Lung cancer

Why lung cancer patients don’t receive guideline recommended therapy


Most patients with lung cancer are receiving guideline-concordant treatment (GCT) but there is still plenty of room for improvement, a Victorian study has shown.

Using data from almost 5,000 patients with NSCLC or SCLC recruited to the Victorian Lung Cancer Registry between 2011 and 2018, the study found 60.36% of patients received guideline-concordant treatment.

Patterns of treatment and guideline concordance varied widely,  and less-intensive-than-recommended treatment was mostly associated with poor performance status, advanced clinical stages, NSCLC type, public hospital insurance, area-level deprivation and comorbidities.

“Localized and locally advanced-NSCLC received less-intensive-than-recommended treatment, most commonly with conventional radiotherapy alone. However, a higher proportion of patients in the advanced-NSCLC and extensive-SCLC groups received no treatment, compared to conventional radiotherapy only,” the study found.

“Among limited-SCLC, chemotherapy only was the most common less-intensive-than-recommended treatment, followed by conventional radiotherapy alone and no treatment.”

The proportion of SCLC patients receiving guideline-concordant treatment increased by clinical stages but decreased with clinical stages among NSCLC.

Rates of guideline-concordant treatment also increased significantly over the years.

The study said ECOG performance status (PS) was the major contributor to guideline-concordant treatment.

“Worse PS was associated with a lower likelihood of GCT, particularly for patients with advanced stage. Therefore, these findings highlight the importance of patient assessment by physicians before treatment since clinical guidelines are supposed to be followed in medically-fit patients and might not be applicable in medically unfit patients.”

And stage III-IV NSCLC patients comprised the largest proportion of those patients receiving less-intensive-than-recommended treatment.

“Despite the availability of multiple treatment options, many patients (14%) did not receive active treatment in this study.”

“As most patients not receiving GCT presented with advanced stage, quality-of-life (QOL) rather than survival could have become an important consideration. Although poor PS or late-stage could have deterred active treatment, 43.81% and 13.51% of those not receiving GCT were of good PS (ECOG-0 or 1) and NSCLC stage I-II.”

The investigators, from the School of Health and Preventive Medicine at Monash University, said factors that could have contributed to not receiving guideline-concordant treatment included a lack of referral to an oncologist or MDM, ageist and nihilistic attitudes towards lung cancer treatment, and patient’s preference against chemotherapy or radiotherapy.

“A possible explanation for socio-economic disparities in the uptake of GCT includes financial burden, out of pocket and indirect costs and longitudinal, protracted nature of combination therapy.”

They said improving access to comprehensive quality care across public hospitals could help address inequalities in the delivery of GCT.

They also found guideline-concordant treatment was significantly associated with a 43% lower risk of two-year mortality outcomes (OR=0.57, 95% Crl=0.5-0.66) after adjusting for clinical stage, lung cancer type, ECOG status, smoking, MDM, hospital insurance, socio-economic disadvantage.

“Thus, quality benchmarking of guideline adherence would be useful as an actionable target to reduce inequalities in the receipt of curative cancer treatment and survival outcomes.”

The study was published in Cancer Epidemiology, Biomarkers & Prevention.

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