Increased Survival in Patients With Metastatic NSCLC Receiving Treatment in Academic vs Community Centers
Patients with metastatic non–small cell lung cancer (NSCLC) receiving treatment at academic centers have an increased 2-year survival compared to patients treated at community-based centers, according to findings published by Ramalingam et al in the Journal of Thoracic Oncology. An overall histology-dependent survival difference was also noted in patients with adenocarcinoma vs squamous cell carcinoma and varied by treatment facility.
Roughly 85% of diagnosed lung cancers are NSCLCs, with about 40% of patients with NSCLC presenting with stage IV metastatic disease. Adenocarcinoma histologic subtype accounts for 40% of all NSCLC and squamous cell carcinoma histologic subtype accounts for roughly 30%. Treatment for metastatic NSCLC has evolved over the last 2 decades, with an increasing focus on treatment strategies driven by histology and molecular profile of the tumor cells. With the availability of new treatment agents and molecular testing, there is growing concern that oncologists at academic centers may have access to resources and specialists that community-based centers may not have access to, and that disparities in care and survival differences may exist.
Study Methods
A group of investigators from Duke University used the National Cancer Database (NCDB) to retrospectively evaluate whether treatment at academic centers was associated with a survival advantage in metastatic NSCLC. The data were selected from 1998 to 2012 after the introduction of novel NSCLC chemotherapy agents. The primary outcome was 2-year survival that was analyzed using a multivariable regression model controlling for age, year of diagnosis, gender, primary payer, histology, and facility type (academic centers vs community-based centers).
A total of 193,279 patients with clinical or pathologic metastatic NSCLC were included in the study. All baseline differences between academic centers and community-based centers were statistically significant at P < .001. In academic centers compared to community-based centers, the mean age was 62.1 vs 64.2 years. There was a higher percentage of black patients in academic centers compared to community-based centers, 17.1% vs 9.6%. There was a lower percentage of patients in academic centers with the Charlson Comorbidity Index score of 2 or greater—7.3% vs 9.3%. There was also a lower percentage of patients insured by Medicare in academic centers compared to community-based centers, 37.4% vs 47.9%.
Findings
A greater increase in survival was noted in academic centers compared to community-based centers. In 1998 the percentage of patients achieving 2-year survival was higher in academic centers vs community-based centers—11.5% vs 9.2%—and by 2010 had increased to 17.4% vs 13.1%. An overall histology-dependent survival difference was also noted in adenocarcinoma vs squamous cell carcinoma, 10.2% vs 9.9% in 1998, increasing to 17.3% vs 10.1% in 2010. Adenocarcinoma survival also varied by treatment facility, where the difference in 2-year survival in academic centers vs community-based centers increased from 12.3% vs 9.1% in 1998 to 20.5% vs 15.5% in 2010.
The authors commented, “To our knowledge, this is the first study comparing outcomes between [academic centers] and [community-based centers] broadly across metastatic NSCLC using a multivariable model to control for confounding factors. We observed that patients treated at [academic centers] and [community-based centers] with metastatic NSCLC had improving survival from 1998 to 2010, and that this improvement in outcomes occurred to a greater extent in patients treated in academic centers. This survival advantage was predominantly seen in patients with adenocarcinoma histology compared to squamous cell carcinoma. Because of the asymmetric increase in treatment options for adenocarcinoma and the absence of data for specific systemic agents in the NCDB, this histology-based difference was consistent with our hypothesis that treatment within [academic centers] has conferred a survival advantage for patients with NSCLC following the introduction of novel targeted therapies that require a molecularly-driven, histologically-specific approach.”
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