Guideline-concordant Care Improves Overall Survival for Locally Advanced Non–Small-cell Lung Carcinoma Patients: A National Cancer Database Analysis

doi:10.1016/j.cllc.2017.04.009

Clinical Lung Cancer

Volume 18, Issue 6, November 2017, Pages 706-718

https://doi.org/10.1016/j.cllc.2017.04.009 Get rights and content

Abstract

Background

Current evidence-based guideline-concordant care (GCC) for locally advanced non–small-cell lung cancer (NSCLC) patients with good performance status is concurrent chemoradiation. In this study we evaluated factors associated with lack of GCC and its effects on overall survival (OS).

Patients and Methods

Unresectable stage III NSCLC patients, diagnosed from 2005 to 2013 with a Charlson–Deyo score of 0, were identified from the National Cancer Database. Primary outcomes were receipt of GCC, defined as concurrent chemoradiation (thoracic radiotherapy, starting within 2 weeks of chemotherapy, to at least 60 Gy), and OS. Multivariable logistic regression modeling identified variables associated with non-GCC. Cox proportional hazard modeling was used to examine OS.

Results

Twenty-three percent of patients (n = 10,476) received GCC. Uninsured patients were more likely to receive non-GCC (odds ratio [OR], 1.54; P < .001) compared with privately insured patients. Other groups with greater odds of receiving non-GCC included: patients treated in the western, southern, or northeastern United States (ORs, 1.39, 1.37, and 1.19, respectively; all Ps < .001) compared with the Midwest; adenocarcinoma histology (OR, 1.48; P < .001) compared with squamous cell carcinoma; and women (OR, 1.08; P = .002). Those who received non-GCC had higher death rates compared with those who received GCC (hazard ratio [HR], 1.42; P < .001). The uninsured (HR, 1.53; P < .001), patients treated in the western, southern, or northeastern United States (HRs, 1.56, 1.41, and 1.34, respectively; P < .001), adenocarcinomas (HR, 1.39; P < .001), and women (HR, 1.44; P < .001) also all had lower OS for non-GCC versus GCC.

Conclusion

Socioeconomic factors, including lack of insurance and geography, are associated with non-GCC. Patient- and disease-specific factors, including increasing adenocarcinoma histology and sex, are also associated with non-GCC. Non-GCC diminishes OS.

Introduction

Lung cancer is the leading cause of cancer-related deaths in the United States with an estimated 158,040 deaths in 2015.¹ Lung cancer is the second most common diagnosed cancer per year, with over 200,000 new cases diagnosed in 2016.¹ Of these newly diagnosed lung cancers, approximately 85% are classified as non–small-cell lung carcinoma (NSCLC). Despite the high incidence of this disease, 5-year survival rates range from 49% for stage IA disease to 1% for stage IV disease.¹ The outcomes for locally advanced cases are particularly dismal, with a 5-year survival rate for stage IIIA NSCLC at approximately 14% and at 5% for stage IIIB.²

According to the American College of Radiology Appropriateness Criteria,³ the American Society for Radiation Oncology,⁴ and the American Society of Clinical Oncology,⁵ the current evidence-based clinical practice guidelines recommend concurrent administration of platinum-based chemotherapy during thoracic radiotherapy (TRT) as the established guideline-concordant care (GCC) for locally advanced NSCLC.⁶ All 3 organizations independently assembled multidisciplinary expert panels that performed extensive reviews of the current medical literature to develop evidence-based recommendations for the treatment of locally advanced NSCLC.

Despite standardized treatment regimens, there are barriers to delivery of GCC. In a systematic review and meta-analysis of socioeconomic (SE) status (SES) and receipt of lung cancer treatment, Forrest et al reported statistically significant associations between lower SES and the likelihood of receiving surgical interventions and chemotherapeutic regimens.⁷ Furthermore, a study that specifically investigated race and sex as effect modifiers of receiving appropriate treatment for NSCLC reported that African American (AA) patients with stage III disease were 34% less likely to receive standard treatment.⁸ In a previous study of National Cancer Database (NCDB) data, Khullar et al analyzed the association of long-term survival of NSCLC patients who underwent pulmonary resection with various SE factors,⁹ and reported that Caucasian patients received lung resections at significantly greater rates than AA patients.⁹

It is evident that despite having clear guidelines in place for standard of care therapy, there are distinct groups at risk for not receiving standard of care treatment. Identification of system-related and patient-related factors that contribute to disparate lung cancer treatment is needed to develop interventions that target populations at risk. In this study we evaluated patient characteristics associated with lack of receipt of GCC for locally advanced NSCLC, to determine those at risk for receiving non-GCC.

