Temporal trends in the management of potentially resectable lung cancer

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 1: a guide to decision-making

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, Stereotactic Body Radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

Based on a systematic review from 2000-2021, evidence regarding relevant outcomes was assembled, with attention to aspects of applicability, uncertainty and effect modifiers. A framework was developed to present this information a format that enhances decision-making at the point of care for individual patients.

Results

While patients often cross over several boundaries, the evidence fits into categories of healthy patients, compromised patients, and favorable tumors. In healthy patients with typical (i.e., solid spiculated) lung cancers, the impact on long-term outcomes is the major driver of treatment selection. This is only slightly ameliorated in older patients. In compromised patients increasing frailty accentuates short-term differences and diminishes long-term differences especially when considering non-surgical vs. surgical approaches; nuances of patient selection (technical treatment feasibility, anticipated risk of acute toxicity, delayed toxicity, and long-term outcomes) as well as patient values are increasingly influential. Favorable (less-aggressive) tumors generally have good long-term outcomes regardless of the treatment approach.

Discussion

A framework is provided that organizes the evidence and identifies the major drivers of decision-making for an individual patient. This facilitates blending available evidence and clinical judgment in a flexible, nuanced manner that enhances individualized clinical care.

Barriers to surveillance imaging adherence in early-staged lung cancer

Background

Frequency of post-treatment surveillance is highly variable following curative resection of non-small cell lung cancer (NSCLC). We sought to characterize surveillance practices after lobectomy for early-stage NSCLC and to identify the impact of various demographic factors on patterns of surveillance.

Methods

We included patients who underwent anatomic lobectomy for pathologic stage I NSCLC from 2007-2017. Demographic characteristics, post-operative imaging studies (internal and external), and travel distance were recorded. We defined the minimal standard of surveillance imaging studies (MSSIS) as ≥7 studies in the first 5 years (computed tomography/positron emission tomography). Patient sex, ethnicity, marital status, and distance traveled were evaluated as predictors of imaging receipt. Standard descriptive statistics, univariate, and multivariate analysis (MVR) were performed.

Results

A total of 1,288 patients were included. The mean age was 65.5±10.1 years, 589 (45.7%) were male, 1,081 (83.9%) were Caucasian, and 924 (71.7%) were married. Only 464 (36%) achieved MSSIS; being married [75.6% (351/464) vs. 68.8% (567/824), P=0.01] and having larger tumor size (2.63±0.04 vs. 2.49±0.05 cm, P=0.03) were both associated with MSSIS. Patients residing <100 miles from the hospital were more likely to have MSSIS, and more imaging at 24 months (4.1±2.2 vs. 3.7±2.0; P=0.006), 60 months (8.0±5.1 vs. 6.6±4.2, P=0.001) and overall (10±7.3 vs. 8.2±6.3; P=0.001). On MVR, tumor size and marital status were associated with MSSIS.

Conclusions

Two-thirds of patients at our institution did not undergo recommended surveillance imaging. Tumor size, being married, and living <100 miles from the medical center were associated with an increased number of imaging studies and greater adherence to guidelines.

A Survival Comparison of Mucin-Producing Adenocarcinoma of the Esophagus to Conventional Adenocarcinoma after Esophagectomy

The objective of this study was to test the hypothesis that mucin-producing adenocarcinoma (MA) exhibits a more advanced clinical presentation and worse prognosis than conventional adeno-carcinoma (CA) in patients undergoing esophagectomy. Patient demographic and clinical variables and cancer-specific survival were collected from the U.S. Surveillance Epidemiology and End Results database between 1988 and 2006. Esophagectomy was performed for 105 patients with MA and 5473 patients with CA. The MA cohort exhibited a similar age at presentation, gender, and anatomic location (lower third of the esophagus/abdominal) as the CA cohort. We found trends toward advanced pathologic stage of disease of MA compared with CA (Stage IIB to IV 56 vs 46%), higher grade tumors (Grade III/IV, 44 vs 34%), positive lymph nodes (51 vs 40%), and poorer mean survival. For both groups, after multivariate analysis, age at diagnosis, tumor stage, and grade were negative predictors of survival (hazard ratios 1.02, 1.39, and 1.32, respectively; P < 0.001). Although this study suggests that patients with resected MA of the esophagus have a trend toward worse clinical presentation and survival than patients with resected CA, the observations are not significant and do not support our hypothesis or results from single-institution studies.

