Perceptions of prognosis, treatment, and treatment impact on prognosis in non-small cell lung cancer

Factors Influencing Physician Prognosis: A Scoping Review

Introduction. Prognosis is an essential component of informed consent for medical decision making. Research shows that physicians display discrepancies in their prognostication, leading to variable, inaccurate, optimistic, or pessimistic prognosis. Factors driving these discrepancies and the supporting evidence have not been reviewed systematically. Methods. We undertook a scoping review to explore the literature on the factors leading to discrepancies in medical prognosis. We searched Medline (Ovid) and Embase (Ovid) databases for peer-reviewed articles from 1970 to 2017. We included articles that discussed prognosis variation or discrepancy and where factors influencing prognosis were evaluated. We extracted data outlining the participants, methodology, and prognosis discrepancy information and measured factors influencing prognosis. Results. Of 4,723 articles, 73 were included in the final analysis. There was significant variability in research methodologies. Most articles showed that physicians were pessimistic regarding patient outcomes, particularly in early trainees and acute care specialties. Accuracy rates were similar across all time periods. Factors influencing prognosis were clustered in 4 categories: patient-related factors (such as age, gender, race, diagnosis), physician-related factors (such as age, race, gender, specialty, training and experience, attitudes and values), clinical situation-related factors (such as physician-patient relationship, patient location, and clinical context), and environmental-related factors (such as country or hospital size). Discussion. Obtaining accurate prognostic information is one of the highest priorities for seriously ill patients. The literature shows trends toward pessimism, especially in early trainees and acute care specialties. While some factors may prove difficult to change, the physician's personality and psychology influence prognosis accuracy and could be tackled using debiasing strategies. Exposure to long-term patient outcomes and a multidisciplinary practice setting are environmental debiasing strategies that may warrant further research.

Highlights

Literature on discrepancies in physician's prognostication is heterogeneous and sparse.Literature shows that physicians are mostly pessimistic regarding patient outcomes.Literature shows that a physician's personality and psychology influence prognostic accuracy and could be improved with evidence-based debiasing strategies.Medical specialty strongly influences prognosis, with specialties exposed to acutely ill patients being more pessimistic, whereas specialties following patients longitudinally being more optimistic.Physicians early in their training were more pessimist than more experienced physicians.

Pediatric neurosurgeons' views regarding prenatal surgery for myelomeningocele and the management of hydrocephalus: a national survey

OBJECTIVE

The Management of Myelomeningocele Study (MOMS) compared prenatal with postnatal surgery for myelomeningocele (MMC). The present study sought to determine how MOMS influenced the clinical recommendations of pediatric neurosurgeons, how surgeons' risk tolerance affected their views, how their views compare to those of their colleagues in other specialties, and how their management of hydrocephalus compares to the guidelines used in the MOMS trial.

METHODS

A cross-sectional survey was sent to all 154 pediatric neurosurgeons in the American Society of Pediatric Neurosurgeons. The effect of surgeons' risk tolerance on opinions and counseling of prenatal closure was determined by using ordered logistic regression.

RESULTS

Compared to postnatal closure, 71% of responding pediatric neurosurgeons viewed prenatal closure as either "very favorable" or "somewhat favorable," and 51% reported being more likely to recommend prenatal surgery in light of MOMS. Compared to pediatric surgeons, neonatologists, and maternal-fetal medicine specialists, pediatric neurosurgeons viewed prenatal MMC repair less favorably (p < 0.001). Responders who believed the surgical risks were high were less likely to view prenatal surgery favorably and were also less likely to recommend prenatal surgery (p < 0.001). The management of hydrocephalus was variable, with 60% of responders using endoscopic third ventriculostomy in addition to ventriculoperitoneal shunts.

CONCLUSIONS

The majority of pediatric neurosurgeons have a favorable view of prenatal surgery for MMC following MOMS, although less so than in other specialties. The reported acceptability of surgical risks was strongly predictive of prenatal counseling. Variation in the management of hydrocephalus may impact outcomes following prenatal closure.

