Real-World Treatment Patterns for Lung Neuroendocrine Tumors: A Claims Database Analysis

Theranostics in Lung Neuroendocrine Tumors

In the last 2 decades, there has been a noticeable increase in the incidence of neuroendocrine tumors, in part due to improved understanding of pathology and/or availability of more sensitive and accurate diagnostic tests. While gastrointestinal tract and pancreas are the most common sites of origin, lung neuroendocrine tumors (LNETs) are also frequently reported and need special considerations from diagnostic as well as therapeutic aspects. Radiopharmaceutical therapy (Theranostics) is a novel approach which utilizes a pair of diagnostic and therapeutic agents that share a common target on tumor sites. Precise treatment of the disease with minimum side effects is the principal aim of Theranostics. It's a known fact that somatostatin receptors (SSTR) are abundantly expressed in neuroendocrine tumors. With the advent of highly specific radiopharmaceuticals targeting SSTR receptors for both diagnosis as well as treatment and other targeted therapies, management of LNETs has become less challenging. Still, there exists significant ambiguity in relation to management of LNETs with a scope of novel diagnostic and therapeutic strategies to pitch in. This review focuses on the role of established evidence for Theranostics strategies in the management of LNETs and highlights the potential future role of newer targets which would be of promising value in addressing such rare and complex tumor biology.

Survival and Chemotherapy Response in Metastatic Lung Carcinoids: Insights from the National Cancer Database

BACKGROUND

Metastatic lung carcinoids (MLCs) represent a rare subset of lung cancers with distinct histologic subtypes. Survival outcomes and prognostic factors have not been well-studied in the real-world setting. This study investigates the impact of various treatments, including chemotherapy, hormonal therapy, and no treatment, on the overall survival (OS) of patients with typical and atypical MLC.

METHODS

Patients with MLC between 2010 and 2020 were included from the National Cancer Database based on histologic codes ICD-O-3 8240/3 and 8249/3. Kaplan-Meier curves and multivariate Cox proportional hazard regression were used to compare OS and evaluate prognostic factors.

RESULTS

The median age at diagnosis was 68 and 69 years for atypical and typical MLC, respectively. The 3-year OS for the atypical MLC cohort was 22.11%, and for typical MLC was 41.94% (P < 0.001). In the atypical MLC cohort, chemotherapy showed a nonsignificant benefit in OS (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.73-1.05; P = 0.21), whereas hormonal therapy was associated with significantly improved OS (HR, 0.72; 95% CI, 0.52-0.98; P =0.04). However, in the typical MLC cohort, chemotherapy was associated with adverse OS (HR, 2.15; 95% CI, 1.85-2.49; P < 0.0001), and hormonal treatment showed better, albeit nonsignificant OS (HR, 0.84; 95% CI, 0.67-1.05; P = 0.13).

CONCLUSION

There is a notable difference in survival outcomes between typical and atypical MLC based on the treatment strategies. While hormonal therapy shows improvement in the OS, the effectiveness of chemotherapy varies depending on the histologic subtype. These findings emphasize the necessity for personalized therapeutic approaches based on the specific characteristics of MLC, ultimately contributing to improved patient outcomes in this challenging oncologic group. Further research is warranted to validate and expand upon these observations.

Targeting neuroendocrine tumors with octreotide and lanreotide: Key points for clinical practice from NET specialists

Octreotide and lanreotide are the two somatostatin analogs (SSA) currently available in clinical practice. They have been approved first to control the clinical syndrome (mainly carcinoid syndrome) associated with functioning neuroendocrine tumors (NET) and later for tumor growth control in advanced low/intermediate grade NET. Although evidence regarding their role, especially as antiproliferative therapy, has been increasing over the years some clinical indications remain controversial. Solicited by AIOM (Italian Association of Medical Oncology) a group of clinicians from various specialties, including medical oncology, endocrinology, and gastroenterology, deeply involved in NET for their clinical and research activity, addressed eight open questions, critically reviewing evidence and guidelines and sharing clinical take-home messages. The questions regarded the use of long-acting octreotide and lanreotide in the following settings: functioning and non-functioning NET refractory to label dose, first-line metastatic pulmonary NET, combination with other therapy with an antiproliferative intent, maintenance in NET responding to other therapies, adjuvant treatment, Ki-67-related cut-off, somatostatin receptor imaging, safety, and feasibility. The level of evidence is not absolute for the majority of these clinical contexts, so it is recommended to distinguish routine versus sporadic utilization in very selected cases. Mention of such specific issues by the main European guidelines (ENETS, European Neuroendocrine Tumor Society, and ESMO, European Society for Medical Oncology) was explored and their position reported. However, different clinical decisions on single patients could be made if the case is carefully discussed within a NET-dedicated multidisciplinary team.

