data raise the question of whether radiation providers accept federal insurance.

“Future study will be important to understand the precise geographic and policy factors responsible for heterogenous standard-of-care delivery,” he said. “It will also be important to determine the root causes of differential outcomes at academic centers and the potential causes of the differential outcomes related to patient selection, access to specialists and coordination of care.” – by Kristie L. Kahl

Reference:

Pezzi TA, et al. Abstract 3A.02. Presented at: International Association for the Study of Lung Cancer Multidisciplinary Symposium in Thoracic Oncology; Sept. 14-16, 2017; Chicago.

Disclosure: Chun reports no relevant financial disclosures.

CHICAGO — Initial treatment with chemotherapy and radiation appeared underused among patients with limited-stage small-cell lung cancer, according to study results presented at the International Association for the Study of Lung Cancer Multidisciplinary Symposium in Thoracic Oncology.

In turn, these patients demonstrated worse survival outcomes.

Combined modality treatment using chemotherapy and radiation plays a role in the initial treatment of limited-stage small-cell lung cancer.

“Despite being the long-held standard of care, we hypothesize there are significant socioeconomic barriers to standard-of-care chemoradiation delivery in this patient population,” Stephen G. Chun, MD, assistant professor in the department of radiation oncology at The University of Texas MD Anderson Cancer Center, said during the presentation. “The purpose of this study was to understand patterns of care in this population and find avenues to improve quality care delivery to limited-stage small-cell lung cancer.”

Chun and colleagues analyzed the initial management of 70,247 patients in the National Cancer Data Base with International Association for the Study of Lung Cancer-defined limited-stage small-cell lung cancer from 2004 to 2013 to determine rates of chemotherapy and radiation delivery, as well as factors associated with utilization and survival.

Median follow-up was 62.3 months.

Initial treatment options included chemotherapy plus radiation (55%), chemotherapy only (20%), radiation only (3%), or neither treatment option (20%).

Patients treated with chemotherapy and radiation demonstrated the longest median OS at 18.2 months, compared with 10.5 months in those who received chemotherapy, 8.3 months in those who received radiation, and 3.7 months for those who received neither treatment (P < .001).

According to multivariable analysis, Medicaid and Medicare insurance yielded no impact on chemotherapy delivery.

However, Medicaid (OR = 0.79; 95% CI, 0.72-0.87) and Medicare (OR = .86; 95% CI, 0.82-0.91) insurance appeared independently associated with a lower likelihood of radiation delivery.

Adjusted analysis showed nonacademic programs, uninsured status, Medicaid and Medicare independently worsened survival (HR > 1; P < .001), whereas chemotherapy and radiation improved survival (HR < 1; P < .001).

These findings are relevant to the ongoing debate in the United States regarding access to health care and programs specifically designed to address access to care, Chun said.

“Regarding chemotherapy, there are targeted action programs such as 340b and the Medicaid Drug Discount Program that allow hospitals to administer chemotherapy at competitive reimbursements, whereas, with federal insurance, hospitals are not reimbursed competitively for administering radiation,” he said. “These data suggest the need for targeted access improvement for this patient population.”

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Chun also noted these data raise the question of whether radiation providers accept federal insurance.

“Future study will be important to understand the precise geographic and policy factors responsible for heterogenous standard-of-care delivery,” he said. “It will also be important to determine the root causes of differential outcomes at academic centers and the potential causes of the differential outcomes related to patient selection, access to specialists and coordination of care.” – by Kristie L. Kahl

Reference:

Pezzi TA, et al. Abstract 3A.02. Presented at: International Association for the Study of Lung Cancer Multidisciplinary Symposium in Thoracic Oncology; Sept. 14-16, 2017; Chicago.

Disclosure: Chun reports no relevant financial disclosures.

    Perspective

    The more basic question [with this study] is why more patients did not receive standard-of-care therapy in the first place. We don’t understand the geographical differences responsible for this heterogenous standard-of-care delivery across the United States. We do know that in lung cancer in general, multimodality therapy seems to be underutilized.

    More research is needed to discover the root causes of underutilization in the standard modalities of care in lung cancer.

    • Lawrence E. Feldman, MD
    • University of Illinois Hospital & Health Sciences System

    Disclosures: Feldman receives research funding from Biothera and Merck.

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