Lung Cancer Patient and Caregiver Health Vulnerabilities and Interest in Health Promotion Interventions: An Exploratory Study

Introduction

Lung cancer patients and their caregivers are at risk for negative health behaviors and poor psychosocial functioning, but few interventions exist that target this population. To inform intervention development, we explored potential targets and interest and concordance in health promotion interventions among lung cancer patients and their caregivers.

Methods

Lung cancer patients (n = 18) with a smoking history and their caregivers (n = 15) participated in a cross-sectional, observational survey study (an average of 1 month postdiagnosis) to assess health behaviors, psychosocial functioning, and interest in health promotion interventions. Fisher’s exact and Wilcoxon rank-sum tests examined factors associated with intervention interest. McNemar’s test examined concordance in interest.

Results

Many caregivers (40%) reported providing care at least 4 days per week, and over half (53.3%) reported a smoking history. Patients reported high cancer self-blame (mean = 3.1, standard deviation = 0.9, range = 1–4). Patients (55.6%) and caregivers (60%) reported clinically significant depressive symptoms. There was high interest and concordance in interest in cancer education (patients, 77.8%; caregivers, 86.7%) and diet and exercise (patients, 66.7%; caregivers, 80%) interventions. Significantly more caregivers were interested in stress reduction (patients, 53.3%; caregivers, 73.3%; P = .05) and yoga (patients, 16.7%; caregivers, 50%; P = .03) than patients. Caregivers interested in stress reduction interventions had higher levels of distress than those not interested.

Discussion

Health promotion interventions are needed and of interest to lung cancer patients and caregivers. Shared interests in interventions suggest dyadic interventions may be appropriate, yet interventions should also address distinct patient and caregiver needs.

Pattern of Imaging after Lung Cancer Resection. 1992-2005

RATIONALE

Imaging intensity after lung cancer resection performed with curative intent is unknown.

OBJECTIVES

To describe the pattern and trends in the use of computed tomography (CT) and positron emission tomography (PET) scans in patients after resection of early-stage lung cancer.

METHODS

Retrospective analysis of the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database. Subjects included 8,621 Medicare beneficiaries (age, ≥66 yr) who underwent lung cancer resection with curative intent between 1992 and 2005. A surveillance CT or PET examination was defined as CT or PET imaging performed in an outpatient setting on patients who did not undergo chest radiography in the preceding 30 days.

MEASUREMENTS AND MAIN RESULTS

Overall, imaging use was higher within the first 2 years versus Years 3-5 after surgical resection. Use of surveillance CT scans increased sharply from 13.7 to 57.3% of those diagnosed in 1996-1997 and 2004-2005, respectively. PET scan use increased threefold, from 6.2% in 2000-2001 to 19.6% in 2004-2005. In multivariable analyses, we observed a 32% increase in the odds of undergoing surveillance CT or PET imaging for every year of diagnosis between 1998 and 2005. There was no substantial decline in the odds of having a surveillance CT or PET scan during each successive follow-up period, suggesting no change in the intensity of surveillance over the first 5 years after surgical resection. The proportion of surveillance CT imaging performed at freestanding imaging centers increased from 18.0% in 1998-1999 to 30.6% in 2004-2005.