Real-World Utilization of Target- and Immunotherapies for Lung Cancer: A Scoping Review of Studies Based on Routinely Collected Electronic Healthcare Data

Routinely collected electronic healthcare data (rcEHD) have a tremendous potential for enriching pre-marketing evidence on target- and immunotherapies used to treat lung cancer (LC). A scoping review was performed to provide a structured overview of available rcEHD-based studies on this topic and to support the execution of future research by facilitating access to pertinent literature both for study design and benchmarking. Eligible studies published between 2016 and 2020 in PubMed and ISI Web of Science were searched. Data source and study characteristics, as well as evidence on drug utilization and survival were extracted. Thirty-two studies were included. Twenty-six studies used North American data, while three used European data only. Thirteen studies linked ≥1 data source types among administrative/claims data, cancer registries and medical/health records. Twenty-nine studies retrieved cancer-related information from medical records/cancer registries and 31 studies retrieved information on drug utilization or survival from medical records or administrative/claim data. Most part of studies concerned non-small-cell-LC patients (29 out of 32) while none focused on small-cell-LC. Study cohorts ranged between 85 to 81,983 patients. Only two studies described first-line utilization of immunotherapies. Results from this review will serve as a starting point for the execution of future rcEHD-based studies on innovative LC pharmacotherapies.

Costs of treatment change following first-line somatostatin analog monotherapy among patients with neuroendocrine tumors

BACKGROUND

This study describes treatment characteristics and healthcare costs prior to and following treatment change from somatostatin analog (SSA) monotherapy among a privately-insured NET patient population in the US.

METHODS

Patients with newly diagnosed NET and treated with SSA monotherapy were retrospectively identified in IBM MarketScan claims between 1/1/2014 and 3/31/2019. NET treatment change was captured ≥30 days after the SSA start date (earliest new treatment = index date). Healthcare costs (reimbursed amount in 2019 dollars) were reported for 1, 3, and 6 months pre- and post-index intervals.

RESULTS

A total of 305 patients were identified (mean age: 58 years; female: 52%; metastatic disease: 49%). Most patients started on octreotide (81%) vs. lanreotide (19%). Common treatment changes included alternate SSA (38%), targeted therapy (30%), or chemotherapy (23%). Total costs increased on average by $13,272 between the month preceding and following treatment change (p < .001), with the highest increase among patients changing to targeted therapy ($19,677, p < .001) vs. an alternate SSA ($10,240, p < .001) or chemotherapy ($4,057, p = .155). The trajectory in mean cost difference using a 1, 3, and 6-month time period followed an increasing trend for patients who changed to targeted therapy (Δ$19,677, Δ$34,856, Δ$58,387) but was flat for patients who changed to the alternate SSA (Δ$10,240, Δ$10,026, Δ$11,727).

CONCLUSIONS

Higher total healthcare costs were observed following treatment change from first-line SSA. Switching to the alternate SSA was associated with a fixed, one-time cost; whereas, switching to targeted therapy was associated with both an initial switching cost and a persistent monthly increase.

Treatment Patterns and Clinical Outcomes in Advanced Lung Neuroendocrine Tumors in Real-World Settings: A Multicenter Retrospective Chart Review Study

BACKGROUND

Using data from four tertiary referral centers in the U.S., we assessed real-world treatment patterns and clinical outcomes of patients with advanced lung neuroendocrine tumors (NETs).

