Evidence suggests that some lung cancer patients could be treated more aggressively to save lives. Imaging with an integrated positron emission tomography-computed tomography (PET/CT) scanner should be performed to stage patients prior to aggressive treatment. In 2014, 91% of patients had a PET/CT scan prior to surgery, exceeding Cancer Care Ontario’s program target of 90%.
Fifty-five percent (55%) of patients with Stage II or IIIA resected non-small cell lung cancer (NSCLC) are being treated with guideline-recommended chemotherapy following surgical removal of their tumour. Inoperable Stage IIIA and IIIB patients include a heterogeneous group of patients, many of whom are frail, with almost half able to receive potentially curative therapy. An additional 38% of patients receive other acceptable treatments, including radiation or chemotherapy, which are intended to palliate cancer-related symptoms.
What is NSCLC?
- There are several different types of lung cancer; NSCLC is the most common type. The types of lung cancer are named for how the cells look under a microscope.
- NSCLC usually grows and spreads slower than the other major type of lung cancer (small cell lung cancer).
- There are different sub-types of NSCLC, each made up of different types of cancer cells.
- Information about the exact type (and sub-type) of cancer and the extent of its spread (see “Stage at Diagnosis”) is important for the selection of the most appropriate treatment1.
- In addition, factors such as physical stamina (performance status), recent weight loss, age and other health problems (co-morbidities) are important considerations that are considered when deciding what is the most appropriate treatment approach.
What are the treatment guidelines for lung cancer?
- Treatment guidelines are evidence-based statements about the best practice for treating different types of cancer.
- A PET scan is a type of nuclear medicine imaging examination; it provides pictures of what is happening inside the body at the molecular and cellular level. PET imaging is typically performed on a combined PET/CT scanner to help localize the information from the PET scan to the patient’s anatomy. For NSCLC, a PET/CT scan should be performed to confirm the tumour has not spread to distant sites (i.e. that it is localized) before proceeding with aggressive therapies.
- Stage II (early stage) NSCLC is usually treated by surgical removal (resection) of the tumour.
- In medically fit patients with Stage II NSCLC who have had their cancer removed by surgery, adjuvant chemotherapy improves survival2.
- Some Stage IIIA (locally advanced stage) cases also may be resected. Surgery alone, however, is not usually adequate to eliminate the disease and prevent it from returning (recurrence). Adjuvant chemotherapy can also improve survival for these patients.
- Stage II and IIIA NSCLC patients who receive platinum-based chemotherapy within 120 days of their surgery are considered to be treated appropriately according to the lung cancer treatment guidelines3,4.
- The use of radiation is not recommended after complete surgical resection of NSCLC.
- For locally advanced (Stage IIIA and IIIB) NSCLC that cannot be removed surgically, research shows that treatment with a combination of chemotherapy and radiation improves survival4. Sequential and concurrent chemotherapy and radiation treatment both are considered acceptable clinical practice.
- Patients must be medically fit, have good performance scores and not have experienced significant weight loss4.
- Stage IIIA and IIIB inoperable patients who begin radiation treatment and platinum-based chemotherapy within 180 days after diagnosis are considered to be treated with curative intent according to the lung cancer treatment guidelines.
- Patients are involved in treatment decisions and may decline recommended treatments.
What do the results show?
Ninety-one percent (91%) of patients had a PET scan prior to lung cancer surgery, which meets the program target (Figure 1).
- Cancer Care Ontario measures general provincial access to PET/CT scans, as well as access for lung and lymphoma cancers.
- In 2014, 91% of NSCLC patients had a PET/CT scan prior to surgery, which exceeds Cancer Care Ontario’s aim of 90%.
- While there is some regional variation, most regions meet or exceed Cancer Care Ontario’s aim. It is noteworthy that some regions without local access to PET/CT scans have higher performance for this metric than some that do have local access. It thus is likely that regional performance has multiple factors, potentially including proximity to a PET/CT scanner and local referral patterns or practice.
- The Canadian Partnership Against Cancer’s (CPAC’s) 2015 Cancer System Performance Report measured the percentage of all NSCLC patients who received a PET scan (versus the indicator in this section, which measures only the percentage who had a PET scan prior to lung cancer surgery). In CPAC’s report, compared to 5 other provinces, Ontario had the highest percentage of patients at 38%5.