New insights into spectral histopathology: infrared-based scoring of tumour aggressiveness of squamous cell lung carcinomas

Spectral histopathology, based on infrared interrogation of tissue sections, proved a promising tool for helping pathologists in characterizing histological structures in a quantitative and automatic manner.

Spectral histopathology, based on infrared interrogation of tissue sections, proved a promising tool for helping pathologists in characterizing histological structures in a quantitative and automatic manner. In cancer diagnosis, the use of chemometric methods permits establishing numerical models able to detect cancer cells and to characterize their tissular environment. In this study, we focused on exploiting multivariate infrared data to score the tumour aggressiveness in preneoplastic lesions and squamous cell lung carcinomas. These lesions present a wide range of aggressive phenotypes; it is also possible to encounter cases with various degrees of aggressiveness within the same lesion. Implementing an infrared-based approach for a more precise histological determination of the tumour aggressiveness should arouse interest among pathologists with direct benefits for patient care. In this study, the methodology was developed from a set of samples including all degrees of tumour aggressiveness and by constructing a chain of data processing steps for an automated analysis of tissues currently manipulated in routine histopathology.

Perception of prognosis of cancer patients by non-oncologists

BACKGROUND

Data are lacking regarding the perception of cancer patients' prognosis by physicians who are not oncologists.

METHODS

This was a multicenter survey of seven university-affiliated hospitals, assessing physicians' perception of the median survival of patients with seven advanced malignancies. The study cohort included physicians from all 73 internal medicine, surgery, emergency medicine and critical care departments in the participating hospitals. Family practitioners were contacted through email. Physicians' specialty, age, professional status and hospital type (secondary vs tertiary) were noted. The primary end-point was defined as the percentage of answers with a pessimistic error of more than a year in perception of prognosis as compared with current literature. The secondary end-point was defined as any pessimistic answer.

RESULTS

Four hundred and eighty-eight physicians filled the questionnaire, including 429 hospital physicians and 59 family practitioners. Perception of prognosis was pessimistic when compared with current literature, with 37% and 59% of the answers meeting the primary and the secondary end-points, respectively. Younger age, resident status and work at a secondary hospital were associated with pessimistic perception (P<.001 for all variables). Pessimistic outlook was similar for all specialties and for most malignancies, including those with considerable cure rates such as Hodgkin's lymphoma and germ cell tumour.

CONCLUSION

Non-oncologists are considerably over pessimistic regarding their perception of the cancer patients' prognosis. A pessimistic perception of prognosis might cause undertreatment and therefore affect both patients' quality of life and their actual survival. Education regarding cancer therapy and its benefits should be emphasised for non-oncologists involved in cancer patient care.

Variations in Oncologist Recommendations for Chemotherapy for Stage IV Lung Cancer: What Is the Role of Performance Status?

PURPOSE

Chemotherapy prolongs survival in patients with advanced non-small-cell lung cancer. However, few studies have included patients with poor performance status. This study examined rates of oncologists' recommendations for chemotherapy by patient performance status and symptoms and how physician characteristics influence chemotherapy recommendations.

METHODS

We surveyed medical oncologists involved in the care of a population-based cohort of patients with lung cancer from the CanCORS (Cancer Care Outcomes Research and Surveillance) study. Physicians were queried about their likelihood to recommend chemotherapy to patients with stage IV lung cancer with varying performance status (Eastern Cooperative Oncology Group performance status 0 [good] v 3 [poor]) and presence or absence of tumor-related pain. Repeated measures logistic regression was used to estimate the independent associations of patients' performance status and symptoms and physicians' demographic and practice characteristics with chemotherapy recommendations.

RESULTS

Nearly all physicians (adjusted rate, 97% to 99%) recommended chemotherapy for patients with good performance status, and approximately half (adjusted rate, 38% to 53%) recommended chemotherapy for patients with poor performance status (P < .001). Compared with patient factors, physician and practice characteristics were less strongly associated with chemotherapy recommendations in adjusted analyses.

