Chest
Volume 117, Issue 5, May 2000, Pages 1239-1246
Journal home page for Chest

Clinical Investigations
CANCER
Who Gets Chemotherapy for Metastatic Lung Cancer?

https://doi.org/10.1378/chest.117.5.1239Get rights and content

Study objectives

To determine the prevalence and factors associated with chemotherapy use in elderly patients presenting with advanced lung cancer.

Design

A retrospective cohort study using administrative data.

Setting and patients

We analyzed the medical bills for the 6,308 Medicare patients > 65 years old with diagnosed stage IV non-small cell lung cancer (NSCLC) in the 11 SEER (survival, epidemiology, and end results) regions between 1991 and 1993. The main outcome measure, chemotherapy administration, was identified by the relevant medical billing codes. Patient sociodemographic and disease characteristics were obtained from the SEER database and census data.

Results

Almost 22% of patients received chemotherapy at some time for their metastatic NSCLC. As expected, younger patients and those with fewer comorbid conditions were more likely to receive chemotherapy. However, several nonmedical factors, such as nonblack race, higher socioeconomic status, treatment in a teaching hospital, and living in the Seattle/Puget Sound or Los Angeles SEER regions, also significantly increased a patient's likelihood of receiving chemotherapy.

Conclusion

Compared to previous reports, the prevalence of chemotherapy use for advanced NSCLC appears to be increasing. However, despite uniform health insurance coverage, there is wide variation in the utilization of palliative chemotherapy among Medicare patients, and nonmedical factors are strong predictors of whether a patient receives chemotherapy. While it is impossible to know the appropriate rate of usage, nonmedical factors should only influence a patient's likelihood of receiving treatment if they reflect patient treatment preference. Research to further clarify the costs, benefits, and patient preferences for chemotherapy in this patient population is warranted in order to minimize the effect of nonmedical biases on management decisions.

Section snippets

Data Sources

We studied patients from the 11 tumor registries participating in the SEER (surveillance, epidemiology, and end results) program of the National Cancer Institute: San Francisco/Oakland, CT, Detroit, HI, IA, NM, Seattle/Puget Sound, UT, Atlanta, San Jose/Monterey, and Los Angeles. These registries collect uniform information on all cancers diagnosed within their geographic regions, capturing about 97% of all incident cases in those areas.12 The geographic areas covered by SEER areas contain

Patient Characteristics

Table 1 shows the characteristics of the 6,308 patients meeting our eligibility criteria. The average patient age was 74.2 years, and almost two-thirds were men. The majority of patients (84%) were non-Hispanic white, with< 10% in each of the other racial groups. Eighty-five percent of patients lived in an urban setting. The Detroit registry contributed the most patients, followed by CT, IA, Seattle/Puget Sound, Los Angeles, and San Francisco/Oakland. The histologic diagnoses were mostly

Discussion

This study, the first to use large population-based data sets to assess chemotherapy utilization in advanced lung cancer, produced several interesting findings. The 21.5% of Medicare patients with stage IV NSCLC receiving chemotherapy for their lung cancer indicates that chemotherapy use is increasing relative to the rates reported in older studies. However, despite the fact that all patients in our cohort had the same health insurance coverage, the use of chemotherapy was far from consistent

Conclusion

The use of palliative chemotherapy appears to be increasing. Chemotherapy or supportive care can be appropriate choices in different clinical situations, so the appropriate level of chemotherapy use cannot be known. However, unless they are markers for patient treatment preferences, nonmedical factors such as race, geographic location, socioeconomic status, or treatment setting should not significantly affect management recommendations. Research to further clarify the costs, benefits, and

References (61)

  • IF Tannock et al.

    When is cancer treatment worthwhile [editorial]?

    N Engl J Med

    (1990)
  • American Society of Clinical Oncology

    Clinical practice guidelines for the treatment of unresectable non-small-cell lung cancer

    J Clin Oncol

    (1997)
  • PG Lopez et al.

    Chemotherapy in stage IV (metastatic) non-small-cell lung cancer

    Cancer Prev Control

    (1997)
  • DS Ettinger et al.

    NCCN non-small-cell lung cancer practice guidelines

    Oncology

    (1996)
  • ER Greenberg et al.

    Social and economic factors in the choice of lung cancer treatment: a population-based study in two rural states

    N Engl J Med

    (1988)
  • C Zippin et al.

    Completeness of hospital cancer case reporting from the SEER program of the National Cancer Institute

    Cancer

    (1995)
  • LAG Ries et al.

    SEER cancer statistics review, 1973–1994

    (1997)
  • AL Potosky et al.

    Potential for cancer related health services research using a linked Medicare-tumor registry database

    Med Care

    (1993)
  • ME Charlson et al.

    A new method of classifying prognostic comorbidity in longitudinal studies: development and validation

    J Chronic Dis

    (1986)
  • ME Charlson et al.

    Morbidity during hospitalization: can we predict it?

    J Chronic Dis

    (1986)
  • C Klabunde

    Assessment of comorbidity using claims data: SEER Medicare Data Users Workshop

    (1998)
  • N Krieger

    Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology

    Am J Pub Health

    (1992)
  • ER Greenberg et al.

    Referral of lung cancer patients to university hospital cancer centers: a population-based study in two rural states

    Cancer

    (1988)
  • BE Hillner et al.

    A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort

    Cancer

    (1998)
  • E Kesson et al.

    Lung cancer management and outcome in Glasgow, 1991–92

    Br J Cancer

    (1998)
  • B Raby et al.

    Does knowledge guide practice?

    Another look at the management of non-small-cell lung cancer J Clin Oncol

    (1995)
  • A Crook et al.

    Survey on the treatment of non-small cell lung cancer (NSCLC) in England and Wales

    Eur Respir J

    (1997)
  • E Rapp et al.

    Chemotherapy can prolong survival in patients with advanced non-small-cell lung cancer: report of a Canadian multicenter randomized trial

    J Clin Oncol

    (1988)
  • E Quoix et al.

    La chimiotherapie comportant du cisplatin est-elle utile dans le cancer bronchique non microcellulaire au stade IV? Resultats d'une etude randomisee

    Bull Cancer

    (1991)
  • R Cellerino et al.

    A randomized trial of alternating chemotherapy versus best supportive care in advanced non-small cell lung cancer

    J Clin Oncol

    (1991)
  • Cited by (0)

    Dr. Earle is a Cancer Care Ontario Research Fellow.

    Supported in part by National Institutes of Health grant CA 72663.

    View full text