Undertreatment trend in elderly lung cancer patients in Brazil

Access to cancer clinical trials for racialised older adults: an equity-focused rapid scoping review protocol

BACKGROUND

The intersection of race and older age compounds existing health disparities experienced by historically marginalised communities. Therefore, racialised older adults with cancer are more disadvantaged in their access to cancer clinical trials compared with age-matched counterparts. To determine what has already been published in this area, the rapid scoping review question are: what are the barriers, facilitators and potential solutions for enhancing access to cancer clinical trials among racialised older adults?

METHODS

We will use a rapid scoping review methodology in which we follow the six-step framework of Arksey and O'Malley, including a systematic search of the literature with abstract and full-text screening to be conducted by two independent reviewers, data abstraction by one reviewer and verification by a second reviewer using an Excel data abstraction sheet. Articles focusing on persons aged 18 and over who identify as a racialised person with cancer, that describe therapies/therapeutic interventions/prevention/outcomes related to barriers, facilitators and solutions to enhancing access to and equity in cancer clinical trials will be eligible for inclusion in this rapid scoping review.

ETHICS AND DISSEMINATION

All data will be extracted from published literature. Hence, ethical approval and patient informed consent are not required. The findings of the scoping review will be submitted for publication in a peer-reviewed journal and presentation at international conferences.

Five-year survival of resectable stage IIIA non-small cell lung cancer in Brazil

BACKGROUND

In stage IIIA non-small cell lung cancer (NSCLC), surgery plays a role in terms of multimodal treatment. Surgery rates have increased in recent years, mainly due to the combination of more accurate imaging tools, electromagnetic navigation bronchoscopy, robotic bronchoscopy, robotic surgery, and a wide range of challenging clinical scenarios to lead surgeons and oncologists to include surgery as an option in therapeutic management.

OBJECTIVES

To assess the prognostic factors, the 5-year overall survival (OS) and cancer-specific survival (CSS) of patients with resectable stage III-NSCLC.

METHODS

Patients' information was extracted from 76 Hospitals' Cancer Registry. OS and CSS were constructed using the Kaplan-Meier method, and the log-rank test was used to assess differences between curves. In addition, Cox regression was conducted to evaluate the patients' characteristics leading to better OS and CSS.

RESULTS

Overall, 433 stage III NSCLC surgical patients followed over 19 years were included. The median age was 61.29 ± 9.62 years, 58.4% male, 50.1% with adenocarcinoma, 29.3% with squamous cell carcinoma, 3.7% with large-cell lung carcinoma, and 16,9% with other lung cancer types. The 5-year OS was 30.6% (95% confidence interval [CI]: 27.4-36.1), and the CSS was 35.0% (95% CI: 29.4-41.0). In the Cox multivariate regression, squamous cell carcinoma was associated with reduced OS (hazard ratio [HR]: 1.40; 95% CI: 1.07-1.83; p=0.014) and CSS (HR: 1.56; 95% CI: 1.17-2.08; p = 0.002), in comparison with adenocarcinoma. The 2015-2019 quinquennial had a 50% reduction in HR (0.49; 95% CI: 0.29-0.81; p = 0.006), and the 2010-2014 group had a 40% reduction (0.59; 95% CI: 0.42-0.83; p = 0.006) in comparison with the 2000-2004 patients' group.

CONCLUSION

The OS and CSS of patients with resectable stage III NSCLC have improved over the past 19 years in our region. Squamous cell carcinoma was associated with increased mortality risk from any cause or specific cancer.

Effect of adherence to treatment guidelines on overall survival in elderly non-small-cell lung cancer patients

OBJECTIVES

Mean age at diagnosis of lung cancer is increasing with increasing age in Western populations. The present study was designed to evaluate the effect of adherence to first-line treatment guidelines on overall survival (OS) in elderly patients with non-small-cell lung cancer (NSCLC) and reasons for non-adherence to treatment guidelines.