CONCLUSION

Strong consensus among oncologists exists for chemotherapy in patients with advanced non-small-cell lung cancer and good performance status. However, the relatively high rate of chemotherapy recommendations for patients with poor performance status despite the unfavorable risk-benefit profile highlights the need for ongoing work to define high-value care in oncology and to implement and evaluate strategies to align incentives for such care.

Nephrologists' likelihood of referring patients for kidney transplant based on hypothetical patient scenarios

Background

There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral.

Methods

A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologists were asked whether they would recommend transplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant.

Results

Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being ‘>10 years from fellowship’ was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary disease were associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant.

Conclusions

The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.

Variations in Receipt of Curative-Intent Surgery for Early-Stage Non-Small Cell Lung Cancer (NSCLC) by State

BACKGROUND

Previous studies reported racial and socioeconomic disparities in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) in the United States. We examined variation in receipt of surgery and whether the racial disparity varies by state.

METHODS

Patients in whom stage I or II NSCLC was diagnosed from 2007 to 2011 were identified from 38 state and the District of Columbia population-based cancer registries compiled by the North American Association of Central Cancer Registries. Percentage of patients receiving curative-intent surgery was calculated for each registry. Adjusted risk ratios were generated by using modified Poisson regression to control for sociodemographic (e.g., age, sex, race, insurance) and clinical (e.g., grade, stage) factors. Non-Hispanic (NH) whites and Massachusetts were used as references for comparisons because they had the lowest uninsured rates.

RESULTS

In all registries combined, 66.4% of patients with early-stage NSCLC (73,475 of 110,711) received curative-intent surgery. Receipt of curative-intent surgery for early-stage NSCLC varied substantially by state, ranging from 52.2% to 56.1% in Wyoming, Louisiana, and New Mexico to 75.2% to 77.2% in Massachusetts, New Jersey, and Utah. In a multivariable analysis, the likelihood of receiving curative-intent surgery was significantly lower in all but nine states/registries compared with Massachusetts, ranging from 7% lower in California to 25% lower in Wyoming. Receipt of curative-intent surgery for early-stage NSCLC was lower for NH blacks than for NH whites in every state, although statistically significant in Florida and Texas.

CONCLUSIONS

Receipt of curative-intent surgery for early-stage NSCLC varies substantially across states in the United States, with northeastern states generally showing the highest rates. Further, receipt of treatment appeared to be lower in NH blacks than in NH whites in every state, although statistically significant in Florida and Texas.

Association between patient-provider communication and lung cancer stigma

PURPOSE

The majority (95 %) of lung cancer patients report stigma, with 48 % of lung cancer patients specifically reporting feeling stigmatized by their medical providers. Typically associated with the causal link to smoking and the historically poor prognosis, lung cancer stigma can be seen as a risk factor for poor psychosocial and medical outcomes in the context of lung cancer diagnosis and treatment. Thus, modifiable targets for lung cancer stigma-reducing interventions are needed. The present study sought to test the hypothesis that good patient-provider communication is associated with lower levels of lung cancer stigma.

METHODS

Lung cancer patients (n = 231) across varying stages of disease participated in a cross-sectional, multisite study designed to understand lung cancer stigma. Patients completed several survey measures, including demographic and clinical characteristics, a measure of patient-provider communication (Consumer Assessment of Healthcare Providers and Systems Program or CAHPS), and a measure of lung cancer stigma (Cataldo Lung Cancer Stigma Scale).

RESULTS

As hypothesized, results indicated that good patient-provider communication was associated with lower levels of lung cancer stigma (r = -0.18, p < 0.05). These results remained significant, even when controlling for relevant demographic and clinical characteristics (Stan. β = -0.15, p < 0.05).

