Journal of Cancer Research and Therapeutics

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 14  |  Issue : 9  |  Page : 410--415

Patterns of care of nonsmall cell lung cancer patients in China and implications for survival


Yutong He1, Xue Qin Yu2, Qingwei Luo3, Xiaoli Xu1, Yudong Wang1, Shumei Li1, Baoen Shan1,  
1 Hebei Cancer Institute, Hebei Medical University Fourth Hospital, Hebei Province, China
2 Cancer Research Division, Cancer Council New South Wales; Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
3 Cancer Research Division, Cancer Council New South Wales, New South Wales, Australia

Correspondence Address:
Baoen Shan
Hebei Cancer Institute, 12 Jiankang Road, Shijiazhuang, Hebei Province
China

Abstract

Purpose: We reported the patterns of care for a cohort of Chinese patients with nonsmall cell lung cancer (NSCLC) and examined the characteristics of those patients who did not receive cancer-specific treatment. Materials and Methods: This was a prospective cohort study. The study population was patients with first primary NSCLC diagnosed and admitted to Hebei Cancer Hospital in Hebei Province in China from January 2004 to December 2005. Logistic regression was used to examine factors associated with no cancer-specific treatment. Cox proportional hazard regression was used to examine the effects of cancer treatment on survival. Results: Of 579 NSCLC patients included in the study, 73.4% were male, 84.3% died by the end of the study after 7 years follow-up, 40.1% were diagnosed at a late stage of disease, and 33.7% had unknown disease stage. Over half (50.8%) of the patients received palliative care, 23.8% for curative care, and 25.4% did not receive any cancer-specific treatment. The probability of not receiving cancer-specific treatment was significantly higher for those who diagnosed at older age (odds ratio [OR] =3.01, 95% confidence interval [95% CI]: 1.79–5.06), had unknown stage at diagnosis (OR = 2.77, 95% CI: 1.41–5.47), or had unclassified histological type (OR = 3.48, 95% CI: 1.94-6.21). After adjusted for other factors, patients received anti-cancer treatment had significantly lower risk of dying from NSCLC P < 0.0001) compared with patients who did not receive any cancer-specific treatment. Conclusions: Despite the benefits of anti-cancer treatments confirmed in this study, over a quarter patients did not receive any such treatment. Finding the reasons for the patients who did not receive cancer-specific treatment may improve the quality of patient care in this population.



How to cite this article:
He Y, Yu XQ, Luo Q, Xu X, Wang Y, Li S, Shan B. Patterns of care of nonsmall cell lung cancer patients in China and implications for survival.J Can Res Ther 2018;14:410-415


How to cite this URL:
He Y, Yu XQ, Luo Q, Xu X, Wang Y, Li S, Shan B. Patterns of care of nonsmall cell lung cancer patients in China and implications for survival. J Can Res Ther [serial online] 2018 [cited 2019 Oct 17 ];14:410-415
Available from: http://www.cancerjournal.net/text.asp?2018/14/9/410/179076


Full Text

 Introduction



Lung cancer is the most common cancer diagnosed in China.[1] The incidence of lung cancer in China increased in last two decades (Chen et al., 2015)[2] while it started decreasing in many developed countries.[3] This increasing trend is predicted to continue into the future due to the aging population, high smoking rates, and more importantly still rising tobacco consumption, especially in younger generation in China.[4]

Nonsmall cell lung cancer (NSCLC) is the most common form of lung cancer. The outlook for NSCLC remains poor as the majority of patients are diagnosed with advanced disease and are not appropriate candidates for surgical resection.[5] Treatment for NSCLC varies considerably according to disease stage and age at diagnosis. Surgery resection provides the greatest chance of cure for early stage of disease, and 5-year survival rates were 50–70% and 35–50% for Stages I and II disease, respectively.[6] Radiotherapy with curative or palliative intent can be effective, with reported 5-year survival rates of 13–39% for cases with inoperable early stages.[7] For cases diagnosed with advanced disease, previous studies suggested palliative therapies (radiotherapy, chemotherapy, or combination of two) may improve survival and quality of life.[8],[9],[10],[11]