Over half of Stage II or IIIA resected NSCLC cancer patients were treated according to guidelines (Figure 2).
- From 2010 to 2013, 55% of patients with Stage II or IIIA NSCLC whose cancer was surgically removed received guideline-recommended adjuvant chemotherapy following surgery.
- Although Cancer Care Ontario continues to collaborate with regions to improve guideline concordance, it is accepted that some patients may not receive adjuvant chemotherapy because they have medical conditions that preclude its use or because they refused the treatment after being referred to a medical oncologist6.
- Large variations in the treatment of Stage II and IIIA resected NSCLC patients with guideline-recommended adjuvant chemotherapy continues to exist between Local Health Integration Networks (LHINs). Treatment rates range from 44% to 75%.
- Evidence suggests that although the use of adjuvant chemotherapy in the treatment of NSCLC is associated with an overall increase in survival7, compliance with adjuvant chemotherapy for patients who have had a lobectomy significantly decreases as age increases8.
- Compared with other provinces, Ontario has the highest percentage of Stage II or IIIA NSCLC patients treated with chemotherapy following surgery5.
Forty-eight percent (48%) of Stage IIIA or IIIB inoperable NSCLC patients are treated with curative intent with combined chemotherapy and radiation therapy, while 38% receive an acceptable alternative treatment within 180 days of diagnosis (Figure 3).
- From 2010 to 2013, 48% of patients with inoperable lung cancer received curative intent combined chemotherapy and radiation therapy treatment consistent with the guideline recommendations for Stage IIIA or IIIB NSCLC, with a regional variation of 31% to 63%.
- Thirty-eight percent (38%) of patients received an alternate acceptable therapy, while 15% received no tumour-targeted treatments within 180 days of diagnosis. These approaches may be medically appropriate, because combined modality therapy is indicated only for those patients who are medically fit and who have not had significant weight loss. Any patients who did not receive tumour-targeted treatment likely were too frail to withstand chemotherapy and/or radiation treatment. These patients often are given other forms of treatment to palliate cancer-related symptoms.
Treatment according to guidelines varies by age of the patient (Figure 4).
- For inoperable Stage IIIA or IIIB NSCLC patients, 69% of patients ages 41 to 60 were treated with curative intent, while only 9% of Stage IIIA and IIIB NSCLC patients ages 81 and older were treated with this aggressive form of combined chemo-radiation.
- The decrease in use of guideline-recommended chemotherapy for older patients has been reported previously9. This may be because trials of adjuvant chemotherapy often do not include the very elderly, so relying on evidence to make assumptions about older patients may be problematic10.
- Additional factors contributing to the decreased use of curative intent chemo-radiation in those ages 81 and above are that older patients may experience more adverse events when receiving combined chemo-radiation therapy, may be too frail or may have comorbidities that raise concerns about offering this type of treatment9.
Nearly all Stage IIIA and IIIB NSCLC patients across the province had a consultation with a medical and/or radiation oncologist (Figure 5)
- Seventy-seven percent (77%) of Stage IIIA and IIIB NSCLC patients had a consultation with both a medical and radiation oncologist, with a regional variation of 57% to 90%.
- Another 18% had a consultation with 1 of the specialists, while 5% of patients received no consultation within 180 days after their diagnosis.
- From a patient perspective, the fact that the majority of patients had a consultation with a specialist highlights how most had the opportunity to discuss treatment options.
- From a system performance perspective, we see that the majority of patients are being referred to specialists, so we can assume that variation in treatment rates are not due to patients not being referred.
Over 30% of inoperable Stage IIIA and IIIB patients who received no treatment had a medical and radiation oncologist consultation regardless of age (Figure 6)
- Among patients who received no treatment, 32% of patients ages 41 to 60 had a medical and radiation oncologist consultation, compared to approximately 40% of patients ages 61 to 80 and 37% of patients ages 81 and over.
- This is an interesting observation, as one may have expected to see a decline in the percentage of patients who received either or both consults with age. It is encouraging that we do not see age discrimination in the consultation rates. The data, however, suggest that there is a certain sub-group of patients who do not receive the consult regardless of age. It may be worthwhile to explor the factors that define and describe this population.
Why is this important to patient care?
- Understanding how and why treatment practices vary can inform efforts to improve quality of care and associated outcomes. Treatment guidelines, based on evidence from the latest clinical research, are meant to help clinicians and patients choose treatments that lead to the best possible outcomes.
