Outcomes for patients who present with non-small cell lung cancer (NSCLC) in England differ significantly from those among patients in the United States, such that there may be as many as 98 excess deaths for every 1000 patients in England compared with the United States, a population-based analysis indicates.
“We frequently discuss our health system as if we are in a vacuum,” senior author, Cary Gross, MD, Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News in an email.
“But developed countries differ dramatically in their approach to healthcare and we can learn about different approaches — and what is working and not working within our own system — by comparing across systems,” he added.
“So these international comparisons can give us a ‘reality check’,” Gross noted, adding that the later stage of presentation observed in English patients, their greater risk of not being treated, and subsequently poorer survival odds may reflect cultural differences in attitudes toward aggressive treatment between the two countries.
The study was published online May 1 in The Journal of Thoracic Oncology.
Investigators relied on data from population-based cancer surveillance registries and administrative databases in both England and the United States to compare diagnostic, treatment, and survival patterns in older patients diagnosed with NSCLC between 2008 and 2012.
Some 86,978 patients aged 66 years and older made up the English cohort, and 84,415 patients were identified for the US cohort.
“The proportion of patients without pathological confirmation was higher in England (37%) than in the United States (15%),” the study investigators point out.
However, among patients whose tumors were pathologically confirmed, the proportion of patients with adenocarcinomas was lower in England than the United States (38% vs 50%), while the proportion of patients who presented with squamous cell carcinoma was slightly higher in England (at 34% vs 29%, respectively).
The proportion of patients for which stage was not available was again higher in England, at 22%, than in the United States, at 11%.
Staging information also varied by age in England, doubling from 15% for patients aged 66 to 70 years to 34% for patients older than age 85.
In the United States, the difference in staging between the two age groups was not large, ranging from 16% for the younger cohort and 23% for those in the oldest group.
Moreover, the investigators note, patients in England were less likely to present with early-stage disease. In England, only 15% of all patients with NSCLC presented with stage I disease compared with 24% of those in the United States.
In contrast, there was little difference between the two countries in the proportion of patients who presented with stage IIIB and IV disease, at 64% in England and 62% in the United States, respectively.
Big Difference in Active Treatment
Looking at the proportion of patients who received any active treatment, investigators noted a large differences between the two countries.
In the overall cohort, 46% of English patients vs 60% of US patients received some form of active treatment.
However, when analysis was restricted to patients whose tumors had been pathologically confirmed, the proportion who received any form of active therapy was similar, at 66% for English patients and 69% for their US counterparts.
The same was also true among patients whose tumors had not been pathologically confirmed, wherein 12.1% of patients in England received some form of active treatment compared with 9.6% of those in the United States.
“Larger differences were observed in the receipt of surgery, however,” the study authors write. Here, 13% of English patients underwent surgery compared with 20% of those in the United States.
Surgical rates for patients with stage I disease followed the same trend, with 52% of patients in England undergoing surgery compared with 60% of US patients.
In addition, slightly over one third of English patients received chemotherapy or radiotherapy compared with 45% of US patients.
“The largest differences in receipt of all treatment modalities were observed for stage II patients,” the authors observe — with 70% of patients in England receiving treatment vs 83% of those in the United States.
Overall Survival
Overall survival (OS) rates at both 1 and 2 years after diagnosis were also considerably lower in England than in the United States.
At 1 year, 29.2% of patients in England were alive compared with 40.1% of those in the United States. At 2 years, the rates were 17% and 27.1%, respectively.
In both countries, women had better OS rates than men, even though OS rates for women in England were lower than OS rates for women in the United States.
That said, “survival disparity between countries varied according to stage at diagnosis,” the investigators point out.
In fact, OS rates at both 1 and 2 years for patients with stage I disease were similar in England and the United States for those with pathologic confirmation as well as for those who received treatment.
In contrast, only about 28% of patients with stage IIIB-IV disease in England were alive at 1 year after any active treatment compared with approximately 39% of their US counterparts.
At 2 years, OS rates were approximately 12% and 21% for the same-staged cohort in England and the United States, respectively.
Investigators also analyzed a random sample of 1000 patients in each country who had pathologic confirmation of their tumor.
Two years from their diagnosis, researchers calculated that there were 98 excess deaths for every 1000 patients in England compared with the United States.
This number would decrease to 54 excess deaths per 1000 patients if stage distribution at diagnosis were taken into account and would further decrease to 36 excess deaths per 1000 patients if the 2-year, stage-specific relative survival were the same in England as in the United States.
“The US health system — and to a degree, our culture — is framed around how to best facilitate access to treatment even if the treatment may not necessarily be helpful,” Gross observed.
“But erring on the side of facilitating access can also ensure access to beneficial therapies,” he added.
As Gross noted, stage distribution will be particularly important to track in the future as lung cancer screening is being introduced in both countries; screening will increase probably diagnosis at an earlier stage of disease.
Gross receives research funding from 21st Century Oncology LLC and has also received research funding from the National Comprehensive Cancer Network–Pfizer and from Johnson & Johnson.
J Thorac Oncol. Published online May 1, 2018. Abstract
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