Internationally, a few studies have examined the patterns of care of NSCLC in countries with well-developed and distributed healthcare systems.[12],[13],[14],[15],[16] Even in these developed countries, considerable proportion of lung cancer patients did not receive any anti-cancer treatment, ranged from 35% in Scotland,[17] 33% in Australia,[13] 30% in Canada [17] to 25% in the United States.[18] The possible reasons for this may include the high proportion of lung cancer patients presented with advanced stage at diagnosis and diagnosed at relatively older age (close to 70 years).[19] Other reasons for not receiving anti-cancer treatment may be due to patient's general health, clinician decision, or patient preference.[12] However, literature on how lung cancer patients are cared in China was limited. In this study, we aimed to report how lung cancer patients were managed in a Chinese provincial cancer hospital and examined the characteristics of those patients who did not receive cancer-specific treatment.

 Materials and Methods



This was a prospective cohort study conducted at Hebei Cancer Hospital, a provincial referral cancer hospital in China serving a population of 72 million people in Hebei Province. Hebei Province is located in Northern China on the North China Plain; it surrounds, but does not govern, China's capital Beijing and the port city of Tianjin. Ethical approval for the study was obtained from the Hebei Cancer Hospital Ethics Committee in 2003.

Study population

The study population was patients with first primary NSCLC diagnosed and admitted to the hospital in January 2004 to December 2005. The histology of all the specimens was examined and diagnosed by experienced pathologists in Hebei Cancer Hospital. Six hundred and fifty-seven patients were identified through the hospital clinic. After excluding three patients who were confirmed noncancer diagnosis and 75 patients who were small cell lung cancer, 579 NSCLC patients have included this study.

Cancer treatment

The type of cancer treatment is referred only to the initial management within the first 6 months of NSCLC diagnosis and did not include subsequent treatment in the course of the illness. The type of treatment was categorized into three groups: Curative care (received curative intent surgery at Stage I, II, or IIIa), palliative care (received at least one cancer-specific treatment without curative intent), and noncancer-specific treatment (refers to symptomatic management only, did not receive cancer-specific treatment which is defined as surgery, chemotherapy or radiotherapy, or combination of these therapies).

Survival outcome

The survival status and cause of death were obtained by regular outpatient review or regular telephone follow-up. Date of death was identified by medical records (for those who died in the hospital) or reports from their next of kin following telephone follow-up. All eligible cases were followed up from the first diagnosis date to the end of March 2011. The survival time was calculated from the date of the first NSCLC diagnosis to the date of death from NSCLC. Those who did not die from NSCLC were censored at the date of death from other causes or at March 31, 2011, if they were still alive.

Other variables

Other covariates include age at diagnosis, gender, disease stage at diagnosis, tumor histological type, site of primary tumor, occupation, and current smoking status. Disease stage was categorized as Stage I, Stages II–IIIa, Stages IIIb–IV, and unknown stage (Stage non-IIIb-IV) using the tumor-node-metastasis system.[20] For data analyses, Stage I and Stages II–IIIa were grouped together due to small sample size. The data were collected by abstracting information from the medical records by three trained field officers.

Statistical analysis

Multivariable binary logistic regression was used to examine the associations between cases' characteristics, and the odds of an NSCLC case did not receive cancer-specific treatment. The Kaplan–Meier method was used to calculate the survival time from NSCLC. Cox proportional hazard regression models were used to examine the effects of cancer treatment on survival after adjusting for other demographic and disease factors. The proportional hazards assumption was assessed and satisfied by testing the interaction of the variables included in the regression with time.[21] STATA (StataCorp version 11.1) was used to perform data analyses. All statistical tests were two-sided, and P < 0.05 was considered to be statistically significant.