- In 2009, the Disease Pathway Management Program at Cancer Care Ontario launched a lung cancer initiative as part of a broader drive to improve the quality of care, outcomes and patient experience for lung cancer patients.
- In partnership with patients, families and caregivers, the Disease Pathway Management Team developed a patient-friendly version of the lung cancer diagnosis pathway, which is being shared with patients through the Diagnostic Assessment Program (see Diagnostic Assessment Program Patient Experience Survey) and through nurse navigators in regional cancer centres across the province.
- Cancer Care Ontario is exploring the reasons why there is regional variability and variation in the uptake practice guidelines.
Guideline adherence is important to ensure patients are offered optimal care
- Although it is not expected that all NSCLC patients will be treated exactly according to a guideline, the current use is felt to be too low. Most clinical trials for chemotherapy after lung resection have involved patients with a good performance status3 and the results therefore cannot be generalized to all patients. Factors such as the intensity of symptoms of cancer and how well patients can perform routine daily activities and care for themselves are taken into account to calculate the performance status. The potential benefits, limitations and toxicity of treatment are discussed with patients3 and a decision is made that takes all of these factors into consideration.
- To understand the variation seen in the current data, Cancer Care Ontario needs better data on the functional status of patients, their personal preferences and if they have weight loss. These factors can determine whether chemotherapy is appropriate after lung surgery or whether the combined use of radiation and chemotherapy is appropriate for inoperable disease.
- We suspect that current concordance rates are lower than they should be and that more patients could potentially benefit from life-saving or life-prolonging treatment, but the fact that the majority of the patients are having consultations indicates that they do have an opportunity to discuss their options. Since not being able to discuss treatment options does not appear to be the limiting factor, Cancer Care Ontario can now probe the discrepancy between the consultation rates and the relatively low rates of patients receiving aggressive guideline-recommended treatment with curative intent.
Find out more
For more information on the evidence based guidelines for lung cancer, you can view the guidelines.
- National Cancer Institute [Internet]. Bethesda (MD); National Institute of Health. General information about non-small cell lung cancer; 2015 May 12 [cited 2016 Feb 16]. Available from: http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/Patient.
- The International Adjuvant Lung Cancer Trial Collaborative Group. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small cell lung cancer. N Engl J Med. 2004; 350:351–360.
- Okawara G, Ung YC, Markman BR, Mackay JA, Evans WK, and members of the Lung Cancer Disease Site Group. Postoperative adjuvant chemotherapy, with or without radiotherapy, in completely resected non-small cell lung cancer: a clinical practice guideline [Internet]. Toronto: Cancer Care Ontario; 2016 [cited 2016 Feb 16]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=351861.
- Okawara G, Mackay JA, Evans WK, Ung YC, and the PEBC Lung Cancer Disease Site Group. Management of unresected stage III non-small cell lung cancer: a clinical practice guideline [Internet]. Toronto: Cancer Care Ontario; 2013 [cited 2016 Feb 16]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=14204.
- Canadian Partnership Against Cancer. The 2015 cancer system performance report [Internet]. Toronto: Cancer Partnership against Canada; 2015 [cited 2016 Feb 23]. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/the_2015_cancer_system_performance_report_en.pdf.
- Kassam F, Shepherd F, Johnston M, Visbal A, Feld R, Darling G, et al. Referral patterns for adjuvant chemotherapy in patients with completely resected non-small cell lung cancer. J Thorac Oncol. 2007; 2(1):39–43.
- Williams CD, Gajra A, Ganti AK, Kelley MJ. Use and impact of adjuvant chemotherapy in patients with resected non-small cell lung cancer. Cancer. 2014; 120(13):1939–47.
- Licht PB, Schytte T, Jakobsen E. Adjuvant chemotherapy compliance is not superior after thoracoscopic lobectomy. Ann Thorac Surg. 2014; 98(2):411–15
- Abrams TA, Brightly R, Mao J, Kirkner G, Meyerhardt JA, Schrag D, et al. Patterns of adjuvant chemotherapy use in a population-based cohort of patients with resected stage II or III colon cancer. J Clin Oncol. 2011; 29(24):3255–62.
- Hubbard J, Jatoi A. Adjuvant chemotherapy in colon cancer: ageism or appropriate care? J Clin Oncol. 2011; 29(24):3209–10.