CONCLUSIONS

Results indicate that good patient-provider communication is associated with lower levels of lung cancer stigma, suggesting that improving patient-provider communication may be a good intervention target for reducing lung cancer stigma.

Clinician perceptions of care difficulty, quality of life, and symptom reports for lung cancer patients: an analysis from the Symptom Outcomes and Practice patterns (SOAPP) study

INTRODUCTION

Despite recent therapeutic advances, lung cancer is a difficult disease to manage. This study assessed clinicians' perceptions of care difficulty, quality of life (QOL), and symptom reports for their lung cancer patients compared with their patients with breast, prostate, and colon cancer.

METHODS

This report focused on secondary analyses from the Eastern Cooperative Oncology Group (ECOG) Symptom Outcomes and Practice Patterns (SOAPP) study (E2Z02); outcome measures included clinician ratings of 3106 solid tumor patients. Univariate analyses focused on patterns of disease-specific perceptions; multivariable analyses examined whether disease-specific differences persisted after covariate inclusion.

RESULTS

In univariate comparisons, clinicians rated lung cancer patients as more difficult to treat than other solid tumor patients, with poorer QOL and higher symptom reports. After covariates were adjusted, the odds of clinicians perceiving lower QOL for their lung cancer patients were 3.6 times larger than for patients with other solid tumors (odds ratio = 3.6 [95% confidence interval, 2.0-6.6]; p < 0.0001). In addition, the odds of clinicians perceiving weight difficulties for their lung cancer patients were 3.2 times larger (odds ratio = 3.2 [95% confidence interval, 1.7-6.0]; p = 0.0004). No other outcome showed significant differences between lung versus other cancers in multivariable models.

CONCLUSION

Clinicians were more pessimistic about the well-being of their lung cancer patients compared with patients with other solid tumors. Differences remained for clinician perceptions of patient QOL and weight difficulty, even after controlling for such variables as stage, performance status, and patient-reported outcomes. These continuing disparities suggest possible perception bias. More research is needed to confirm this disparity and explore the underpinnings.

Lung cancer chemotherapy decisions in older patients: the role of patient preference and interactions with physicians

PURPOSE

Lung cancer chemotherapy decisions in patients ≥ 70 years old are complex because of toxicity, comorbidity and the limited data on patient preferences. We examined the relationships between preferences and chemotherapy use in this group of patients.

METHODS AND PATIENTS

We used a questionnaire describing four hypothetical lung cancer treatment options. Eighty-three elderly (≥ 70 years old) lung cancer patients were informed about their diagnosis and therapeutic choices and then asked to choose one of the four options. Patients had previously been included in a prospective study to explore geriatric evaluation in an oncology unit and all had given written informed consent.

RESULTS

Older patients (n=83) diagnosed with lung cancer (non-small- and small-cell lung cancer) from January 2006 to February 2008 were recruited from a single centre. The mean patient age was 77 years (range: 70-91). Eighty-one patients (97.6%) were men. Non-small-cell lung cancer (NSCLC) was the diagnosis in 63 patients (76%). Most patients selected active treatment (38.6% most survival benefit, 18% less survival benefit) and 31.3% selected no active treatment. Elderly lung cancer patients were significantly more likely to accept aggressive treatments despite high reported toxicities. Although most of the patients were symptomatic at diagnosis, the "symptom relief" option was chosen less frequently than the options that could prolong survival. Factors significantly related to patients' attitude toward chemotherapy were age (p<0.001), frailty (p=0.0039), depression and poor performance status (PS).

CONCLUSION

Elderly lung cancer patients want to be involved in the decision-making process. Survival was the main treatment objective for more than half of the patients in this study. We have not found other published studies about elderly lung cancer patients' decisions about chemotherapy.