MATERIALS AND METHODS

All patients aged ≥ 65 years diagnosed with NSCLC in Ostrobothnia, Finland, during the years 2016 to 2020 were identified from hospital registries. Adherence of first-line treatment to contemporary treatment guidelines was analysed based on diagnosis, tumour stage and performance status (PS), as was the effect of adherence on OS.

RESULTS

A review of hospital registries identified 238 NSCLC patients aged ≥ 65 years. Guideline adherence by stage decreased significantly with age, with 66.4% of patients aged 65 to 74 years, but only 33.3% of those aged > 80 years treated according to guidelines (p < 0.001). Other factors associated with non-adherence to guidelines included poor PS, frailty, and limited lung function. Of the patients with PS 0-2, 26.9% were under-treated according to guidelines. Reasons for under-treatment included comorbidities, decreased lung function, physician decision to reduce treatment intensity or recommend best supportive care, patient choice and PS decline before treatment initiation. Guideline adherence increased overall OS of elderly NSCLC patients in all stages. Elderly PS 2 patients appear to benefit from guideline adherence and active treatment. In contrast, active treatment did not benefit patients with PS 3-4.

CONCLUSIONS

Guideline adherence was associated with increased OS in elderly NSCLC patients. Almost 10% of elderly and otherwise fit NSCLC patients were not treated according to guidelines and could have benefitted from more intensive treatment.

Surgical under-treatment of older adult patients with cancer: A systematic review and meta-analysis

BACKGROUND

Older patients with cancer often have lower surgery rates and survival than younger patients, but this may reflect surgical contraindications of advanced disease, comorbidities, and frailty - and not necessarily under-treatment.

OBJECTIVES

This review aims to describe variations in surgery rates and observed or net survival among younger (<75) and older (≥75) patients with breast, lung and colorectal cancer, while taking account of pre-existing health factors, in order to understand how under-treatment is defined and estimated in the literature.

METHOD

MEDLINE, EMBASE, Web of Science and PubMed databases were searched for studies reporting surgery rates and observed or net survival among younger and older patients with breast, lung, and colorectal cancer. Study quality was assessed using the Newcastle Ottawa Scale, and random effects meta-analyses were used to combine study results. The I-squared statistic and subgroup analyses were used to assess heterogeneity.

RESULTS

Thirty relatively high-quality studies of patients with breast (230,200; 71.9%), lung (77,573; 24.2%), and colorectal (12,407; 3.9%) cancers were identified. Compared to younger patients, older patients were less likely to receive surgical treatment for 1) breast cancer after adjusting for comorbidity, performance status (PS), functional status and patient choice, 2) lung cancer after accounting for stage, comorbidity, PS, and 3) colorectal cancer after adjusting for stage, comorbidity, and gender. The pooled unadjusted analyses showed lower surgery receipt in older patients with breast (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.78), lung (OR 0.54, 95% CI 0.39-0.75), and colorectal (OR 0.59, 95% CI 0.51-0.68) cancer. In separate analyses, older patients with breast, lung and colorectal cancer had lower observed and net survival, compared to younger patients.

CONCLUSIONS

Lower surgery rates in older patients may contribute to their poorer survival compared to younger patients. Future research quantifying under-treatment should include necessary clinical factors, patient choice, patient's quality of life and a statistically-robust approach, which will demonstrate how much of the survival deficit in older patients is due to their receiving lower surgery rates.

Factors associated with time to initiate lung cancer treatment in Minas Gerais, Brazil

The aim was to verify the association of individual factors and healthcare system characteristics with time to initiate treatment of lung cancer by the Brazilian National Health System, in Minas Gerais state. A retrospective cohort study, with patients who initiated treatment for lung cancer by the SUS, from 2008 to 2015. Sociodemographic and clinical characteristics of patients, besides organizational variables of the healthcare system were selected. The logistic regression model evaluated the association of selected explanatory variables with the outcome of initiating treatment within 60 days after diagnosis. Odds ratio (OR) and respective 95% confidence interval were used to measure the power of association. Most treatments for lung cancer in the state of Minas Gerais initiated within 60 days after diagnosis. However, being male and diagnosed as stage IV increased the likelihood of starting treatment within 60 days. On the other hand, the patient's age, radiation therapy as first treatment, and the place of residence decreased such chance. Time to initiate treatment is associated with individual characteristics and provision of services in macroregions, and the observed inequalities possibly raised from the better or worse access of the population to the services provided by SUS.

