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Brief Report
August 9, 2018

Barriers to Combined-Modality Therapy for Limited-Stage Small Cell Lung Cancer

Author Affiliations
  • 1Division of Radiation of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston
  • 2Department of Radiation Oncology, University of Tennessee Health Sciences Center, Memphis
  • 3Department of Clinical Oncology and Nuclear Medicine, Alexandria University, Alexandria, Egypt
  • 4Division of Surgery, Department of Thoracic and Cardiovascular Surgery, University of Texas M.D. Anderson Cancer Center, Houston
  • 5Division of Surgery, Baptist M.D. Anderson Cancer Center, Jacksonville, Florida
JAMA Oncol. 2018;4(8):e174504. doi:10.1001/jamaoncol.2017.4504
Key Points

Question  What barriers affect utilization of combined-modality therapy for limited-stage small cell lung cancer (SCLC)?

Findings  In this analysis of National Cancer Database data, substantial proportions of patients did not receive chemotherapy (23%) or radiation therapy (41%) for limited-stage SCLC. Government insurance (Medicaid or Medicare) had no effect on chemotherapy administration but was independently associated with a lower likelihood of radiation therapy delivery, which was in turn, associated with worse survival.

Meaning  There are substantial barriers to standard-of-care therapy for limited-stage SCLC such as government insurance.


Importance  Combined-modality therapy with chemotherapy and radiation therapy plays a crucial role in the upfront treatment of patients with limited-stage small cell lung cancer (SCLC), but there may be barriers to utilization in the United States.

Objective  To estimate utilization rates and factors associated with chemotherapy and radiation therapy delivery for limited-stage SCLC using the National Cancer Database.

Design, Setting, and Participants  Analysis of initial management of all limited-stage SCLC cases from 2004 through 2013 in the National Cancer Database.

Main Outcomes and Measures  Utilization rates of chemotherapy and radiation therapy at time of initial treatment. Multivariable analysis identified independent clinical and socioeconomic factors associated with utilization and overall survival.

Results  A total of 70 247 cases met inclusion criteria (55.3% female; median age, 68 y [range, 19-90 y]). Initial treatment was 55.5% chemotherapy and radiation therapy, 20.5% chemotherapy alone, 3.5% radiation therapy alone, and 20.0% neither (0.5% not reported). Median survival was 18.2 (95% CI, 17.9-18.4), 10.5 (95% CI, 10.3-10.7), 8.3 (95% CI, 7.7-8.8), and 3.7 (95% CI, 3.5-3.8) months, respectively. Being uninsured was associated with a lower likelihood of both chemotherapy (odds ratio [OR], 0.65; 95% CI, 0.56-0.75; P < .001) and radiation therapy (OR, 0.75; 95% CI, 0.67-0.85; P < .001) administration on multivariable analysis. Medicare/Medicaid insurance had no impact on chemotherapy use, whereas Medicaid (OR, 0.79; 95% CI, 0.72-0.87; P < .001) and Medicare (OR, 0.86; 95% CI, 0.82-0.91; P < .001) were independently associated with a lower likelihood of radiation therapy delivery. Lack of health insurance (HR, 1.19; 95% CI, 1.13-1.26; P < .001), Medicaid (HR, 1.27; 95% CI, 1.21-1.32; P < .001), and Medicare (HR, 1.12; 95% CI, 1.09-1.15; P < .001) coverage were independently associated with shorter survival on adjusted analysis, while chemotherapy (HR, 0.55; 95% CI, 0.54-0.57; P < .001) and radiation therapy (HR, 0.62; 95% CI, 0.60-0.63; P < .001) were associated with a survival benefit.

Conclusions and Relevance  Substantial proportions of patients documented in a major US cancer registry did not receive radiation therapy or chemotherapy as part of initial treatment for limited-stage SCLC, which, in turn, was associated with poor survival. Lack of radiation therapy delivery was uniquely associated with government insurance coverage, suggesting a need for targeted access improvement in this population. Additional work will be necessary to conclusively define exact population patterns, specific treatment deficiencies, and causative factors leading to heterogeneous care delivery.