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. 2023 Dec 1;64(6):ezad383.
doi: 10.1093/ejcts/ezad383.

Is underutilization of adjuvant therapy in resected non-small-cell lung cancer associated with socioeconomic disparities?

Jorge Humberto Rodriguez-Quintero  1 , Mohamed K Kamel  2 , Rajika Jindani  1 , Roger Zhu  1 , Patricia Friedmann  1 , Marc Vimolratana  1 , Neel P Chudgar  1 , Brendon Stiles  1
Affiliations

Is underutilization of adjuvant therapy in resected non-small-cell lung cancer associated with socioeconomic disparities?

Jorge Humberto Rodriguez-Quintero et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: Although adjuvant systemic therapy (AT) has demonstrated improved survival in patients with resected non-small-cell lung cancer (NSCLC), it remains underutilized. Recent trials demonstrating improved outcomes with adjuvant immunotherapy and targeted treatment imply that low uptake of systemic therapy in at-risk populations may widen existing outcome gaps. We, therefore, sought to determine factors associated with the underutilization of AT.

Methods: The National Cancer Database (2010-2018) was queried for patients with completely resected stage II-IIIA NSCLC and stratified based on the receipt of AT. Logistic regression was used to identify factors associated with AT delivery. The Kaplan-Meier method was applied to estimate survival after propensity-matching to adjust for confounders.

Results: Of 37 571 eligible patients, only 20 616 (54.9%) received AT. While AT rates increased over time, multivariable analysis showed that older age [adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.43-0.47], male sex (aOR 0.88, 95% CI 0.85-0.93) and multiple comorbidities (aOR 0.86, 95% CI: 0.81-0.91) were associated with decreased AT. Socioeconomic factors were additionally associated with underutilization, including public insurance (aOR 0.70, 95% CI: 0.66-0.74), lower education indicators (aOR 0.93, 95% CI: 0.88-0.97) and living more than 10 miles from a treatment facility (aOR 0.89, 95% CI: 0.85-0.93). After propensity matching, receipt of adjuvant therapy was associated with improved overall survival (median 76.35 vs 47.57 months, P ≤ 0.001).

Conclusions: AT underutilization in patients with resected stage II-III NSCLC is associated with patient, institutional and socioeconomic factors. It is critical to implement measures to address these inequities, especially in light of newer adjuvant immunotherapy and targeted therapy treatment options which are expected to improve survival.

Keywords: Adjuvant therapy; Disparities; Immunotherapy; Non-small-cell lung cancer; Systemic therapy.

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Conflict of interest statement

Conflict of interest: Brendon Stiles: Medtronic, AstraZeneca, Genentech, Pfizer, Arcus Biosciences, Merck, Bristol Myers Squib, BMS Foundation, Galvanize Therapeutics and the Lung Cancer Research Foundation. The rest of the authors have no conflicts of interest to disclose. Neel P. Chudgar: AstraZeneca.

Figures

Figure 1:
Figure 1:
Flow chart of the study cohort characteristics.
Figure 2:
Figure 2:
Proportion of patients who received adjuvant systemic therapy by year of diagnosis during the study period.
Figure 3:
Figure 3:
Proportion of patients who received adjuvant systemic therapy by geographic distribution in the USA.
Figure 4:
Figure 4:
Survival analysis comparing adjuvant systemic therapy versus surgery only.
Figure 5:
Figure 5:
Survival analysis adjusted for immortal time bias. aAT: adjuvant systemic therapy adjusted for immortal time bias; aS: surgery adjusted for immortal time bias; AT: adjuvant systemic therapy; HR: hazard ratio; S: surgery only. *Hazard ratio in the AT and S groups adjusted for immortal time bias. aAT line overlaps with the AT line.
None
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