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Gains in Lung Cancer Survival Extend to Low-Income Patients

Notable gains in early-stage non-small cell lung cancer (NSCLC) survival in recent years have extended to one of the most at-risk groups, an analysis of the National Cancer Database (NCDB) revealed.

In patients with a median income below $38,000, the 1-year overall survival (OS) rate improved from 74.2% in 2004-2008 to 82.8% in 2013-2014, while OS at 2 years improved from 57.8% to 68.3% for these time periods, respectively (P<0.001 for both), reported Brendon Stiles, MD, of Weill Cornell Medicine/NewYork-Presbyterian Hospital in New York City.

“Here’s the punchline: better treatment, and probably better staging, leads to better survival,” Stiles said during a media briefing at the virtual World Conference on Lung Cancer.

The proportion of low-income patients who received no treatment at all dropped from 15% (2004-2008) to 12% by the end of the study (2013-2014). These patients were less likely to get chemoradiation over time, which is not considered standard of care for stage I/II disease, and were more likely to receive radiation by the end of the study, probably as stereotactic radiation became more available, Stiles suggested.

Meanwhile, rates of surgery increased from 52% at the start of the study to 57.9% by the end.

“These may not sound like huge differences, but when you apply them to the large population of patients who have lung cancer, it really can make a difference,” said Stiles. “Importantly, we did better with the treatments.”

Short-term 90-day mortality significantly decreased from 5.3% (2004-2008) to 3.9% (2013-2014), as did 30-day readmission rates, dropping from 4.9% to 3.3% during the study period.

“So we’re treating more patients, we’re treating them safer, [and] we’re doing a better job at keeping them out of the hospital,” said Stiles.

Previous NCDB analyses in NSCLC have shown socioeconomic risk factors — including race, education, insurance, and income — to be associated with 10-20% absolute decreases in 5-year survival.

“Obviously several factors contribute to these differences in survival, and that includes tumor factors and biology — there’s just some bad tumors,” said Stiles. “But there’s also diagnostic and treatment differences. Are we staging patients adequately? Are they getting guideline-based therapy? And the sad fact of the matter remains that socioeconomic factors are still associated with survival in many studies.”

But record decreases in mortality have been reported by the American Cancer Society in recent years, led by gains in lung cancer treatment, screening, and care, which has seen a roughly 5% drop in mortality.

“What we really wanted to know is whether the most at-risk patients were also enjoying these improvements, were they also spread across the board?” said Stiles.

For their study, the researchers looked at 242,575 patients with stage I/II NSCLC included in the NCDB treated from 2004 to 2014. Income was divided into four quartiles (<$38,000; $38,000-$47,999; $48,000-$62,999; ≥$63,000). The lowest income quartile included 47,437 patients. Four time periods were used to examine changes over time (2004-2008, 2009-2010, 2011-2012, and 2013-2014).

Factors significantly associated with improved OS included:

  • Female sex (HR 0.75, 95% CI 0.72-0.77)
  • Earlier stage (HR 0.69, 95% CI 0.66-0.72)
  • Treatment at an academic center (HR 0.93, 95% CI 0.89-0.96)
  • Private insurance (HR 0.84, 95% CI 0.80-0.89)
  • Surgery (HR 0.49, 95% CI 0.46-0.51)
  • Later year of diagnosis (HR 0.81, 95% CI 0.75-0.88)

“The association of later year of diagnosis speaks to the whole theme of this study; if you were diagnosed in a later time period you were 19% less likely to die,” said Stiles. “Earlier clinical staging improves survival, so how do we change that? With lung cancer screening. We have to get better access to screening for low-income at-risk patients.”

  • Ian Ingram joined MedPage Today in 2018 as Deputy Managing Editor, and covers oncology for the site.


Stiles disclosed relationships with AstraZeneca, Pfizer, Flame Biosciences, Galvanize Therapeutics, Genentech, Bristol Myers Squibb, and Ribon.