Temporal trends and predictors of perioperative chemotherapy use in elderly patients with resected nonsmall cell lung cancer

Institutional factors associated with adherence to quality measures for stage I and II non-small cell lung cancer

OBJECTIVE

Although previous studies have identified variation in quality lung cancer care, existing quality metrics may not fully capture the complexity of cancer care. The Thoracic Surgery Outcomes Research Network recently developed quality measures to address this. We evaluated baseline adherence to these measures and identified factors associated with adherence.

METHODS

Patients with pathologic stage I and II non-small cell lung cancer from 2010 to 2015 were identified in the National Cancer Database. Patient-level and hospital-level adherence to 7 quality measures was calculated. Goal hospital adherence threshold was 85%. Factors influencing adherence were identified using multilevel logistic regression.

RESULTS

We identified 253,182 patients from 1324 hospitals. Lymph node sampling was performed in 91% of patients nationally, but only 76% of hospitals met the 85% adherence mark. Similarly, 89% of T1b (seventh edition staging) tumors had anatomic resection, with 69% hospital-level adherence. Sixty-nine percent of pathologic stage II patients were recommended chemotherapy, with only 23% hospitals adherent. Eighty-three percent of patients had biopsy before primary radiation, with 64% hospitals adherent. Higher volume and academic institutions were associated with nonadherence to adjuvant chemotherapy and radiation therapy measures. Conversely, lower volume and nonacademic institutions were associated with inadequate nodal sampling and nonanatomic resection.

CONCLUSIONS

Significant gaps continue to exist in the delivery of quality care to patients with early-stage lung cancer. High-volume academic hospitals had higher adherence for surgical care measures, but lower rates for coordination of care measures. This requires further investigation, but suggests targets for quality improvement may vary by institution type.

Improved survival associated with neoadjuvant chemoradiation in patients with clinical stage IIIA(N2) non-small-cell lung cancer

INTRODUCTION

Optimal management of clinical stage IIIA-N2 non-small-cell lung cancer (NSCLC) is controversial. This study examines whether neoadjuvant chemoradiation plus surgery improves survival rates when compared with other recommended treatment strategies.

METHODS

Adult patients from the National Cancer Database, with clinical stage IIIA-N2 disease definitively treated between 1998 and 2004 at American College of Surgeons Commission on Cancer accredited facilities, were included in the study. Treatment was defined as neoadjuvant chemoradiation plus either lobectomy (NeoCRT+L) or pneumonectomy (NeoCRT+P), lobectomy plus adjuvant therapy (L+AT), pneumonectomy plus adjuvant therapy (P+AT), and concurrent chemoradiation (CRT). Median follow-up and overall survival (OS) were defined from date of diagnosis to last contact. Five-year OS was estimated using Kaplan-Meier methods. Cox proportional hazard regression was used to estimate hazard ratios and 95% confidence intervals (CIs), adjusting for sociodemographic, clinical, and facility characteristics.

RESULTS

Median follow-up was 11.8 months for 11,242 eligible patients. Five-year OS was 33.5%, 20.7%, 20.3%, 13.35%, and 10.9% for NeoCRT+L, NeoCRT+P, L+AT, P+AT, and CRT, respectively (p < 0.0001). On multivariable analysis, the estimated hazard ratio was 0.51 (CI: 0.45-0.58) for NeoCRT+L; 0.77 (0.63-0.95) for NeoCRT+P; 0.66 (0.59-0.75) for L+AT; 0.69 (0.54-0.88) for P+AT; and 1.0 (reference) for the CRT group. Comorbidity did not attenuate the relationship between treatment and survival.

CONCLUSION

This large study demonstrates that patients with clinical stage IIIA-N2 NSCLC, who underwent neoadjuvant chemoradiation followed by lobectomy, were associated with an improved survival.

Identifying specific chemotherapeutic agents in Medicare data: a validation study

BACKGROUND

Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment.

METHODS

We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents.

RESULTS

Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%).

CONCLUSIONS

Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

Identifying specific chemotherapeutic agents in Medicare data: a validation study

BACKGROUND

Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment.

METHODS

We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents.

RESULTS

Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%).

CONCLUSIONS

Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

Incidence and predictors of venous thromboembolism (VTE) among ambulatory patients with lung cancer

BACKGROUND

The incidence and economic impact of lung cancer-associated venous thromboembolic (VTE) events in a contemporary ambulatory setting is unknown.

PATIENTS AND METHODS

We conducted a retrospective cohort analysis utilizing the IMS Patient-Centric database of US healthcare claims and recorded VTE events occurring 3-12 months after chemotherapy initiation.

RESULTS

Lung cancer (n=6732) and control (n=17 284) cohorts had 51% women, with a mean age of 64 years. VTE occurred in 13.9% of the lung cancer cohort (odds ratio [OR], 3.15; 95% confidence interval [CI] 2.55, 3.89), and 1.4% of the control cohort (P<0.0001). Charlson Comorbidity Index ≥ 5 (CCI; OR, 2.56; 95% CI 1.02, 6.39; P=0.045), the use of erythropoiesis-stimulating agents (ESAs; OR, 1.63; 95% CI 1.40, 1.89; P<0.0001), and congestive heart failure (CHF; OR, 1.29; 95% CI 1.01, 1.66; P=0.045) were associated with VTE. Bleeding occurred in 22.1% of the lung cancer cohort and 7.0% of the control cohort (P<0.0001). Among lung cancer patients the average total healthcare payment was $84,187 in patients with VTE compared to $56,818 in patients without VTE (P<0.0001).

CONCLUSIONS

VTE is common among lung cancer patients receiving chemotherapy and is associated with increased healthcare utilization.

