DURHAM, NC—Earlier in the 21st century, only one-quarter of VHA patients with Stage III non-small cell lung cancer (NSCLC) received chemotherapy and radiation within four months of diagnosis and had unresectable disease. In most cases, nearly 60%, patients received concurrent chemoradiation therapy (CCRT), not sequential CRT (SCRT), according to a new study.
The question raised by researchers from Duke University School of Medicine and the Durham, NC, VAMC is whether and how those rates have changed. In an article in BMC Cancer, they reported that CCRT rates among VHA patients with unresectable, Stage III NSCLC incrementally increased from 2013 to 2017. In 2017, only half were receiving CCRT, the study noted.1
“Older patients and those with multiple comorbidities were less likely to receive CCRT and even when controlling for these factors, non-white patients were less likely to receive CCRT,” the authors advised.
The study team had sought to determine the rate of use of CCRT among veterans with unresectable NSCLC, reporting recent CCRT treatment patterns in VHA patients and identifying characteristics associated with receipt of CCRT. VA Cancer Registry System data linked to VA electronic medical records were used to determine rates of of CCRT, SCRT, radiation therapy (RT) only, chemotherapy (CT) only and neither treatment.
Results indicated that, among 4,054 VHA patients who met study criteria, CCRT rates rose slightly from 44% to 50% between 2013 and 2017.
Researchers determined that factors associated with decreased odds of CCRT receipt compared with any other treatment included:
- Increasing age (adjusted odds ratio [aOR] per 10 years = 0.67; 95% CI: 0.60-0.76),
- Charlson-Deyo comorbidity score (aOR = 0.94; 95% CI: 0.91-0.97), and
- White race (aOR = 1.24; 95% CI: 1.004-1.53).
Of special note, they said, was that, in a chart review sample of 200 patients, fewer than half had a documented reason for not receiving CCRT. “Among these, 29% declined treatment, and 71% did not receive CCRT due to ‘not being a candidate’ for reasons related to frailty or lung nodules being too far apart for radiation therapy,” the authors explained.
It remained unclear why older patients and those with multiple comorbidities were less likely to receive CCRT, according to the report, which added that “even when controlling for these factors, non-white patients were less likely to receive CCRT.”
Since the 1990s, randomized controlled trials have found high-level evidence that patients with unresectable Stage III NSCLC have improved overall survival with CCRT vs. RT alone. Treatment guidelines also note, however, that the ability to tolerate CCRT is a factor in choosing that therapy.
“For example, CCRT has a higher rate of grade 3 or 4 esophagitis than SCRT. As a result, frail patients may not be able to tolerate CCRT,” the authors noted.
The study also pointed out that, compared to the general U.S. population, VHA patients tend to be older, have lower levels of income and education and have a higher comorbidity burden. In 2010, 18% of incident veteran cancer cases diagnosed in the VHA were lung cancer, according to the authors, who added, “Many VHA patients are current (16%) or past (61%) smokers, which can impact histology and treatment of NSCLC.”
In good news, researchers wrote, “Our analysis of the 2013–2017 data showed that this proportion increased to 79%, demonstrating that prescribers are following the increasing evidence that CCRT is more efficacious than SCRT.”
They added, “However, among the whole cohort of VHA patients with unresectable stage III NSCLC, less than half (47%) are receiving CCRT.”
The study pointed out that, after excluding those who received no treatment, approximately 55% of veterans in the specific lung cancer cohort received CCRT, in line with the 52% that was recently reported to have received CCRT in a U.S. Medicare population based on 2009 to 2014 data.
“Our results should be interpreted with an understanding of the VHA patient population, which is more likely to smoke currently or formerly compared to the general U.S. population,” the authors explained, adding, “The high rate of smoking may be concerning since studies in stage III NSCLC patients indicate that current smoking is associated with poorer prognosis.”
In this study, 52% of veteran patients had squamous histology compared to 42% reported in the Medicare population cohort. “In our study, neither smoking status nor squamous histology was associated with receipt of CCRT after adjusting for other patient- and facility-level factors,” researchers stated.
Furthermore, they advised that, based on chart review, most of the documented reasons for veterans not receiving CCRT were related to frailty. “This is aligned with a recent survey of U.S. oncologists in which the most reported reason (64%) for not recommending CCRT was that the patient would be unlikely to tolerate due to comorbidities, poor performance status, and/or advanced age. Other reported reasons included patient preference (47%), targetable mutation identified in the patient (40%), ability of the patient to travel consistently to receive treatment (40%), and cost (34%).”
The authors raised questions about why advancing age appeared to be a much stronger negative predictor of treatment receipt than comorbidity at the VHA, despite guidelines emphasizing the importance of assessing comorbidity.
They also expressed concerns about differences in CCRT rates by race, stating, “Future studies should be performed to better understand these potential racial disparities and reasons for non-receipt of CCRT so that effective interventions can be developed to address barriers to NCCN recommended care.”
- Hung A, Lee KM, Lynch JA, Li Y, et. al. Chemoradiation treatment patterns among United States Veteran Health Administration patients with unresectable stage III non-small cell lung cancer. BMC Cancer. 2021 Jul 16;21(1):824. doi: 10.1186/s12885-021-08577-y. PMID: 34271861; PMCID: PMC8285779.