Prevalence of cancer visits by physician specialty, 1997-2006

Understanding the prevalence of cancer-related visits by physician specialty may help target educational and quality improvement initiatives. Using the 1997-2006 National Ambulatory Medical Care Survey, adult ambulatory visits (N = 161,278) were classified by cancer diagnosis and patients' characteristics and compared with physician specialty. The prevalence of cancer visits within each specialty varied from 0% to 62%. Aside from hematology/oncology (hem/onc) specialties, nine surgical specialties and four medical specialties had more than 1% cancer visits. Cancer patients with private insurance or Medicaid coverage were less likely to see hem/onc specialists compared to Medicare patients. Whereas hem/onc specialists primarily see cancer patients, general surgeons and primary care physicians provide a large amount of cancer services, particularly to underinsured patients. Thus, when trying to contact cancer patients or their physicians, health administrators, researchers, and practitioners should consider targeting general surgeons and primary care physicians in addition to hem/onc specialists.

Beliefs among Physicians in the Diagnostic and Therapeutic Approach to Non-small Cell Lung Cancer

PURPOSE

The American College of Chest Physicians (ACCP) has established evidence-based guidelines for the evaluation and treatment of patients with lung cancer. Physicians' beliefs and practice patterns may differ significantly from established guidelines. We conducted a survey to assess and compare physician beliefs against the evidence-based guidelines.

METHODS

A survey was sent by electronic mail (e-mail) in March 2006 to 2100 randomly selected physicians who were members of the ACCP practicing in the United States, followed by two reminder e-mails.

RESULTS

Three hundred forty-seven surveys were completed and evaluable. The majority (84%) of the respondents reported having read, consulted, or used the guidelines to set practice policies, and 75% found the guidelines helpful. The respondents' practice beliefs were in agreement with the guidelines on the evaluation of operable patients with enlarged mediastinal lymph nodes, the role of chemotherapy in the treatment of stage III disease, and the evaluation of a solitary pulmonary nodule. Nevertheless, a significant percentage of respondents' practice beliefs differed from the guidelines on issues such as screening for lung cancer, the survival benefit of chemotherapy in stage IV disease, and postoperative radiation therapy. Only a minority of respondents believed that chemotherapy improved quality of life in stage IV disease. The survey results indicate that there has been acceptance of the adjuvant chemotherapy and increasing integration of positron emission tomography in the evaluation of a solitary pulmonary nodule and in staging the mediastinum.

CONCLUSIONS

The majority of physicians found the evidence-based guidelines beneficial; nevertheless, practice beliefs differ from the guidelines in select areas.

Patient attitudes towards chemotherapy as assessed by patient versus physician: a prospective observational study in advanced non-small cell lung cancer

BACKGROUND

In the treatment of advanced cancer, a physician's ability to accurately identify a patient's attitude towards treatment is critical. This paper describes the extent of any differences observed between patient attitudes towards chemotherapy for advanced non-small cell lung cancer (NSCLC) as assessed by patients themselves versus their physicians.

PATIENTS AND METHODS

Patients with stage IIIB or IV NSCLC who received gemcitabine plus cisplatin or carboplatin were enrolled into this prospective observational study. Patients and their physicians completed questionnaires containing descriptions of seven patient-specific attitudes. A pre-defined algorithm was used to categorize patients into one of the three 'need' categories based on the questionnaire responses: (A) "maximum extension of survival with acceptance of high toxicity", (B) "maximum extension of survival only if coupled with normal life style", and (C) "relief of symptoms". Each patient was categorized based on his own response, as well as his physician's response.

RESULTS

A total of 1895 patients were enrolled from 19 countries across 3 continents. Data from 1884 patients were analysed. Based on patient versus physician responses, respectively, the distribution of patients was 60% versus 39% in need category A, 26% versus 33% in B, and 14% versus 29% in C. Patient self-assessed versus physician-assessed need category identification was aligned for 891 patients (47.3%): 541 (29%) in A, 218 (12%) in B, 132 (7%) in C. While there was slight agreement between the identification of 'need' categories by physicians and patients (kappa=0.18, 95% CI: 0.15-0.21), physicians also tended to place patients further down the scale (towards C) than patients placed themselves (P<0.001).

