The number of patients with advanced lung cancer who decide not to undergo treatment is increasing despite better systemic treatments that are more tolerable and that significantly improve overall survival, a new study shows.
Analysis of data from the National Cancer Database reveals that from 1998 to 2012, 21% of patients with primary non–small cell lung cancer (NSCLC) received no treatment, resulting in significantly shorter overall survival (P < .0001) regardless of disease stage, reports a research team led by Elizabeth A. David, MD, of the University of California, Davis, Medical Center in Sacramento.
The proportion of patients with stage IIIA or stage IV disease who received no treatment increased by 0.21% and 0.4%, respectively (P = .003 and P < .0001), during the study period.
The proportion of untreated patients with NSCLC ranges from 7% to 45% depending on stage. However, up to 90% of older, medically inoperable patients do not receive treatment. Standard treatment often includes a combination of radiation therapy, chemotherapy, and/or surgery in certain circumstances, the researchers note.
The findings appear in a report published online January 18 in the Journal of Thoracic Oncology.
The analysis also shows that a high percentage of untreated patients were statistically similar to treated patients in terms of age, sex, race, income, education, tumor size, nodal status, Charlson-Deyo score, and treatment facility type. For this reason, the study should not be "interpreted as yet another article demonstrating a selection bias for treated patients," the researchers suggest.
The analysis shows that in 6144 matched stage IIIA patient pairs treated with chemoradiation vs no treatment, median overall survival was shorter for untreated patients than for treated patients (6.1 months vs 16.5 months).
Similarly, in 19,046 matched stage IV patient pairs treated with chemotherapy vs no treatment, median overall survival was shorter in untreated patients than in those who received therapy (2.1 months vs 9.3 months).
Untreated patients tend to be older, black, uninsured, and more socioeconomically disadvantaged than patients who undergo treatment for NSCLC. This is significant and underscores "the impact of socioeconomic, racial, and other disparities in treatment decisions," the researchers say.
Dramatic Differences in Survival
Among patients with advanced-stage disease, survival outcomes are "superior with treatment, independent of selection bias," they emphasize, noting that the 5-year survival rate for NSCLC remains "a dismal 17.2%" and has largely been unchanged since the 1990s.
"There are many factors that influence the decision not to undergo treatment for NSCLC, including patient and disease characteristics, as well as physician referral patterns and preferences," the researchers say. Physicians should make sure that "patients from disparate populations are evaluated and counseled thoroughly by multidisciplinary teams before choosing to forego treatment for NSCLC."
In an interview, Dr David said that although the number of untreated patients brings overall survival rates down, "this may not be readily apparent to patients or even to clinicians themselves." She added, "This is an area that needs further study."
Many patients who are diagnosed with NSCLC may not be aware of the dramatic differences in survival between treated and untreated patients and believe that cancer treatment is worse than the disease, she told Medscape Medical News.
"For a lot of patients, that isn't true anymore, so treatment options should be fully explored before patients decide not to have any treatment," she said.
It is also important for clinicians "to recognize the stigma that NSCLC still carries despite efforts to fight it and the negative influence that the stigma can have on perception of the disease and treatment," Dr David said.
Physicians need to explore what improved overall survival could mean for individual patients, she suggested. For some patients with stage IIIA disease, for example, the difference between having treatment that gives them 16 more months of life vs having 6 months if they decide against treatment "might be very important."
Similarly, patients with stage IV NSCLC might decide to undergo treatment if they knew it would prolong survival by 9 months compared to 2 months without treatment.
Different patients will respond differently to the option, Dr David pointed out.
A 7-month survival advantage might mean a lot to one patient. Another patient "might prefer a shorter time that doesn't involve trips to the doctor or hospitals," she said. "It's not reasonable to expect that all patients with any kind of cancer are going to want treatment."
There is a need for studies into other barriers to treatment, such as variations in regional treatment, which could influence decision making and lead to improved treatment with targeted interventions, the researchers say.
Calling for "creative solutions," Dr David noted that her group has incorporated telemedicine into their multidisciplinary lung cancer practice, making it possible for rural patients to participate in clinical trials and to receive multimodality therapy. Their practice includes dedicated social workers for cancer patients.
Resources such as these can help some patients overcome barriers to treatment. When patients are not motivated, however, these barriers can be "very difficult to overcome," she said.
This study received funding from the National Center for Advancing Translational Sciences, the National Institutes of Health, and the Department of Surgery Outcomes Research Group. The authors have disclosed relevant financial relationships.
J Thorac Oncol. Published online January 18, 2017. Full text
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