Adjuvant chemotherapy for non-small-cell lung cancer in the elderly: a population-based study in Ontario, Canada

PURPOSE

Non-small-cell lung cancer (NSCLC) is predominantly a disease of the elderly. Retrospective analyses of the National Cancer Institute of Canada Clinical Trials Group JBR.10 trial and the Lung Adjuvant Cisplatin Evaluation (LACE) meta-analysis suggest that the elderly benefit from adjuvant chemotherapy. However, the elderly were under-represented in these studies, raising concerns regarding the reproducibility of the study results in clinical practice.

PATIENTS AND METHODS

By using the Ontario Cancer Registry, we identified 6,304 patients with NSCLC who were treated with surgical resection from 2001 to 2006. Registry data were linked to electronic treatment records. Uptake of chemotherapy was compared across age groups: younger than 70, 70 to 74, 75 to 79, and ≥ 80 years. As a proxy of survival benefit from chemotherapy, we compared survival of patients diagnosed from 2004 to 2006 with survival of those diagnosed from 2001 to 2003. Hospitalization rates within 6 to 24 weeks of surgery served as a proxy of severe chemotherapy-related toxicity.

RESULTS

In all, 2,763 (43.8%) of 6,304 surgical patients were elderly (age ≥ 70 years). Uptake of adjuvant chemotherapy in the elderly increased from 3.3% (2001 to 2003) to 16.2% (2004 to 2006). Among evaluable elderly patients, 70% received cisplatin and 28% received carboplatin-based regimens. Requirements for dose adjustments or drug substitutions were similar across age groups. Hospitalization rates within 6 to 24 weeks of surgery were similar across age groups (28.0% for patients age < 70 years; 27.8% for patients age ≥ 70 years; P = .54). Four-year survival of elderly patients increased significantly (47.1% for patients diagnosed from 2001 to 2003; 49.9% for patients diagnosed from 2004 to 2006; P = .01). Survival improved in all subgroups except patients age ≥ 80 years.

CONCLUSION

Uptake of adjuvant chemotherapy for NSCLC increased in patients age 70 years or older following reporting of pivotal adjuvant chemotherapy trials, but it remained below that for patients younger than age 70 years. Adoption of adjuvant chemotherapy appears to be associated with significant survival benefit in the elderly (age ≥ 70 years), with tolerability apparently similar to that of patients who are younger than age 70 years.

Effect of urologists and medical oncologists on treatment of elderly men with Stage IV prostate cancer

OBJECTIVES

To examine, among elderly men with incident advanced prostate cancer (PCa), their treatment, in general, and chemotherapy, in particular, in association with a posturologist medical oncologist/hematologist (PUMOH) visit. The role of specialists in the management of advanced PCa is evolving in response to positive chemotherapy trials of PCa.

METHODS

Linked Surveillance, Epidemiology, and End results and Medicare data included patients with Stage IV PCa diagnosed from 1994 to 2002 who had visited a urologist after the diagnosis and received treatment. The visits and treatment were examined, comparing patients with and without PUMOH visits.

RESULTS

Most (77%) patients received treatment of their PCa and 85% of treated patients had a subsequent visit with a urologist, of whom 91% saw the urologist first (n = 5435). Of these, 43% saw only the urologist, 41% saw a medical oncologist/hematologist, and 32% saw a radiation oncologist. Of the 5435 patients, 16% received chemotherapy and the adjusted odds of chemotherapy receipt were 7.2 times greater (95% confidence interval 6.0-8.7, P < .001) among those with a PUMOH visit. Compared with non-Hispanic whites, black Americans were less likely (adjusted odds ratio 0.53, P < .001) to receive chemotherapy, although the likelihood of a PUMOH visit was similar (adjusted odds ratio 0.86, P = .14) among the groups.

CONCLUSIONS

The results of our study have shown that nearly one quarter of men with Stage IV PCa receive no PCa treatment. Although a PUMOH visit is a significant predictor of chemotherapy receipt, many men with advanced PCa received chemotherapy without a medical oncologist/hematologist visit. Black American and elderly men were less likely to receive chemotherapy for advanced PCa.

Lung cancer treatment costs, including patient responsibility, by disease stage and treatment modality, 1992 to 2003

OBJECTIVES

The objective of this analysis was to estimate costs for lung cancer care and evaluate trends in the share of treatment costs that are the responsibility of Medicare beneficiaries.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1991-2003 for 60,231 patients with lung cancer were used to estimate monthly and patient-liability costs for clinical phases of lung cancer (prediagnosis, staging, initial, continuing, and terminal), stratified by treatment, stage, and non-small- versus small-cell lung cancer. Lung cancer-attributable costs were estimated by subtracting each patient's own prediagnosis costs. Costs were estimated as the sum of Medicare reimbursements (payments from Medicare to the service provider), co-insurance reimbursements, and patient-liability costs (deductibles and "co-payments" that are the patient's responsibility). Costs and patient-liability costs were fit with regression models to compare trends by calendar year, adjusting for age at diagnosis.

RESULTS

The monthly treatment costs for a 72-year-old patient, diagnosed with lung cancer in 2000, in the first 6 months ranged from $2687 (no active treatment) to $9360 (chemo-radiotherapy); costs varied by stage at diagnosis and histologic type. Patient liability represented up to 21.6% of care costs and increased over the period 1992-2003 for most stage and treatment categories, even when care costs decreased or remained unchanged. The greatest monthly patient liability was incurred by chemo-radiotherapy patients, which ranged from $1617 to $2004 per month across cancer stages.

CONCLUSIONS

Costs for lung cancer care are substantial, and Medicare is paying a smaller proportion of the total cost over time.