 Results



Of the 579 NSCLC patients included in the study, 73.4% were male, 55.6% were current smokers at diagnosis, 84.3% died by the end of the study after 7 years follow-up, 40.1% were diagnosed at a late stage of disease, and 33.7% had unknown disease stage. The percentages of patients received curative care and palliative care were 23.8% and 50.8%, respectively. Over one-quarter of the patients did not receive any cancer-specific treatment. The distribution of patients' characteristics by cancer treatment was presented in [Table 1]. Surgery was the most common intervention for early stage disease (Stages I–IIIA). Cases with unknown stage at diagnosis had highest proportion of no cancer-specific treatment [Table 2].{Table 1}{Table 2}

Results from the multivariable logistic regression examining association between patients' characteristics and the likelihood of not receiving cancer-specific treatment are presented in [Table 3]. The probability of not receiving cancer-specific treatment was significantly higher for those who diagnosed at older age (odds ratio [OR] =3.01, 95% confidence interval [95% CI]: 1.79–5.06), had unknown stage at diagnosis (OR = 2.77, 95% CI: 1.41–5.47), or had unclassified histological type (OR = 3.48, 95% CI: 1.94–6.21).{Table 3}

One-year and 5-year overall survival rates were 51.5% and 18.0%, respectively. The median survival time for curative care, palliative care, and noncancer-specific treatment were 37.7, 11.5, and 4.5 months, respectively. [Figure 1] and [Figure 2] presented the survival distribution function by type of cancer treatment and stage at diagnosis. Patients received curative care or diagnosed with early stage had higher survival than other patients.{Figure 1}{Figure 2}

The unadjusted and adjusted hazard ratios (HRs) comparing the risk of dying from NSCLC were presented in [Table 4]. After adjusting for age, gender, tumor histological type, disease stage at diagnosis, site of primary tumor, occupation, and smoking status at diagnosis, patients received curative care (adjusted HR = 0.44, 95% CI: 0.31–0.64), or palliative care (adjusted HR = 0.75, 95% CI: 0.60–0.93) had significantly lower risk of dying from NSCLC (P < 0.0001) compared with patients who did not receive any cancer-specific treatment. Other significant predictors of survival include age, stage at diagnosis, histological type of tumor, and site of lung cancer.{Table 4}

 Discussion



This is the first prospective cohort study, to our knowledge, to examine patterns of care for NSCLC and long-term survival in a clinical setting in China. Despite the well-established evidence for benefits of anti-cancer treatment,[8],[9],[10],[11] over one-quarter of NSCLC patients admitted to this provincial referral hospital did not receive any anti-cancer treatment. Consistent with previous studies,[22],[23] this study also confirmed that cancer-specific treatment, including curative care and palliative care (chemotherapy, radiotherapy, or combination of the two), significantly improved patients' survival. These patients who did not receive any cancer-specific treatment had poorer survival even after accounted for differences in age at diagnosis and disease stage at diagnosis (two most important predictors for lung cancer survival).

There are several possible explanations why considerable proportion of NSCLC patients in this cohort did not receive cancer-specific treatment. Primarily, stage of disease at diagnosis is the main factor to determine the appropriate treatment for NSCLC.[20] In this cohort, unknown stage at diagnosis was found to be associated significantly with no anti-cancer treatment. Consistent with the literature,[24],[25],[26] this study confirmed that older patients or patients with “unclassified” histological types of cancer were more likely to have unknown stage, indicating that these patients may have received an incomplete diagnostic evaluation. We also found patients living in rural areas were more likely to have unknown stage which is a potential sign of socioeconomic disparities.

Patient factors may be associated with lack of cancer-specific treatment including increasing age, lower socioeconomic status, and poorer performance status.[14],[16],[27] Although numerous studies proved the benefits of treatment and improved survival for the elderly,[28],[29] we found that older patients were less likely to receive anti-cancer treatment. However, we did not find significant association between occupation of patients and anti-cancer treatment which may be because the study sample was limited to hospitalized patients who were considered to be in relatively similar socioeconomic status level.

The unawareness of palliative care benefits may also affect the decisions of both treating clinicians and patients. Clinician's attitude has been associated with cancer treatment recommendations in lung cancer.[19] A lack of consideration of palliative care benefits by treating clinicians or nihilistic attitudes toward lung cancer may contribute to the underuse of palliative therapy.[19] On the other hand, patients may refuse to receive anti-cancer treatment due to unaware of the potential beneficial of anti-cancer treatment on survival and quality of life.[16],[18] Previous studies provided quantitative evidence that lung cancer patients who are still alive 1 year after their cancer diagnosis, even those diagnosed at older age, would have much better survival outlook over the next 5 years than they did at diagnosis.[30] This information should be used by clinicians as a tool to make appropriate recommendations on treatment when discussing with patients about fears, hopes, and changing survival expectations over time.

Finally, the high cost of medical bills and unsatisfactory health outcomes may be important factors for making decisions to treatment or not.[31],[32] Unlike other developed countries, China is a country with no universal national health insurance coverage although this situation is changing now. On top of patients who did not receive hospital cancer care, patients admitted in hospitals may choose not to receive anti-cancer treatment due to economic barrier. The third National Health Services Survey (2003) showed that the residents in rural areas were less like to have health insurance compared with their counterparts in urban areas (13% vs. 63%).[33] The average cost of one admission to hospital was roughly equivalent to half year's income for a labor worker and was too expensive for low-income patients,[33] and the cost was even higher for hospitalized cancer care. Even for those insured, patients bear heavy costs of medical care (50% for inpatient cost)[34] which is too high for the vulnerable groups in the population. The actual reasons for not receiving anti-cancer treatment in this study are not clear based on the current data, but the vulnerable group and area inequality may be evident and require further attention.

In China, cancer care is received almost entirely in hospital rather than seeing a nonhospital-based practitioner.[35] The patterns of care in this cohort of lung cancer patients may be comparable to other similar level of hospitals in China. However, the actual nontreatment rate in the general population is expected to be much higher as a large number of patients who did not receive hospitalized care was not included in this study. Nevertheless, the findings of this study give causes for concern and call for further investigation on the number of patients who did not receive any anti-cancer care and its potential reasons for not receiving such treatment.

The study has some limitations. First, we do not have detail information on patient's performance status and comorbidities, thus, limited our ability to study the possible reasons for not receiving any anti-cancer treatment. Comorbidity has been found to be a factor in determining treatment for NSCLC.[12] Second, this is a single institution study and consequently, the results cannot be generalized to the whole population in Hebei Province. Indeed, it is possible that this cohort of patients may represent a group of patients with better outcomes than other lung cancer patients who never showed up at the hospital. As a result, the rate of no cancer treatment was potentially much higher in the general population in China. Last, we only recorded the cancer treatment during the first 6 months of NSCLC diagnosis. Even though half of the patients were dead after 1 year, the additional therapies may confound the results.

Despite the limitations discussed above, we believe this is an important study as it is the first study of the patterns of care of NSCLC patients in China using hospital based data. Despite the benefits of anti-cancer treatments confirmed in this study, a considerable number of patients did not receive any anti-cancer treatment. Identifying the reasons for not receiving any cancer-specific treatment may improve the quality of cancer care in this population; thus, appropriately detailed data to help understand these reasons are required, so interventions and policy changes can be guided by appropriate evidence. If we apply this rate (25.4%) to the estimated incidence rate of lung cancer in China in 2009 based on the most recent publication,[2] there would be about 148,200 patients with NSCLC in China who would not have received any anti-cancer treatment in 2009. Therefore, these findings are extremely important for the health service planning in China so that adequate resources for lung cancer patients, especially those living in rural areas, can be provided.

Acknowledgment

This study was supported by grants from the NSFC(81272682) and Financial department of Hebei Province (No. (2014)1257).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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