Prospective Analysis of Health-Related Quality of Life in Older Adults With Cancer

OBJECTIVE

The aim of the present study was to evaluate health-related quality of life (HRQoL) changes at 6 to 12 months after cancer diagnosis and to assess the impact of age in older adults with cancer.

METHODS

A cohort study using patients ≥60 years old diagnosed with cancer. Health-related quality of life scores were calculated according to the European Organisation for Research and Treatment of Cancer questionnaire. Student's t tests for paired samples and a binomial logistic regression were performed.

RESULTS

The study included 241 patients. At diagnosis, the affected HRQoL functions were physical and emotional functions, financial difficulties, pain, and insomnia. At follow-up, cognitive function (P < .001) and dyspnea (P = .004) worsened, while emotional function improved (P = .003).

DISCUSSION

At the 6 to 12 months of follow-up, older adult cancer patients showed worsening cognitive function and dyspnea and improved emotional function. These HRQoL changes were not associated with age.

Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review

PURPOSE

The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms.

METHODS

We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability.

RESULTS

Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%).

CONCLUSION

Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

Life-long follow-up of second primary lung and extra-pulmonary cancer in lung cancer patients is needed

Background: Lung cancer (LC) patients are at high risk of developing second primary cancer (SPC). This study aimed to explore the risk factors associated with SPC and provide an individualized risk prediction model for LC patients. Methods: Initial primary lung cancer (IPLC) patients diagnosed between 1998 and 2011 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. A Fine-Gray multivariate competing-risk model was used to estimate the risk of SPC, and the model was assessed regarding discrimination and calibration. A nomogram was designed for clinical convenience to predict the 3-, 5-, and 10- year probabilities of developing SPCs. Results: A total of 142,491 IPLC patients were considered in this study and 14,374(10.01%) developed SPC within a maximum study period of approximately 19 years. Seven independent prognostic factors were identified according to the competing-risk model, and the SEER summary stage and surgery were the strongest predictors. The model was well calibrated and had good discrimination ability(C-index = 0.746). Conclusions: LC survivors had an increased risk of SPC and factors associated with good prognosis often predicted SPC. Consideration should be given to increasing the duration of routine follow-up even after 10 years of initial diagnosis for those at the highest risk and site-specific follow-up strategy is also required.

Tumor-node-metastasis staging and treatment patterns of 73,167 patients with lung cancer in Brazil

OBJECTIVE

To characterize the clinical and histological profile, as well as treatment patterns, of patients with early-stage, locally advanced (LA), or advanced/metastatic (AM) lung cancer, diagnosed between 2000 and 2014, in Brazil.

METHODS

This was an analytical cross-sectional epidemiological study employing data obtained for the 2000-2014 period from the hospital cancer registries of two institutions in Brazil: the José Alencar Gomes da Silva National Cancer Institute, in the city of Rio de Janeiro; and the São Paulo Cancer Center Foundation, in the city of São Paulo.

RESULTS

We reviewed the data related to 73,167 patients with lung cancer. The proportions of patients with early-stage, LA, and AM lung cancer were 13.3%, 33.2%, and 53.4%, respectively. The patients with early-stage lung cancer were older and were most likely to receive a histological diagnosis of adenocarcinoma; the proportion of patients with early-stage lung cancer remained stable throughout the study period. In those with LA lung cancer, squamous cell carcinoma predominated, and the proportion of patients with LA lung cancer decreased significantly over the period analyzed. Those with AM lung cancer were younger and were most likely to have adenocarcinoma; the proportion of patients with AM lung cancer increased significantly during the study period. Small cell carcinoma accounted for 9.2% of all cases. In our patient sample, the main treatment modality was chemotherapy.

