A significant percentage of patients with limited-stage small cell lung cancer (SCLC) in the United States receive inadequate treatment or no treatment at all, suggesting substantial barriers to receiving standard of care, researchers report.
Concurrent chemotherapy and radiation is recommended for the initial treatment of SCLC patients without metastatic disease.
But an analysis of initial treatment data from the National Cancer Database found that just under 60% of patients with limited-stage SCLC received radiation and one in five patients received neither treatment.
The analysis, published online in JAMA Oncology, also showed that while federally insured patients received chemotherapy as often as privately insured patients, Medicare and Medicaid recipients were much less likely to be treated with radiation.
Medicare and Medicaid coverage was also associated with worse survival.
Federal programs such as 340B and the Medicaid drug discount programs, which allow hospitals to provide chemotherapy with competitive reimbursement, have been shown to improve chemotherapy access among federally insured patients. But no such reimbursement programs exist for radiation treatment.
The Trump administration has announced plans to reduce funding for the 340B program by as much as $1.6 billion, but several of the nation’s leading hospital groups, including the American Hospital Association and the Association of American Medical Colleges, have filed lawsuits to block the move.
“Given the debate about the future of 340B and the Medicaid drug discount program, the findings of our study are particularly pertinent,” said Stephen G. Chun, MD, of the University of Texas MD Anderson Cancer Center in Houston.
“It doesn’t matter what political side you are on,” he told MedPage Today. “The fact that one in five patients with limited-stage SCLC in this country can walk into a treatment center and get no treatment tells me that we really need to take a look at our cancer policies in this country.”
The study included data on 70,247 cases of limited-stage SCLC recorded in the National Cancer Database from 2004 through 2013. The median patient age was 68, and 55.3% of patients were female.
Among the main study findings:
- Just over half (55.5%) of patients had combined-modality treatment with chemotherapy and radiation as their initial therapy, while 20.5% had chemotherapy alone, 3.5% had radiation alone, and 20% had neither therapy (0.5% not reported)
- Median survival was 18.2 months (95% CI, 17.9-18.4) with combined treatment, 10.5 months (95% CI, 10.3-10.7) with chemotherapy alone, 8.3 months (95% CI, 7.7-8.8) with radiation alone, and 3.7 months (95% CI, 3.5-3.8) with neither treatment
- Being uninsured was associated with a lower likelihood of receiving both chemotherapy (odds ratio [OR], 0.65; 95% CI, 0.56-0.75; P< 0.001) and radiation therapy (OR, 0.75; 95% CI, 0.67-0.85; P<0.001) on multivariable analysis
- Having Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95% CI, 0.72-0.87; P<0.001) and Medicare (OR, 0.86; 95% CI, 0.82-0.91; P<0.001) 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<0.001), Medicaid (HR, 1.27; 95% CI, 1.21-1.32; P<0.001), and Medicare (HR, 1.12; 95% CI, 1.09-1.15; P<0.001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95% CI, 0.54-0.57; P<0.001) and radiation therapy (HR, 0.62; 95% CI, 0.60-0.63; P<0.001) were associated with a survival benefit.
Treatment at a non-academic center was also associated with significantly shorter survival.
Chun noted that while previous studies have shown a survival advantage associated with treatment at an academic center among patients with non-small cell lung cancer, this study is among the first to show this in patients with SCLC.
“While the reasons for these differences in outcomes in different practice settings are not clear, possible explanations for better outcomes at academic centers include patient selection, coordination of care, and access to subspecialists,” he and his colleagues wrote.
Funding for the study was provided primarily by the National Institutes of Health’s Institute for Dental and Craniofacial Research and the National Cancer Institute.
The principal researchers reported having no relevant relationships with industry related to the study.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner