Not All Small-Cell Lung Cancer Treatment Is Equal

Although researchers have come far in developing the best treatments and regimens for patients with cancer, there are still many barriers to the care they receive.

For patients with lung cancer, time is of the essence. About 10 to 15 percent of all lung cancers are cases of small-cell lung cancer (SCLC), which tends to grow faster than non-small cell lung cancer.

Standard-of-care for the initial management of patients with non-metastatic SCLC consists of chemotherapy combined with radiation. However, large percentages of patients in the United States do not receive these treatments, and had worse overall survival, according to a recent study published in the Journal of the American Medical Association Oncology.

“What was surprising was the large percentage of patients not getting radiation therapy — probably about 45 percent,” said Stephen G. Chun, M.D., assistant professor of radiation oncology at The University of Texas MD Anderson Cancer Center in Houston. “What was more startling was that 1 in 5 patients received neither chemotherapy nor radiation and had dismal survival of three to four months.”

The team of researchers used the National Cancer Database — a nationwide outcomes registry of the American College of Surgeons, the American Cancer Society and the Commission on Cancer — to identify 70,247 patients diagnosed with non-metastatic, or limited-stage, SCLC. They examined survival and socioeconomic factors to determine obstacles in cancer treatment across the country.

Initial treatment of patients, of which the majority were women (55.3 percent) included: chemotherapy and radiation (55.5 percent), chemotherapy alone (20.5 percent), radiation alone (3.5 percent), neither chemotherapy or radiation (20 percent) and not reported (0.5 percent).

Compared with the other treatment groups, patients who received neither chemotherapy nor radiation had a median survival of 3.7 months. The patients who received a combination of both chemotherapy and radiation had a median survival of 18.2 months. For those who received either chemotherapy or radiation alone, the median survival was 10.5 months and 8.3 months, respectively.

“What we saw reaffirmed what we already knew — that chemotherapy and radiation therapy had a significant survival benefit,” said Chun. “If you look at three months versus 18 months, you’re talking about a six-fold increase in survival. The chance of being cured without chemotherapy and radiation is extremely unlikely.”

Treatment at a non-academic center, no health insurance and Medicare or Medicaid coverage were associated with shorter survival. The researchers found that patients without health insurance were significantly less likely to receive chemotherapy or radiation therapy compared with patients who had private or managed care insurance. Patients with Medicare or Medicaid had similar chances of receiving chemotherapy as those with private insurance. However, they were less likely to receive radiation if they had Medicare or Medicaid.

“We speculated in our manuscript that might have something to do with targeted access programs for chemotherapy, such as 340B and the Medicaid Drug Rebate Program, that subsidize hospitals to deliver medications like chemotherapy,” said Chun. These programs provide no subsidies for radiation and may explain why patients with federal insurance were less likely to receive radiation, he added.

Breaking Barriers

The best way for a person to ensure that they receive standard-of-care is to advocate for themselves, said Chun.

“Patients should always feel comfortable getting a second opinion and make sure they receive multidisciplinary evaluation,” he said. “In this study, we were looking at combined modality care, meaning evaluation by the different specialties — surgery, medical oncology, radiation oncology.”

Chun posed the question, could the playing field be better leveled through targeted access programs for radiation in the same way that there are targeted access programs for chemotherapy? The jury is still out on this. More research will need to be conducted and these programs will need to be put in place to learn the true outcomes.

Clinical trials are another way in which patients with lung cancer can obtain some of the best care. Treatment with immunotherapy, specifically anti-PD1 or PD-L1 directed therapies, are showing promise in patients. Chun explained that at MD Anderson, and nationally, immunotherapy is being incorporated into treatment of SCLC through clinical trials.

“Not too long ago, small-cell lung cancer was one of the cancers that many would have thought was a death sentence, but with the incorporation of combined modality therapies patients shouldn’t lose hope,” Chun said. He hopes patients look at clinical trials as a way to “move the needle forward.”

One limitation of the study was a small amount of cases with insufficient data or follow-up. Researchers plan to conduct further research to define population patterns, specific treatment insufficiencies and the contributing factors to wide-ranging care delivery.

“We sought to determine the rates of standard of care delivery and we saw that for a substantial number of patients it wasn’t being delivered,” said Chun. “It’s associated with worse survival. We would like to see the playing field leveled for all patients — whether that be through a targeted access program or some other mechanism — so everyone has a chance.”