CONCLUSIONS

The use of CT and PET imaging for surveillance after curative-intent surgical resection of early-stage lung cancer increased sharply in the United States between 1997-1998 and 2005. In the absence of evidence demonstrating favorable outcomes, this practice was likely driven by prevailing expert opinion embedded in clinical practice guidelines made available during that time. Research is clearly needed to determine the role and optimal approach to surveillance thoracic imaging after surgical resection of lung cancer.

Indoleamine 2,3-dioxygenase activity and clinical outcome following induction chemotherapy and concurrent chemoradiation in Stage III non-small cell lung cancer

Indoleamine 2,3-dioxygenase (IDO) has recently been proposed to account for tumor-induced immunosuppression by influencing the conversion of tryptophan (Trp) into kynurenine (Kyn). The objective of our study was to correlate IDO activity with disease outcome in non-small cell lung cancer (NSCLC) patients treated with multimodal combination therapy. In a single-arm Phase II trial involving induction gemcitabine and carboplatin followed by concurrent paclitaxel, carboplatin and 74 Gy thoracic radiation in stage III NSCLC patients, plasma was drawn at baseline, post-induction, and post-concurrent therapy. The mean plasma Kyn/Trp ratio was used as a surrogate indicator of IDO activity. The 33 participants were distributed as follows: 15 females, 18 males; median age = 62; median overall survival (OS) = 22.4 (95% CI 19.3-25.1) months; median progression-free survival (PFS) = 11.5 (95% CI 6.7-16.3) months. The mean Kyn/Trp ratio at baseline (4.5 ± 2.8) was higher than that of healthy controls (2.9 ± 1.9, p = 0.03) and increased after induction therapy (5.2 ± 3.2, p = 0.08) and chemoradiation (5.8 ± 3.9, p = 0.01). The post-treatment Kyn/Trp ratio and radiologic responses were not significantly associated at any time point. No significant correlation was found between baseline Kyn/Trp ratios and OS (HR = 1.1, 95% CI 0.45-2.5) or PFS (HR = 0.74, 95% CI 0.30-1.82). A post-induction chemotherapy increase in IDO activity portended worse OS (HR = 0.43, 95% CI 0.19-0.95, p = 0.037) and PFS (HR = 0.47, 95% CI 0.22-1.0, p = 0.055). This observed increase in IDO transcription may be a means for tumors to evade immunosurveillance.

Benefit of adjuvant chemotherapy after resection of stage II (T1-2N1M0) non-small cell lung cancer in elderly patients

BACKGROUND

We evaluated the use and efficacy of adjuvant chemotherapy after resection of T1-2N1M0 non-small cell lung cancer (NSCLC) in elderly patients.

METHODS

Factors associated with the use of adjuvant chemotherapy in patients older than 65 years of age who underwent surgical resection of T1-2N1M0 NSCLC without induction chemotherapy or radiation in the Surveillance, Epidemiology, and End Results-Medicare database from 1992 to 2006 were assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census tract characteristics. Overall survival (OS) was analyzed using the Kaplan-Meier approach and inverse probability weight-adjusted Cox proportional hazard models.

RESULTS

Overall, 2,781 patients who underwent surgical resection as the initial treatment for T1-2N1M0 NSCLC and survived at least 31 days after surgery were identified, with adjuvant chemotherapy given to 784 patients (28.2 %). Factors that predicted adjuvant chemotherapy use were younger age and higher T status. The 5-year OS was significantly better for patients who received adjuvant chemotherapy compared with patients not given adjuvant chemotherapy: 35.8 % (95 % confidence interval [CI] 31.9-39.6) vs. 28.0 % (95 % CI 25.9-30.0) (p = 0.008). In the inverse probability weight-adjusted Cox proportional hazard regression model, adjuvant chemotherapy use predicted significantly improved survival (hazard ratio 0.84; 95 % CI 0.76-0.92; p = 0.0002).

CONCLUSIONS

Adjuvant chemotherapy after resection of T1-2N1M0 NSCLC is associated with significantly improved survival in patients older than 65 years. These data can be used to provide elderly patients with realistic expectations of the potential benefits when considering adjuvant chemotherapy in this setting.