CONCLUSIONS

It is noteworthy that the frequency of AM lung cancer increased significantly during the study period, whereas that of LA lung cancer decreased significantly and that of early-stage lung cancer remained stable. Cancer treatment patterns, by stage, were in accordance with international guidelines.

"Age matters"-German claims data indicate disparities in lung cancer care between elderly and young patients

Background

Although lung cancer is most commonly diagnosed in elderly patients, evidence about tumor-directed therapy in elderly patients is sparse, and it is unclear to what extent this affects treatment and care. Our study aimed to discover potential disparities in care between elderly patients and those under 65 years of age.

Methods

We studied claims from 13 283 German patients diagnosed with lung cancer in 2009 who survived for at least 90 days after diagnosis. We classified patients as “non-elderly” (≤ 65), “young-old” (65–74), “middle-old” (75–84), and “old-old” (≥ 85). We compared receipt of tumor-directed therapy (6 months after diagnosis), palliative care, opioids, antidepressants, and pathologic diagnosis confirmation via logistic regression. We used generalized linear regression (gamma distribution) to compare group-specific costs of care for 3 months after diagnosis. We adjusted all models by age, nursing home residency, nursing care need, comorbidity burden, and area of residence (urban, rural). The age group “non-elderly” served as reference group.

Results

Compared with the reference group “non-elderly”, the likelihood of receiving any tumor-directed treatment was significantly lower in all age groups with a decreasing gradient with advancing age. Elderly lung cancer patients received significantly fewer resections and radiotherapy than non-elderly patients. In particular, treatment with antineoplastic therapy declined with increasing age (“young-old” (OR = 0.76, CI = [0.70,0.83]), “middle-old” (OR = 0.45, CI = [0.36,0.50]), and “old-old” (OR = 0.13, CI = [0.10,0.17])). Patients in all age groups were less likely to receive structured palliative care than “non-elderly” (“young-old” (OR = 0.84, CI = [0.76,0.92]), “middle-old” (OR = 0.71, CI = [0.63,0.79]), and “old-old” (OR = 0.57, CI = [0.44,0.73])). Moreover, increased age was significantly associated with reduced quotas for outpatient treatment with opioids and antidepressants. Costs of care decreased significantly with increasing age.

Conclusion

This study suggests the existence of age-dependent care disparities in lung cancer patients, where elderly patients are at risk of potential undertreatment. To support equal access to care, adjustments to public health policies seem to be urgently required.

Increased incidence, morbidity and mortality rates for lung cancer in women in Brazil between 2000 and 2014: An analysis of three types of sources of secondary data

INTRODUCTION

Lung cancer is the principal cause of death from cancer worldwide. However, little is known of its epidemiological and histological profile and of the incidence and mortality rates in Brazil according to sex.

OBJECTIVES

To evaluate the incidence, morbidity and mortality rates of lung cancer in Brazil from 2000 to 2014, as well as the epidemiological, clinical and morphological profile of women with lung cancer in Brazil is described.

METHODS

An ecological study was conducted using three reliable sources of secondary data: population-based cancer registries, hospital-based cancer registries and the national mortality database.

RESULTS

The incidence rate in women increased from 7.92/100,000 in 2000 to 9.12/100,000 in 2012, while mortality increased from 6.02/100,000 in 2000 to 8.29/100,000 in 2014. In men, the incidence decreased from 23.40/100,000 in 2000 to 18.47/100,000 in 2012 and mortality also fell from 16.12/100,000 to 15.11/100,000 in 2014. There was a reduction in the male-to-female ratio from 2.54 in 2000 to 1.46 in 2014. Women tended to be younger (p < 0.001), black (p < 0.001), non-smokers (p < 0.001), to have adenocarcinoma or small-cell lung cancer (p < 0.001), and to have metastatic disease (p < 0.001). In addition, the time between diagnosis and the start of cancer treatment was longer in women (p < 0.001). In relation to treatment, women were more likely to have undergone chemotherapy, surgery or surgery in combination with chemotherapy (p < 0.001) and to have response to the initial treatment (p < 0.001).

CONCLUSION

Incidence, morbidity and mortality rates of lung cancer in women of Brazil increased in the most recent years.