Barriers to combined-modality therapy for limited-stage small cell lung cancer

Todd A. Pezzi, David L. Schwartz, Abdallah S.R. Mohamed, James W. Welsh, Ritsuko U. Komaki, Stephen M. Hahn, Boris Sepesi, Christopher M. Pezzi, Clifton D. Fuller, Stephen G. Chun

Research output: Contribution to journalArticle

12 Citations (Scopus)

Abstract

IMPORTANCE Combined-modality therapy with chemotherapy and radiation therapy plays a crucial role in the upfront treatment of patients with limited-stage small cell lung cancer (SCLC), but there may be barriers to utilization in the United States. OBJECTIVE To estimate utilization rates and factors associated with chemotherapy and radiation therapy delivery for limited-stage SCLC using the National Cancer Database. DESIGN, SETTING, AND PARTICIPANTS Analysis of initial management of all limited-stage SCLC cases from 2004 through 2013 in the National Cancer Database. MAIN OUTCOMES AND MEASURES Utilization rates of chemotherapy and radiation therapy at time of initial treatment. Multivariable analysis identified independent clinical and socioeconomic factors associated with utilization and overall survival. RESULTS A total of 70 247 cases met inclusion criteria (55.3% female; median age, 68 y [range, 19-90 y]). Initial treatment was 55.5% chemotherapy and radiation therapy, 20.5% chemotherapy alone, 3.5% radiation therapy alone, and 20.0% neither (0.5% not reported). Median survival was 18.2 (95% CI, 17.9-18.4), 10.5 (95% CI, 10.3-10.7), 8.3 (95% CI, 7.7-8.8), and 3.7 (95% CI, 3.5-3.8) months, respectively. Being uninsured was associated with a lower likelihood of both chemotherapy (odds ratio [OR], 0.65; 95% CI, 0.56-0.75; P < .001) and radiation therapy (OR, 0.75; 95% CI, 0.67-0.85; P < .001) administration on multivariable analysis. Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95% CI, 0.72-0.87; P < .001) and Medicare (OR, 0.86; 95% CI, 0.82-0.91; P < .001) were independently associated with a lower likelihood of radiation therapy delivery. Lack of health insurance (HR, 1.19; 95% CI, 1.13-1.26; P < .001), Medicaid (HR, 1.27; 95% CI, 1.21-1.32; P < .001), and Medicare (HR, 1.12; 95% CI, 1.09-1.15; P < .001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95% CI, 0.54-0.57; P < .001) and radiation therapy (HR, 0.62; 95% CI, 0.60-0.63; P < .001) were associated with a survival benefit. CONCLUSIONS AND RELEVANCE Substantial proportions of patients documented in a major US cancer registry did not receive radiation therapy or chemotherapy as part of initial treatment for limited-stage SCLC, which, in turn, was associated with poor survival. Lack of radiation therapy delivery was uniquely associated with government insurance coverage, suggesting a need for targeted access improvement in this population. Additional work will be necessary to conclusively define exact population patterns, specific treatment deficiencies, and causative factors leading to heterogeneous care delivery.

Original languageEnglish (US)
Article numbere174504
Pages (from-to)12DUMMY
JournalJAMA oncology
Volume4
Issue number8
DOIs
StatePublished - Aug 1 2018

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Combined Modality Therapy
Small Cell Lung Carcinoma
Radiotherapy
Drug Therapy
Medicaid
Medicare
Odds Ratio
Survival
Databases
Therapeutics
Neoplasms
Insurance Coverage
Health Insurance
Insurance
Population
Registries

ASJC Scopus subject areas

  • Oncology
  • Cancer Research

Cite this

Pezzi, T. A., Schwartz, D. L., Mohamed, A. S. R., Welsh, J. W., Komaki, R. U., Hahn, S. M., ... Chun, S. G. (2018). Barriers to combined-modality therapy for limited-stage small cell lung cancer. JAMA oncology, 4(8), 12DUMMY. [e174504]. https://doi.org/10.1001/jamaoncol.2017.4504

Barriers to combined-modality therapy for limited-stage small cell lung cancer. / Pezzi, Todd A.; Schwartz, David L.; Mohamed, Abdallah S.R.; Welsh, James W.; Komaki, Ritsuko U.; Hahn, Stephen M.; Sepesi, Boris; Pezzi, Christopher M.; Fuller, Clifton D.; Chun, Stephen G.

In: JAMA oncology, Vol. 4, No. 8, e174504, 01.08.2018, p. 12DUMMY.