Variability in the treatment of elderly patients with stage IIIA (N2) non-small-cell lung cancer

INTRODUCTION

: We evaluated treatment patterns of elderly patients with stage IIIA (N2) non-small-cell lung cancer (NSCLC).

METHODS

: The use of surgery, chemotherapy, and radiation for patients with stage IIIA (T1-T3N2M0) NSCLC in the Surveillance, Epidemiology, and End Results-Medicare database from 2004 to 2007 was analyzed. Treatment variability was assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census track variables. Overall survival was analyzed using the Kaplan-Meier approach and Cox proportional hazard models.

RESULTS

: The most common treatments for 2958 patients with stage IIIA (N2) NSCLC were radiation with chemotherapy (n = 1065, 36%), no treatment (n = 534, 18%), and radiation alone (n = 383, 13%). Surgery was performed in 709 patients (24%): 235 patients (8%) had surgery alone, 40 patients (1%) had surgery with radiation, 222 patients had surgery with chemotherapy (8%), and 212 patients (7%) had surgery, chemotherapy, and radiation. Younger age (p < 0.0001), lower T-status (p < 0.0001), female sex (p = 0.04), and living in a census track with a higher median income (p = 0.03) predicted surgery use. Older age (p < 0.0001) was the only factor that predicted that patients did not get any therapy. The 3-year overall survival was 21.8 ± 1.5% for all patients, 42.1 ± 3.8% for patients that had surgery, and 15.4 ± 1.5% for patients that did not have surgery. Increasing age, higher T-stage and Charlson Comorbidity Index, and not having surgery, radiation, or chemotherapy were all risk factors for worse survival (all p values < 0.001).

CONCLUSIONS

: Treatment of elderly patients with stage IIIA (N2) NSCLC is highly variable and varies not only with specific patient and tumor characteristics but also with regional income level.

Microsimulation model predicts survival benefit of radiofrequency ablation and stereotactic body radiotherapy versus radiotherapy for treating inoperable stage I non-small cell lung cancer

OBJECTIVE

A subset of patients with stage IA and IB non-small cell lung cancer (NSCLC) is ineligible for surgical resection and undergoes radiation therapy. Radiofrequency ablation (RFA) and stereotactic body radiotherapy are newer potentially attractive alternative therapies.

MATERIALS AND METHODS

We added RFA and stereotactic body radiotherapy treatment modules to a microsimulation model that simulates lung cancer's natural history, detection, and treatment. Natural history parameters were previously estimated via calibration against tumor registry data and cohort studies; the model was validated with screening study and cohort data. RFA model parameters were calibrated against 2-year survival from the Radiofrequency Ablation of Pulmonary Tumor Response Evaluation (RAPTURE) study, and stereotactic body radiotherapy model parameters were calibrated against 3-year survival from a phase 2 prospective trial. We simulated lifetime histories of identical patients with early-stage NSCLC who were ineligible for resection, who were treated with radiation therapy, RFA, or stereotactic body radiotherapy under a range of scenarios. From 5,000,000 simulated individuals, we selected a cohort of patients with stage I medically inoperable cancer for analysis (n = 2056 per treatment scenario). Main outcomes were life expectancy gains.

RESULTS

RFA or stereotactic body radiotherapy treatment in patients with peripheral stage IA or IB NSCLC who were nonoperative candidates resulted in life expectancy gains of 1.71 and 1.46 life-years, respectively, compared with universal radiation therapy. A strategy where patients with central tumors underwent stereotactic body radiotherapy and those with peripheral tumors underwent RFA resulted in a gain of 2.02 life-years compared with universal radiation therapy. Findings were robust with respect to changes in model parameters.

CONCLUSION

Microsimulation modeling results suggest that RFA and stereotactic body radiotherapy could provide life expectancy gains to patients with stage IA or IB NSCLC who are ineligible for resection.

