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    Original Investigation
    October 5, 2018

    Hospitalization and Survival of Medicare Patients Treated With Carboplatin Plus Paclitaxel or Pemetrexed for Metastatic, Nonsquamous, Non–Small Cell Lung Cancer

    Author Affiliations
    • 1The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
    • 2Department of Medicine, Geisel School of Medicine, Lebanon, New Hampshire
    • 3Norris Cotton Cancer Center, Lebanon, New Hampshire
    • 4Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
    JAMA Netw Open. 2018;1(6):e183023. doi:10.1001/jamanetworkopen.2018.3023
    Key Points español 中文 (chinese)

    Question  Does the risk of hospitalization among elderly patients receiving chemotherapy for metastatic, nonsquamous, non–small cell lung cancer vary by chemotherapy regimen?

    Findings  In a cohort study of 2182 propensity-matched Medicare beneficiaries with non–small cell lung cancer, the 30-day hospitalization risk was 5% lower for patients receiving carboplatin with pemetrexed (21%) than for those receiving carboplatin with paclitaxel (26%), a statistically significant difference.

    Meaning  When multiple standard-of-care chemotherapy regimens are available in a specific treatment setting, measures of regimen-specific hospitalization risk may be relevant for treatment selection.


    Importance  Chemotherapy is a mainstay treatment of metastatic non–small cell lung cancer. However, little is known about the comparative risk of hospitalization associated with commonly used chemotherapy regimens.

    Objective  To evaluate the real-world association of specific lung cancer chemotherapy regimens with measures of acute hospital care (primary objective) and survival (secondary objective).

    Design, Setting, and Participants  Retrospective, propensity-matched, cohort study using the Surveillance, Epidemiology, and End Results–Medicare linked data for cancer diagnoses between 2008 and 2013, with follow-up through 2014. Patients were Medicare beneficiaries 66 years of age or older receiving initial chemotherapy for treatment of stage IV, nonsquamous, non–small cell lung cancer. Analyses were performed between September 2017 and April 2018.

    Exposures  Receipt of chemotherapy with carboplatin-pemetrexed or carboplatin-paclitaxel, with or without concurrent bevacizumab.

    Main Outcomes and Measures  The primary outcome was risk of hospitalization within 30 days of chemotherapy initiation. Secondary measures included cumulative 90-day hospitalizations, 90-day mean hospital-free survival time, and overall survival.

    Results  Of the 3310 eligible patients, 1823 received carboplatin-pemetrexed, and 1487 received carboplatin-paclitaxel. The median age at diagnosis was 73 years (interquartile range, 69-77 years), 1784 patients (53.9%) were men, and 2909 patients (87.9%) were non-Hispanic white. In total, 2182 patients were included in the propensity-matched analysis. The 30-day hospitalization risk was 20.7% (95% CI, 18.3%-23.1%) among patients receiving carboplatin-pemetrexed vs 26.0% (95% CI, 23.4%-28.6%) among patients receiving carboplatin-paclitaxel (5.3% difference; P = .003). The 90-day cumulative hospitalizations did not differ significantly between the 2 treatment groups; however, the 90-day mean hospital-free survival time was improved for patients receiving carboplatin-pemetrexed (68.4 days [95% CI, 66.5-70.4 days] vs 63.6 days [95% CI, 61.6-65.7 days]; P = .001). The median survival time was 9.0 months (95% CI, 8.4-9.5 months) with carboplatin-pemetrexed therapy vs 7.6 months (95% CI, 7.0-8.4 months) with carboplatin-paclitaxel therapy (P = .005). Stratified analyses showed no association of bevacizumab use with hospitalization risk or survival when combined with either chemotherapy regimen.

    Conclusions and Relevance  The findings from this study suggest that patients receiving carboplatin-pemetrexed compared with those receiving carboplatin-paclitaxel have a lower 30-day hospitalization risk, a greater 90-day hospital-free survival, and improved overall survival. Information about hospitalization risk may provide valuable context for evaluating real-world cancer treatment outcomes.