Research output: Contribution to journalArticle

Pezzi, TA, Schwartz, DL, Mohamed, ASR, Welsh, JW, Komaki, RU, Hahn, SM, Sepesi, B, Pezzi, CM, Fuller, CD & Chun, SG 2018, 'Barriers to combined-modality therapy for limited-stage small cell lung cancer', JAMA oncology, vol. 4, no. 8, e174504, pp. 12DUMMY. https://doi.org/10.1001/jamaoncol.2017.4504
Pezzi, Todd A. ; Schwartz, David L. ; Mohamed, Abdallah S.R. ; Welsh, James W. ; Komaki, Ritsuko U. ; Hahn, Stephen M. ; Sepesi, Boris ; Pezzi, Christopher M. ; Fuller, Clifton D. ; Chun, Stephen G. / Barriers to combined-modality therapy for limited-stage small cell lung cancer. In: JAMA oncology. 2018 ; Vol. 4, No. 8. pp. 12DUMMY.
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abstract = "IMPORTANCE Combined-modality therapy with chemotherapy and radiation therapy plays a crucial role in the upfront treatment of patients with limited-stage small cell lung cancer (SCLC), but there may be barriers to utilization in the United States. OBJECTIVE To estimate utilization rates and factors associated with chemotherapy and radiation therapy delivery for limited-stage SCLC using the National Cancer Database. DESIGN, SETTING, AND PARTICIPANTS Analysis of initial management of all limited-stage SCLC cases from 2004 through 2013 in the National Cancer Database. MAIN OUTCOMES AND MEASURES Utilization rates of chemotherapy and radiation therapy at time of initial treatment. Multivariable analysis identified independent clinical and socioeconomic factors associated with utilization and overall survival. RESULTS A total of 70 247 cases met inclusion criteria (55.3{\%} female; median age, 68 y [range, 19-90 y]). Initial treatment was 55.5{\%} chemotherapy and radiation therapy, 20.5{\%} chemotherapy alone, 3.5{\%} radiation therapy alone, and 20.0{\%} neither (0.5{\%} not reported). Median survival was 18.2 (95{\%} CI, 17.9-18.4), 10.5 (95{\%} CI, 10.3-10.7), 8.3 (95{\%} CI, 7.7-8.8), and 3.7 (95{\%} CI, 3.5-3.8) months, respectively. Being uninsured was associated with a lower likelihood of both chemotherapy (odds ratio [OR], 0.65; 95{\%} CI, 0.56-0.75; P < .001) and radiation therapy (OR, 0.75; 95{\%} CI, 0.67-0.85; P < .001) administration on multivariable analysis. Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95{\%} CI, 0.72-0.87; P < .001) and Medicare (OR, 0.86; 95{\%} CI, 0.82-0.91; P < .001) were independently associated with a lower likelihood of radiation therapy delivery. Lack of health insurance (HR, 1.19; 95{\%} CI, 1.13-1.26; P < .001), Medicaid (HR, 1.27; 95{\%} CI, 1.21-1.32; P < .001), and Medicare (HR, 1.12; 95{\%} CI, 1.09-1.15; P < .001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95{\%} CI, 0.54-0.57; P < .001) and radiation therapy (HR, 0.62; 95{\%} CI, 0.60-0.63; P < .001) were associated with a survival benefit. CONCLUSIONS AND RELEVANCE Substantial proportions of patients documented in a major US cancer registry did not receive radiation therapy or chemotherapy as part of initial treatment for limited-stage SCLC, which, in turn, was associated with poor survival. Lack of radiation therapy delivery was uniquely associated with government insurance coverage, suggesting a need for targeted access improvement in this population. Additional work will be necessary to conclusively define exact population patterns, specific treatment deficiencies, and causative factors leading to heterogeneous care delivery.",
author = "Pezzi, {Todd A.} and Schwartz, {David L.} and Mohamed, {Abdallah S.R.} and Welsh, {James W.} and Komaki, {Ritsuko U.} and Hahn, {Stephen M.} and Boris Sepesi and Pezzi, {Christopher M.} and Fuller, {Clifton D.} and Chun, {Stephen G.}",
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T1 - Barriers to combined-modality therapy for limited-stage small cell lung cancer

AU - Pezzi, Todd A.

AU - Schwartz, David L.

AU - Mohamed, Abdallah S.R.

AU - Welsh, James W.

AU - Komaki, Ritsuko U.

AU - Hahn, Stephen M.

AU - Sepesi, Boris

AU - Pezzi, Christopher M.

AU - Fuller, Clifton D.

AU - Chun, Stephen G.