Identifying specific chemotherapeutic agents in Medicare data: a validation study

BACKGROUND

Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment.

METHODS

We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents.

RESULTS

Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%).

CONCLUSIONS

Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

Identifying specific chemotherapeutic agents in Medicare data: a validation study

BACKGROUND

Large health care databases are increasingly used to examine the dissemination and benefits and harms of chemotherapy treatment in routine practice, particularly among patients excluded from trials (eg, the elderly). Misclassification of chemotherapy could bias estimates of frequency and association, warranting an updated assessment.

METHODS

We evaluated the validity of Medicare claims to identify receipt of chemotherapy and specific agents delivered to elderly stage II/III colorectal (CRC), in situ/early-stage breast, non-small-cell lung, and ovarian cancer patients using the National Cancer Institute's Patterns of Care studies (POC) as the gold standard. The POC collected data on chemotherapy treatment by reabstracting hospital records, contacting physicians, and reviewing medical records. Patients' POC data were linked and compared with their Medicare claims for 2 to 12 months postdiagnosis. κ, sensitivity, specificity, positive and negative predictive values and 95% confidence intervals were calculated for the receipt of any chemotherapy and specific agents.

RESULTS

Sensitivity and specificity of Medicare claims to identify any chemotherapy were high across all cancer sites. We found substantial variation in validity across agents, by site and administration modality. Capecitabine, an oral CRC treatment, was identified in claims with high specificity (98%) but low sensitivity (47%), whereas oxaliplatin, an intravenously administered CRC agent had higher sensitivity (75%) and similar specificity (97%).

CONCLUSIONS

Receipt of chemotherapy and specific intravenous agents can be identified using Medicare claims, showing improvement from prior reports; yet, variation exists. Future studies should assess newly approved agents and the impact of coverage decisions for these agents under the Medicare Part D program.

A checklist for ascertaining study cohorts in oncology health services research using secondary data: report of the ISPOR oncology good outcomes research practices working group

OBJECTIVES

The ISPOR Oncology Special Interest Group formed a working group at the end of 2010 to develop standards for conducting oncology health services research using secondary data. The first mission of the group was to develop a checklist focused on issues specific to selection of a sample of oncology patients using a secondary data source.

METHODS

A systematic review of the published literature from 2006 to 2010 was conducted to characterize the use of secondary data sources in oncology and inform the leadership of the working group prior to the construction of the checklist. A draft checklist was subsequently presented to the ISPOR membership in 2011 with subsequent feedback from the larger Oncology Special Interest Group also incorporated into the final checklist.

RESULTS

The checklist includes six elements: identification of the cancer to be studied, selection of an appropriate data source, evaluation of the applicability of published algorithms, development of custom algorithms (if needed), validation of the custom algorithm, and reporting and discussions of the ascertainment criteria. The checklist was intended to be applicable to various types of secondary data sources, including cancer registries, claims databases, electronic medical records, and others.

CONCLUSIONS

This checklist makes two important contributions to oncology health services research. First, it can assist decision makers and reviewers in evaluating the quality of studies using secondary data. Second, it highlights methodological issues to be considered when researchers are constructing a study cohort from a secondary data source.

Potentially curable lung cancer patients not offered operation

BACKGROUND

Recent reports have noted the decreased resection rate in early stage lung cancer. Our surgical population includes 25% second surgical opinion (SSO) patients not offered surgical intervention after initial evaluation at other institutions. This study assesses the reasons those patients were initially rejected for operation at other institutions and determines the outcome of operative intervention.

METHODS

This report is an analysis of 103 consecutive patients undergoing lung operation for cancer by a single surgeon from June 2006 through June 2008. This included 26 patients (25%) in the SSO group and 77 patients (75%) seen initially at our cancer center (control).

