The initial management and standard of care for limited-stage small cell lung cancer (SCLC) is concurrent chemotherapy and thoracic radiation therapy, but a new study shows that a substantial proportion of patients are not receiving optimal treatment.
The findings, from a large, retrospective, population-based study, show that 23% of patients did not receive chemotherapy and 41% did not receive radiation therapy. Overall survival for these patients was significantly shorter than for patients who received both therapies.
But most concerning was the role that the type of insurance played in treatment.
Being covered by government insurance (Medicaid or Medicare) had no effect on receipt of chemotherapy, but it was independently associated with a lower likelihood of receiving radiation therapy.
The study was published online January 4 in JAMA Oncology.
Lead author Stephen G. Chun, MD, assistant professor of radiation oncology at the the University of Texas MD Anderson Cancer Center, Houston, emphasized that unlike some cancer types, there is very little controversy about the standard of care for limited-stage SCLC.
Dr Stephen Chun
“This has been the standard of care for 30 years,” Dr Chun told Medscape Medical News. “So while there may be legitimate reasons why some patients are not getting treated with chemoradiation, we also found a link with insurance status.”
Even after adjusting for confounders, patients with federal insurance plans were still less likely to receive radiation therapy as compared to those with other types of insurance, he explained. “But for chemotherapy, there was no difference between patients with private insurance and those with Medicare or Medicaid.”
The discrepancy could be at least partially explained by the fact that programs such as 340b and the Medicaid Drug Discount Program have improved chemotherapy access. “These programs provide very competitive reimbursement, and data suggest that these programs have been successful in increasing access to medication,” said Dr Chun. “But they provide no financial assistance for radiation therapy. In the absence of a similar program, we found that federal insurance was uniquely associated with lack of radiation therapy.
We have to figure out how to level the playing field.
“It’s one thing to have the standard of care, but it needs to be implemented to be effective,” Dr Chun added. “We have to figure out how to level the playing field.”
Insurance and Treatment Location Affect Survival
For their study, Dr Chun and his colleagues used the National Cancer Data Base to identify 70,247 patients who were diagnosed with limited-stage SCLC between 2004 through 2013.
Within this group, 55.5% of patients received initial chemotherapy and radiation therapy, 20.5% received chemotherapy alone, 3.5% received radiation therapy alone, and 20% received neither chemotherapy nor radiation therapy. Treatment was not reported for 0.5%.
Not surprisingly, at a median follow-up of 62.3 months, median survival was significantly better for patients who received chemotherapy and radiation therapy than for any other cohort: 18.2 months as compared to 10.5 months with chemotherapy alone, and 8.3 months with radiation therapy alone (P < .001). The poorest survival was seen in patients who received neither chemotherapy nor radiation therapy, at 3.7 months (P < .001).
A lack of any type of insurance (odds ratio [OR], 0.75; P < .001) and being insured by Medicaid (OR, 0.79; P < .001) and Medicare (OR, 0.86; P < .001) were independently associated with a lower likelihood of receiving therapy in comparison with private insurance or a managed care plan.
Having no insurance was the only variable associated with a lower likelihood of receiving chemotherapy (OR, 0.65; P < .001). Neither Medicaid (OR, 1.01; P = .86) nor Medicare (OR, 0.97; P = .36) were associated with chemotherapy delivery.
The authors note that on multivariable analysis, there were several predictors of improved survival. There was a significant difference in survival depending on where patients received their treatment. For those treated at an academic/research program, survival was better than for those treated in a community cancer program (HR, 1.19; P < .001), a comprehensive community cancer program (HR, 1.08; P < .001), or an integrated cancer program (HR, 1.07; P = .001).
A lack of insurance (HR, 1.19; P < .001), being insured under Medicaid (HR, 1.27; P < .001), and being insured under Medicare (HR, 1.12; P < .001) were also independently associated with worse survival.
Treatment with chemotherapy (HR, 0.55; P < .001) and radiation therapy (HR, 0.62; P < .001) remained highly associated with better survival on multivariable analysis.
“In primary care, it has been recognized that many providers do not accept Medicaid or Medicare insurance due to poorer reimbursement,” said Dr Chun. “In the current healthcare debate, there are discussions of cutting Medicare and Medicaid funding. If programs such as the 340b and Medicaid Drug Discount Program are scaled back, this could affect access to care and survival for these patients.”
Dr Chun also noted that even though survival was better for patients treated at academic centers, the reasons for that were not examined in this study. “It could be that the patients had a higher level of education and more means, or there were more specialists available,” he speculated, “But we don’t know the answer to that, and we need to address why outcomes are better.”
The authors plan to continue their research and further define population patterns, specific treatment insufficiencies, and the contributing factors to wide-ranging care delivery.
The study was supported in part by a grant from the National Institute of Health/National Cancer Institute to the University of Texas MD Anderson Cancer Center. One coauthor has received speaker travel funding from Elekta AB. The other authors have disclosed no relevant financial relationships.
JAMA Oncol. Published online January 4, 2018. Abstract
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