CONCLUSIONS

Patients have varying needs from cancer chemotherapy and it may not always be correctly identified by the treating physician. Physicians may underestimate patient's desire for extended survival compared with symptom relief.

Differences of Opinion

STUDY OBJECTIVES

To quantify clinician knowledge and bias regarding the role of chemotherapy for stage IV non-small cell lung cancer (NSCLC).

DESIGN, SETTING, AND PARTICIPANTS

A 16-question, multiple-choice questionnaire was sent to all Australian general internists, pulmonary and palliative care physicians, medical and radiation oncologists, and thoracic surgeons to assess beliefs concerning the role of chemotherapy in metastatic NSCLC. An overall assessment of "pessimism" and "optimism" regarding the role of chemotherapy in metastatic NSCLC was made, and knowledge of specific outcome measures was evaluated.

MEASUREMENTS AND RESULTS

A total of 1,325 questionnaires were mailed, with 679 replies (51%) received and 544 replies (41%) assessable. Overall, 60% of respondents were deemed to have good knowledge. There was a wide variation in knowledge between specialist groups (p < 0.0001), with more medical oncologists (76%) but fewer thoracic surgeons (35%) and general internists (50%) with good knowledge. Fewer medical oncologists (6%) were classified as pessimistic compared with palliative care physicians (31%), radiation oncologists (28%), or pulmonary physicians (22%). Sixty-eight percent of respondents agreed that most patients receiving chemotherapy have symptomatic improvement. More medical oncologists (77%) and pulmonary physicians (73%), but fewer general internists (55%) and palliative care physicians (57%) agreed with this. Medical oncologists were far more likely to agree that chemotherapy was of benefit in patients aged > or = 70 years compared with any of the other specialist groups.

CONCLUSIONS

There were significant differences regarding the perceived role of chemotherapy in metastatic disease between the various specialty groups involved in the treatment of NSCLC. Many clinicians had a poor understanding of contemporary data regarding the use of chemotherapy in metastatic NSCLC. This study raises substantial issues regarding the beliefs of clinicians treating NSCLC and emphasizes the importance of multidisciplinary assessment.

Histology-related variation in the treatment and survival of patients with lung carcinoma in Canada

OBJECTIVES

The aim of the study was to examine histologic differences in lung cancer treatment and survival, and to define recent survival trends in Ottawa, Canada.

METHODS

From 1994 to 2000, 3,237 patients with invasive lung cancer were registered at the Ottawa Regional Cancer Centre (ORCC) and were followed up to 31 December 2001. Five-year relative survival rates (RSRs) and relative excess risks (RERs) of dying were calculated by stage and dominant initial treatment modalities for major cellular histologies using a relative survival model.

RESULTS

The overall 5-year survival rate was 14%, and female patients had significantly better survival. Patients with stage I and II non-small cell lung cancer (NSCLC) who were treated by surgery alone were more likely to survive (5-year RSRs were 72 and 48%, respectively) than those who received other treatments. Patients with stage III NSCLC had a 5-year survival rate of 9% after chemotherapy plus radiotherapy, whereas stage IV patients who received only chemotherapy had better survival for up to 2 years than patients with other treatments. In cases of limited-stage small cell lung cancer (SCLC), survival was better for patients who received chemotherapy plus radiotherapy than for those who received only chemotherapy.

CONCLUSIONS

The relatively superior survival of surgical patients with stage I NSCLC implies that a considerable number of patients have the potential to be treated successfully. The overall poor survival of lung cancer patients suggests a need for more national public health emphasis on lung cancer prevention, improved screening and early diagnosis, and better treatment.