Section snippets

Patients and Methods

This study used the NCDB, a nationally recognized clinical oncology database containing clinical as well as demographic information collected from patients treated at >1500 Commission on Cancer (CoC)-accredited institutions, which is jointly supported by the American College of Surgeons and the American Cancer Society. Unresected stage IIIA/IIIB NSCLC patients, diagnosed from 2005 to 2013 and with a Charlson–Deyo Score of 0, were identified. Exclusion criteria included patients with any distant

Patient Characteristics

Unresected stage IIIA and IIIB NSCLC patients (n = 45,825) with a Charlson–Deyo score of 0 diagnosed between 2005 and 2013 met inclusion criteria (Figure 1). Patient characteristics are represented in Table 1. Overall, 23% of patients were treated with GCC. Approximately 28% of patients received neither chemotherapy nor TRT; 23% received chemotherapy but no TRT; 13% received chemotherapy and TRT to <60 Gy; 5% received sequential chemoradiation to ≥60 Gy; 4% received no chemotherapy but received

Discussion

Despite gains in knowledge regarding optimal treatment regimens, use of GCC was only 23% in this study using a large database that contains approximately 70% of cancer cases in the United States. This study shows a clear positive association between certain SE risk factors, including insurance status and facility geographic location, and non-SE variables, such as sex, race/ethnicity, increasing patient age, and histology, and receipt of GCC. It also shows a clear improvement in OS for those who

Conclusion

Although GCC was associated with significant differences in OS, only 23% of patients received GCC. SE factors, including lack of insurance and geography, are associated with non-GCC. Patient-specific factors, including sex, race/ethnicity, and increasing age are also associated with non-GCC, as are disease-specific factors, such as adenocarcinoma histology. Future interventions might target these groups as an opportunity to improve provision of GCC, as it is so crucial to improving survival.

Disclosure

The authors have stated that they have no conflicts of interest.

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Original StudyGuideline-concordant Care Improves Overall Survival for Locally Advanced Non–Small-cell Lung Carcinoma Patients: A National Cancer Database Analysis

Abstract

Background

Patients and Methods

Results

Conclusion

Introduction

Section snippets

Patients and Methods

Patient Characteristics

Discussion

Conclusion

Disclosure

Pract Radiat Oncol

Patient Educ Couns

Clin Lung Cancer

J Urol

Vaccine

Cancer Epidemiol

Cancer Epidemiol

J Geriatr Oncol

Int J Radiat Oncol Biol Phys

Cancer Facts & Figures

Cancer Treatment & Survivor Facts & Figures 2014-2015

ACR Appropriateness Criteria(R) nonsurgical treatment for locally advanced non–small-cell lung cancer: good performance status/definitive intent

Oncology (Williston Park)

Definitive and adjuvant radiotherapy in locally advanced non–small-cell lung cancer: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the American Society for Radiation Oncology Evidence-Based Clinical Practice Guideline

J Clin Oncol

Concurrent chemoradiotherapy in non–small-cell lung cancer

Cochrane Database Syst Rev

Socioeconomic inequalities in lung cancer treatment: systematic review and meta-analysis

PLoS Med

Race and sex differences in the receipt of timely and appropriate lung cancer treatment

Med Care

Socioeconomic risk factors for long-term mortality after pulmonary resection for lung cancer: an analysis of more than 90,000 patients from the National Cancer Data Base

J Am Coll Surg

The role of health literacy in reducing negative perceptions of breast health and treatment among uninsured primary care patients

J Community Health

Reasons for underuse of recommended therapies for colorectal and lung cancer in the Veterans Health Administration

Cancer

Original Study
Guideline-concordant Care Improves Overall Survival for Locally Advanced Non–Small-cell Lung Carcinoma Patients: A National Cancer Database Analysis