SUBJECTS, MATERIALS, AND METHODS

We performed a retrospective chart review of adult patients with locally advanced/metastatic (typical/atypical) lung NETs treated between July 2011 and December 2014. Index date was histologically confirmed typical/atypical carcinoid tumor diagnosis date. Data included baseline characteristics, treatment patterns, progression, death, and lung NET-related health care resource use from index date through last contact/death. Time to treatment discontinuation and first progression, time from first to second progression, and overall survival (OS) were estimated using Kaplan-Meier analysis.

RESULTS

We identified 83 patients; 19 (23%) had functional NET. First-line treatments included somatostatin analogs (SSAs) alone (56%) or in combination with other therapies (6%), cytotoxic chemotherapy (20%), external beam radiation therapy (EBRT) (9%), liver-directed therapy (LDT) (4%), and everolimus/other (5%). Sixty patients had second-line therapy including SSA alone (18%) or in combination (40%), cytotoxic chemotherapy (17%), everolimus (12%), LDT (7%), EBRT (3%), and other treatments (3%). Median time (months) to first-line discontinuation were as follows: SSAs, 43.3; cytotoxic chemotherapy, 3.6. Overall median time (months) to investigator-assessed progression following treatment initiation was 12.4. Median OS (months) following treatment initiation was 66.4 for all patients and 81.5 for patients receiving SSAs.

CONCLUSION

SSAs, alone and in combination, are common treatments for advanced lung NETs. Patients have additional treatment options and relatively long survival compared with patients with other advanced cancers. Treatment pattern assessment following approval of newer treatments is needed.

IMPLICATIONS FOR PRACTICE

Somatostatin analogs (SSAs), cytotoxic chemotherapy, EBRT, liver-directed therapy, and targeted therapies are common treatments for locally advanced/metastatic (typical/atypical) lung neuroendocrine tumors (NETs). SSAs alone or in combination with other treatment modalities were the most common first- and second-line therapy, followed by cytotoxic chemotherapy. Patients continued treatment with SSAs long-term with median treatment duration of 43 months. Median overall survival was 66 months following initiation of first-line therapy for all patients. Treatment pattern assessment beyond the time period of this study is needed given recent U.S. Food and Drug Administration approvals for additional treatments for lung NETs that will likely be incorporated in the treatment landscape.

Treatment adherence, healthcare resource utilization, and costs in patients with lung neuroendocrine tumors (lung NETs) in the USA

OBJECTIVE

To assess first-line treatment adherence, healthcare resource utilization, and costs in lung NET patients initiating pharmacologic treatments.

METHODS

In two US claims databases, patients aged ≥18 years with ≥1 inpatient or ≥2 outpatient lung NET claims within 12 months were identified. The first claim for pharmacologic treatments (e.g. somatostatin analogs [SSAs], cytotoxic chemotherapy [CC], targeted therapy [TT]) following diagnosis, between July 1, 2009-December 31, 2014, was defined as the index date. A 6-month pre-index period without any NET treatment, and ≥1-year post-index enrollment were required. Proportion of days covered (PDC) was calculated during follow-up. Descriptive statistics, including means, standard deviations, and frequencies/percentages for continuous and categorical data, respectively, were reported.

RESULTS

Of 354 patients with 1-year of follow-up, 252 initiated CC, 89 SSA, 3 TT, and 10 various combinations. Due to sample sizes, the remaining results focus only on CC and SSAs. Mean PDC (SD) was 0.320 (0.176) for CC and 0.673 (0.322) for SSAs; CC users had a mean (SD) of 33.3 (23.8) office visits and 0.79 (1.39) hospitalizations; SSA users had 23.1 (12.4) visits and 0.48 (1.07) hospitalizations. Mean total (SD) annual cost for CC users was $124,383 (135,836) and $98,713 (81,495) for SSA users. Among 163 patients with 2 years of follow-up, the annual mean cost in the second-year was $43,026 lower and $8110 higher than the first-year for CC and SSAs, respectively.

CONCLUSIONS

The majority of patients with lung NETs initiated CC; only about one quarter initiated SSA in the first-line. This descriptive study updates the utilization and costs of pharmacologically-treated lung NETs.