RESULTS

Reasons for initial rejection in the SSO group were the following: (1) anatomically unresectable (14 patients); (2) radiologic contraindication (11 patients); (3) multiple lesions (6 patients); (4) inadequate pulmonary reserve (5 patients); (5) significant medical comorbidities (2 patients); (6) advanced age (2 patients); (7) patient misunderstandings (2 patients); (8) prior high dose radiation (1 patient); (9) negative diagnostic study (1 patient) and negative exploratory thoracotomy (1 patient). Age and comorbidities were similar for both groups. The planned resection was completed in 25 of 26 patients. Two SSO patients (8%) and nine control patients (11%) had positive N2 nodes. Length of stay was identical and the single death was in a control patient.

CONCLUSIONS

An SSO after initial rejection for resection of lung cancer is highly desirable. The short-term outcomes in these SSO patients screened at a multidisciplinary lung cancer center are comparable with patients offered resection after initial evaluation at a large multidisciplinary cancer center.

Why do some lung cancer patients receive no anticancer treatment?

INTRODUCTION

A significant proportion of lung cancer patients receive no anticancer treatment. This varies from 19% in USA, 33% in Australia, 37% in Scotland, and 50% in Ireland. The aim of this study was to identify the reasons behind this.

METHODS

The Lung Cancer Multidisciplinary Meeting (MDM) in South-West Sydney prospectively collects data on all patients presented. All new lung cancer patients presented between December 1, 2005, and December 31, 2007, were reviewed. Patients were assigned optimal treatment based on evidence-based guidelines. Those patients in whom guidelines recommended no treatment (GNT) were compared with those whom the MDM recommended no treatment (MNT) and with those who actually received no treatment (ANT).

RESULTS

There were 335 patients with a median age of 69 years. A total of 82% had non-small cell lung cancer, 14% had small cell lung cancer, and 4% had no pathologic diagnosis. Eighty-five percent had locally advanced or metastatic disease. GNT was recommended in 4% (n = 13), MNT in 10% (n = 32) but ANT comprised 20% (n = 66). The differences between GNT and MNT were mainly due to patient comorbidities and clinician decision, but the differences between MNT and ANT were due to patient preference and declining performance status. In multivariate analysis, older age, poorer Eastern Cooperative Oncology Group status, non-small cell lung cancer, and non-English language predicted for ANT.

CONCLUSIONS

The proportion of patients with lung cancer receiving no treatment is greater than that predicted by guidelines or recommended by the MDM but lower than that described in population-based studies suggesting that MDMs can improve treatment utilization in lung cancer.

Survival comparison of adenosquamous, squamous cell, and adenocarcinoma of the lung after lobectomy

BACKGROUND

Primary adenosquamous carcinoma (ASC) of the lung is a rare tumor that may carry a poor prognosis. We examined a national database to see if ASC exhibited distinct clinical behavior from squamous cell (SC) and adenocarcinoma (AC) of the lung.

METHODS

This is a retrospective study querying the Surveillance, Epidemiology, and End Results database to identify 872 surgical patients diagnosed with ASC, 7888 with SC, and 12,601 with AC of the lung from 1998 to 2002. Analysis characterized clinical variables to determine patterns of presentation and compared survival among the above three histologic groups after lobectomy for stage I and II disease.

RESULTS

ASC represented 4.1% of the 21,361 patients examined. ASC tended toward right side (56.9%) laterality and upper lobe (60.0%) location. Compared with AC, patients with ASC and SC were more likely to be male (p < 0.0001), and ASC patients had worse histologic grade (p< 0.0001). Survival after lobectomy for stage I and II disease was significantly reduced in ASC and SC compared with AC (p < 0.0001). ASC had a significantly increased hazard ratio of 1.35 and 1.27 relative to AC and SC, respectively. Other significant negative predictors of survival included tumor grade of III and IV, stage II, age, and black ethnicity.

CONCLUSIONS

This large review demonstrates that ASC is an uncommon tumor with distinct clinical behavior and worse prognosis than AC and SC. Further insight into the molecular profile of ASC is needed to determine the cause of its biologic aggressiveness.