Surgery for early stage non-small cell lung cancer

Lung cancer accounts for 28.2% of all cancer-related deaths in the United States. Most patients present with advanced-stage disease, with only 15% having disease confined to the lung. Surgical resection is the optimal treatment for Stage I and II non-small cell lung cancer. Pre-resection staging includes various radiographic modalities, including PET scan and mediastinoscopy. Survival and local recurrence statistics favor full anatomic lobar resection over sublobar resection, although cases must be judged individually. Lobectomy via thoracoscopic approach appears to have equivalent outcome as lobectomy via thoracotomy. Characteristics of the counseling physician and the hospital volume at which the surgery is performed can also influence outcome. After surgical resection, stage IA patients have about 70% 5-year survival, but this falls below 50% for stage IIB patients. Methods that identify early-stage lung cancer patients at greatest risk for recurrence are needed to identify patients who may benefit from additional therapies.

Impact of referral patterns on the use of chemotherapy for lung cancer

PURPOSE

To determine the extent to which unexplained variation in the use of chemotherapy for advanced lung cancer is due to access to oncologists' services as opposed to treatment decisions made after seeing an oncologist.

METHODS

We performed a retrospective cohort study of 12,015 patients over age 65 diagnosed with metastatic lung cancer between 1991 and 1996 while living in one of 11 regions monitored by a Survival, Epidemiology, and End Results (SEER) tumor registry. Assessment by an oncologist and subsequent treatment with chemotherapy were determined by examining linked Medicare claims.

RESULTS

Of patients who did not receive chemotherapy, 36% were never assessed by a physician who provides chemotherapy. Patients living in certain areas, those diagnosed in more recent years, and those who received care in a teaching hospital were all more likely to see a cancer specialist. These factors were unrelated to subsequent treatment decisions, however. Conversely, age and comorbidity did not have a significant effect on whether a patient was seen by an oncologist, but they were associated with the likelihood of subsequently receiving chemotherapy. Black race, probably acting as a proxy for lower socioeconomic status, was associated with both a diminished likelihood of seeing a cancer specialist and subsequently receiving chemotherapy.

CONCLUSION

Nonmedical factors are important determinants of whether a lung cancer patient is seen by a physician who provides chemotherapy. After seeing such a physician, treatment decisions seem to be mostly explained by appropriate medical factors. Racial and socioeconomic disparities still exist at both steps, however. As therapeutic options expand, referring physicians must ensure that biases and barriers to care do not deprive patients of the opportunity to consider all of their treatment options.

Beliefs among pulmonologists and thoracic surgeons in the therapeutic approach to non-small cell lung cancer

STUDY OBJECTIVES

The physicians who initially evaluate patients with non-small cell lung cancer (NSCLC) strongly impact the course of therapy. Their beliefs in treatment and prognosis may contribute to practices of variable quality and appropriateness. We sought to better describe beliefs among pulmonologists and thoracic surgeons who were selected for guiding early therapy and referrals in patients with NSCLC.

DESIGN

Mail questionnaire focusing on survival estimates, treatment perceptions, and referral patterns.

PARTICIPANTS

Twelve hundred pulmonologists and 800 thoracic surgeons who were clinically active members of the American College of Chest Physicians.

MEASUREMENTS AND RESULTS

Response rates of 50% for pulmonologists and 52% for thoracic surgeons were obtained after two mailings. Five-year survival estimates for patients with resected stage I NSCLC revealed that 30% of respondents overestimated survival rates and 18% underestimated survival rates. The underestimation of survival rate was found among more respondents who are practicing pulmonology than thoracic surgery (22% vs 10% [corrected], respectively), who were trained before 1980 than after 1980 (29% vs 10% [corrected], respectively), and who were seeing < 10 lung cancer patients annually than those who were seeing > 25 (31% vs 0.14%, respectively). Beliefs in the survival benefit of adjuvant chemotherapy or of radiation in stage I-IIIA disease divided respondents within both specialties. Chemotherapy plus radiation vs radiation alone in unresectable stage IIIA-B NSCLC was viewed as benefiting survival less often by physicians seeing < 10 lung cancer patients annually rather than > 25 (57% vs 77% [corrected], respectively) and by physicians underestimating rather than correctly estimating survival in early-stage disease (58% vs 72% [corrected], respectively). Chemotherapy was believed to confer survival benefits in patients with stage IV disease by one third of respondents.

