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Many patients with lung cancer do not receive treatment
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Approximately one in five patients with the most common form of lung cancer did not receive cancer-specific treatment, according to study results published in Journal of Thoracic Oncology.
Elizabeth A. David, MD, FACS, assistant professor of surgery at UC Davis Health and thoracic surgeon at UC Davis Comprehensive Cancer Center, and colleagues used the National Cancer Data Base to analyze treatment receipt for 190,539 patients with non–small cell lung cancer between 1998 and 2012.
Results showed 21% of patients received no specific cancer treatment, such as surgery, chemotherapy or radiotherapy. Many of those untreated patients were elderly, minorities, low income or uninsured.
In addition, the number of patients with late-stage disease — defined as stage IIIa or stage IV — who did not receive treatment increased during the study period.
HemOnc Today spoke with David about the findings, the potential explanations behind them, and their implications for patients and health care providers.
Question: What prompted this study?
Answer: I was part of a similar type of publication that we used at California Cancer Registry for a year prior to look at trends in lung cancer treatment. We found a high rate of untreated lung cancer. We thought that, if this was happening in California, it’s probably a good idea to look at national-level data to examine the trends. It started as an exploratory analysis.
Q: Can you provide a brief overview of how you conducted the study, as well as the results you reported?
A: We did an analysis of the National Cancer Data Base, which represents about 70% of new lung cancer cases in the United States, to give ourselves a good sense of the overall care of these patients. Then, we did a logistics regression analysis to determine the number of patients in each treatment group during the study period. We basically used regression analysis to determine if the number of patients in each group changed over time. That’s where we saw the increases in untreated patients among those with stage IIIa and stage IV disease.
Q: Did the findings surprise you?
A: We were surprised that the percentage of patients who went untreated increased. We would hope to see a statistic like that decrease as there is more education of both patients and providers, but we didn’t see that. It raises many questions about why the number of untreated patients is increasing.
Q: Is it possible that the stigma of lung cancer contributes to some patients not receiving treatment?
A: Lung cancer has been presumed to be a cancer that occurs primarily in people who smoke for a long time. There is this sense among some who think, ‘People smoked, so that’s why they have this cancer.’ Also, some patients will come to us and say, ‘I did this to myself, and this is just how it is going to be.’ This mindset influences the patient’s treatment decisions. Unfortunately, we are seeing more lung cancer in people who have never smoked, but the stigma still negatively affects both providers and patients. We need to fight against that stigma because it doesn’t really matter if they smoked or not. They have a cancer and we have a lot of treatment options for patients with all stages of this disease. It’s a matter of getting the right patient connected with the right treatment.
Q: What role do other factors — such as sex, age, race, income or insurance status — play in the decision to seek treatment? How can providers address these influences?
A: Those are all huge factors. We know that race, rural location, lower education level and lesser insurance status all are associated with disparities in treatment. Patients in these groups may be less likely to see a physician. If they do see a primary care physician, maybe they don’t make it to a specialist. It is hard to make sweeping generalizations about exactly what the problem is but, as specialty providers, those are the patients we really need to look out for. We need to think, ‘This person is coming from a rural area, so we might need to have more telephone follow-up with that person as opposed to having them coming in for a visit every week.’ We need to come up with creative solutions for patients. In our institution, our virtual tumor board — connected with some of our partner rural facilities — allows us to offer additional treatment to patients that may not be available to them locally. Programs like that can help overcome some of those disparities, but it’s really on the providers to be aware of those disparities and actively work to combat them.
Q: Do you think some patients are making an informed decision to not seek treatment?
A: I definitely do. I don’t think it’s reasonable to expect that every patient with lung cancer is going to want to be treated. In fact, it is probably not appropriate for every patient to be treated. Patients should be aware of the fact that, when they look at the OS statistics for lung cancer, there is a high percentage of untreated patients in those statistics that pull them down. Among patients with stage IIIa disease, survival is 16.5 months among those who receive treatment and 6 months among those who do not. Among those with stage IV disease, survival is 9 months among those who receive treatment and 2 months among those who do not. That might be the difference between somebody making it to a wedding or seeing a grandchild graduate from college. Patients need to know that, if they are able to have some treatment, their outcomes may be better than they expect.
Q: What are the implications of these results?
A: I hope they will raise awareness among providers — not only the specialty providers in lung cancer, but also the nonspecialty providers, the primary care physicians and other caregivers who are on the front lines of this disease and who may need some help having those initial conversations with patients to help them make the decision to see a specialist. It is important for providers to be aware that we do see these disparities.
Q: What else is important for members of the clinical community to know?
A : We must make sure patients and providers really understand that all of the treatment modalities are easier to tolerate than they used to be. Surgery is easier, people don’t spend as long in the hospital, and there is a little less pain than before because of advances in surgical techniques. Radiation treatments also are a bit easier to tolerate and, in some cases, they can be given over a shorter course of time. In addition, the advances in systemic treatments — such as chemotherapy and molecular-targeted therapy — have been huge. Not only are they easier to tolerate, but patients live a lot longer than they used to. We should make sure both patients and providers understand those principles, and that people are not being turned away from treatment before they hear all the options. – by Kyle Doherty
For more information:
Elizabeth David, MD, FACS, can be reached at UC Davis Comprehensive Cancer Center, 2279 45th St., Sacramento, CA 95817;email: eadavid@ucdavis.edu.
Disclosure: David reports no relevant financial disclosures.