Health care utilization among surgically treated Medicare beneficiaries with lung cancer

BACKGROUND

Markers of increased health care utilization are surrogates for adverse events, and one such metric--prolonged length of stay greater than 14 days (PLOS)--was recently endorsed as a provider-level performance measure.

METHODS

This is a cohort study (1992 through 2002) aimed to describe increased health care utilization among 21,067 operated lung cancer patients using the Surveillance, Epidemiology, and End-Results-Medicare database. Increased utilization was defined by PLOS, discharge to an institutional care facility (ICF), or readmission within 30 days.

RESULTS

Twelve percent of patients had a PLOS, 13% were discharged to an ICF, and 15% were readmitted. In multivariate analyses, factors associated with a higher odds ratio of PLOS, discharge to ICF, or readmission included age older than 80 years, increasing comorbidity index, not being married, and pneumonectomy (all p < 0.05). Relative to patients living in the West, those in the Midwest or South had a higher odds ratio of PLOS and readmission but a lower odds ratio of discharge to an ICF (all p < 0.05). Adjusted rates of PLOS decreased significantly with time, whereas adjusted ICF and readmission rates increased (all p < 0.01). Patients who required increased utilization had higher adjusted 2.5-year mortality rates compared with those who did not (PLOS, 42% versus 20%; ICF, 32% versus 20%; readmission, 33% versus 19%; all p < 0.001).

CONCLUSIONS

Baseline health status and nonclinical factors were associated with increased utilization, nonuniform trends in utilization were observed with time, and increased utilization was associated with worse long-term outcomes. These findings have implications for quality-improvement initiatives that measure increased health care utilization as a surrogate for provider performance.

Cisplatin-vinorelbine chemotherapy in non-small cell lung cancer is safe and well tolerated: results of a retrospective Hungarian clinical data analysis

OBJECTIVE

The efficacy of cisplatin-vinorelbine chemotherapy (CT) in NSCLC is well established. In this retrospective data analysis, haematological safety and tolerability, furthermore the effects of cisplatin-vinorelbine combination on patients' quality of life (QoL) are examined by reviewing the clinical data of NSCLC patients in a retrospective manner.

RESEARCH DESIGN/METHODS

All patients (n = 25) received the following regimen: cisplatin (80 mg/m(2) on day 1 by i.v. infusion) and vinorelbine (30 mg/m(2) on days 1 and 8 by i.v. infusion; 21-day cycles; patients received four cycles of CT). Haematological laboratory and QoL data on day 1 of all cycles were collected. Quality of life was assessed by reviewing the data of patients' charts considering physical limitation, fatigue, nausea, vomiting, diarrhoea, constipation, social activities, fever, appetite and weight loss. The absence of problems was scored as 0, moderate complaints as 1 and serious deterioration as 2.

RESULTS

The QoL data showed no significant deterioration in the analysed symptoms of patients during the four cycles of cisplatin-vinorelbine CT (total QoL score was 3.0 +/- 1.4 points before treatment versus 3.6 +/- 0.5 on day 1 of the last cycle, p > 0.05). Haemoglobin values were 118.4 +/- 12.3 g/l before CT and 109.0 +/- 11.3 g/l on day 1 of last cycle of CT (p > 0.05). The mean number of platelets in the beginning and in the end was 256 +/- 123(*)10(12)/l and 217 +/- 119(*)10(12)/l, respectively (p < 0.05). White blood cell count was 8.36 +/- 3.21(*)10(9)/l, absolute granulocyte count 5.95 +/- 5.81(*)10(9)/l before the treatment, and these data were 4.50 +/- 1.96(*)10(9)/l and 2.15 +/- 1.21(*)10(9)/l, respectively, on day 1 of last cycle of CT (both p < 0.005).

CONCLUSIONS

Cisplatin-vinorelbine CT is a safe and well-tolerated chemotherapeutic option of NSCLC.