PY - 2018/8/1

Y1 - 2018/8/1

N2 - IMPORTANCE Combined-modality therapy with chemotherapy and radiation therapy plays a crucial role in the upfront treatment of patients with limited-stage small cell lung cancer (SCLC), but there may be barriers to utilization in the United States. OBJECTIVE To estimate utilization rates and factors associated with chemotherapy and radiation therapy delivery for limited-stage SCLC using the National Cancer Database. DESIGN, SETTING, AND PARTICIPANTS Analysis of initial management of all limited-stage SCLC cases from 2004 through 2013 in the National Cancer Database. MAIN OUTCOMES AND MEASURES Utilization rates of chemotherapy and radiation therapy at time of initial treatment. Multivariable analysis identified independent clinical and socioeconomic factors associated with utilization and overall survival. RESULTS A total of 70 247 cases met inclusion criteria (55.3% female; median age, 68 y [range, 19-90 y]). Initial treatment was 55.5% chemotherapy and radiation therapy, 20.5% chemotherapy alone, 3.5% radiation therapy alone, and 20.0% neither (0.5% not reported). Median survival was 18.2 (95% CI, 17.9-18.4), 10.5 (95% CI, 10.3-10.7), 8.3 (95% CI, 7.7-8.8), and 3.7 (95% CI, 3.5-3.8) months, respectively. Being uninsured was associated with a lower likelihood of both chemotherapy (odds ratio [OR], 0.65; 95% CI, 0.56-0.75; P < .001) and radiation therapy (OR, 0.75; 95% CI, 0.67-0.85; P < .001) administration on multivariable analysis. Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95% CI, 0.72-0.87; P < .001) and Medicare (OR, 0.86; 95% CI, 0.82-0.91; P < .001) were independently associated with a lower likelihood of radiation therapy delivery. Lack of health insurance (HR, 1.19; 95% CI, 1.13-1.26; P < .001), Medicaid (HR, 1.27; 95% CI, 1.21-1.32; P < .001), and Medicare (HR, 1.12; 95% CI, 1.09-1.15; P < .001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95% CI, 0.54-0.57; P < .001) and radiation therapy (HR, 0.62; 95% CI, 0.60-0.63; P < .001) were associated with a survival benefit. CONCLUSIONS AND RELEVANCE Substantial proportions of patients documented in a major US cancer registry did not receive radiation therapy or chemotherapy as part of initial treatment for limited-stage SCLC, which, in turn, was associated with poor survival. Lack of radiation therapy delivery was uniquely associated with government insurance coverage, suggesting a need for targeted access improvement in this population. Additional work will be necessary to conclusively define exact population patterns, specific treatment deficiencies, and causative factors leading to heterogeneous care delivery.

AB - IMPORTANCE Combined-modality therapy with chemotherapy and radiation therapy plays a crucial role in the upfront treatment of patients with limited-stage small cell lung cancer (SCLC), but there may be barriers to utilization in the United States. OBJECTIVE To estimate utilization rates and factors associated with chemotherapy and radiation therapy delivery for limited-stage SCLC using the National Cancer Database. DESIGN, SETTING, AND PARTICIPANTS Analysis of initial management of all limited-stage SCLC cases from 2004 through 2013 in the National Cancer Database. MAIN OUTCOMES AND MEASURES Utilization rates of chemotherapy and radiation therapy at time of initial treatment. Multivariable analysis identified independent clinical and socioeconomic factors associated with utilization and overall survival. RESULTS A total of 70 247 cases met inclusion criteria (55.3% female; median age, 68 y [range, 19-90 y]). Initial treatment was 55.5% chemotherapy and radiation therapy, 20.5% chemotherapy alone, 3.5% radiation therapy alone, and 20.0% neither (0.5% not reported). Median survival was 18.2 (95% CI, 17.9-18.4), 10.5 (95% CI, 10.3-10.7), 8.3 (95% CI, 7.7-8.8), and 3.7 (95% CI, 3.5-3.8) months, respectively. Being uninsured was associated with a lower likelihood of both chemotherapy (odds ratio [OR], 0.65; 95% CI, 0.56-0.75; P < .001) and radiation therapy (OR, 0.75; 95% CI, 0.67-0.85; P < .001) administration on multivariable analysis. Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95% CI, 0.72-0.87; P < .001) and Medicare (OR, 0.86; 95% CI, 0.82-0.91; P < .001) were independently associated with a lower likelihood of radiation therapy delivery. Lack of health insurance (HR, 1.19; 95% CI, 1.13-1.26; P < .001), Medicaid (HR, 1.27; 95% CI, 1.21-1.32; P < .001), and Medicare (HR, 1.12; 95% CI, 1.09-1.15; P < .001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95% CI, 0.54-0.57; P < .001) and radiation therapy (HR, 0.62; 95% CI, 0.60-0.63; P < .001) were associated with a survival benefit. CONCLUSIONS AND RELEVANCE Substantial proportions of patients documented in a major US cancer registry did not receive radiation therapy or chemotherapy as part of initial treatment for limited-stage SCLC, which, in turn, was associated with poor survival. Lack of radiation therapy delivery was uniquely associated with government insurance coverage, suggesting a need for targeted access improvement in this population. Additional work will be necessary to conclusively define exact population patterns, specific treatment deficiencies, and causative factors leading to heterogeneous care delivery.

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