CONCLUSIONS

Certain physician characteristics, particularly the length of time since training and NSCLC patient volume, are associated with beliefs not conclusively supported in the medical literature or with opinions inconsistent within and between specialties.

Patterns of practice survey for nonsmall cell lung carcinoma in the U.S

BACKGROUND

Nonsmall cell lung carcinoma comprises approximately 75% of all lung carcinoma cases in the U.S. Newly evolving strategies have created considerable controversy regarding the optimal treatment for patients diagnosed with this disease.

METHODS

A 17-item survey was designed to collect demographic data and information regarding practice patterns for nonsmall cell lung carcinoma, including patient assessment, treatment approaches, and roles of chemotherapy and radiotherapy. Surveys were mailed in the summer of 1997 to approximately 9200 oncologists of all types throughout the U.S. Practice settings included private office, private hospital, academic, university-affiliated office, government, and Veterans Administration institutions.

RESULTS

Approximately 10% of the oncologists responded (n = 979), including 499 medical oncologists (51%), 464 radiation oncologists (47%), and 16 others (2%). For the adjuvant treatment of surgically resected N1-2 disease, combined modality treatment was preferred over radiation therapy alone by medical oncologists (48% vs. 16%; P<0.001) and radiation therapy alone was preferred over combined modality treatment by radiation oncologists (55% vs. 38%; P<0.001). The combination of paclitaxel and carboplatin was the preferred first-line regimen for all stages of nonsmall cell lung carcinoma by the majority of medical oncologists (55%), whereas the majority of radiation oncologists (58%) chose the combination of etoposide and platinum. With regard to the optimal combined modality approach, respondents were divided evenly between concurrent chemoradiotherapy (34%) and sequential chemoradiotherapy (31%). Overall, respondents reported basing treatment decisions largely on published literature (55%) compared with personal experience (19%), seminars and colleagues (16%), and clinical trial availability (10%) (P<0.001).

CONCLUSIONS

This survey confirms many differences in practice patterns among medical oncologists and radiation oncologists in the treatment of patients with nonsmall cell lung carcinoma and suggests the need for the multidisciplinary management of this entity. In addition, the current study demonstrates that reliance on the medical literature as a basis for treatment steadily declines the longer the physician has been in practice.

The role of new agents in advanced non-small-cell lung carcinoma

Over the past 5 to 7 years, new and promising systemic agents have entered the therapeutic armamentarium in the treatment of advanced non-small-cell lung cancer. In particular, the taxanes, irinotecan, vinorelbine, and gemcitabine, have each been shown to perturb the natural history of this disease. In combination with cisplatin, these agents have yielded improvements in response rates and in survival, compared with either cisplatin alone or with older platinum combinations, with consistent 1-year survival rates of 30% to 40% or more and response rates exceeding 25%. Other factors may also be responsible for improved survival rates, including patient selection, improved supportive care, and more extensive screening procedures, such as CT and positron emission tomography, which have resulted in stage migration. Future directions will focus on the role of nonplatinum combinations, particularly in the elderly and in patients with compromised performance status; salvage therapy in patients with intact performance status; quality of life and quality adjusted survival; and the role of new biologic agents, which alter the tumor milieu and may be readily integrated into standard cytotoxic regimens. Except for unfit or unwilling patients, there is no room for therapeutic nihilism.

Treatment Strategies for Metastatic Non–Small-Cell Lung Cancer

This review article provides evidence to support the use of chemotherapy for non small-cell lung cancer (NSCLC). Chemotherapy plays an important role in the management of advanced NSCLC. Chemotherapy offers symptom palliation, modest but real survival benefits and improves quality of life. The survival benefits achieved with newer drug regimens offer chemotherapy as a strategy for the treatment of NSCLC patients with good performance, no medical or psychological contraindications.