One in 5 Patients With Metastatic Cancer Receives No Treatment

Yael Waknine

June 12, 2012

June 12, 2012 (Chicago, Illinois) — Twenty-one percent of patients with stage IV cancer do not receive treatment, according to research presented here at the 2012 Annual Meeting of the American Society of Clinical Oncology (ASCO).

Patients with primary tumors in the kidney or lungs had the highest rates of nontreatment (25.5% and 24.0%, respectively); those with disease originating in the prostate had the lowest (11.1%).

Nontreatment was associated with a lack of medical insurance, older age, lower economic status, and being black.

"The strongest predictor of not receiving treatment in our study was lack of medical insurance, leading to a 47% to 246% higher likelihood of being untreated, which certainly speaks to healthcare disparities and access-to-care issues," said Alexander Small in an interview with Medscape Medical News. He is a fourth-year medical student at Mount Sinai School of Medicine in New York City and Doris Duke clinical research fellow in the division of hematology and medical oncology.

No multivariate analysis was performed to determine whether these factors are independently associated with nontreatment, he added.

"It is true that factors such as age, race, lack of insurance, and low income are associated with not receiving treatment — but they could all interrelate with each other," said Sylvia Adams, MD, assistant professor at the New York School of Medicine in New York City. She was not involved in the study, and was acting as an ASCO spokesperson.

"Advanced age and not having been seen by a doctor for a long time because of lack of insurance could result in a very low ECOG performance status," indicating that it is reasonable not to treat, Dr. Adams told Medscape Medical News, noting that the risk/benefit ratio is reversed in patients with these cancers who are bed-bound for more than 50% of the day.

"There are likely multiple reasons why patients with metastatic cancer do not receive anticancer therapy...such as poor functional status, comorbidities, and patient preference," Dr. Adams said. Small agreed, noting that rapid disease onset and progression can also influence treatment, or lack thereof.

More studies are needed to determine the reasons for nontreatment and its association with various factors, such as ECOG performance status, the number of patients refusing therapy, and what access to care was available after diagnosis, Dr. Adams explained.

More Than 750,000 New Diagnoses

The researchers examined data for 773,233 patients in a national hospital-based cancer registry, sponsored by the American College of Surgeons and the American Cancer Society, which includes data for more than 75% of new cancer cases in the United States.

The team looked at patients with stage IV nonsmall-cell lung [NSCLC], small-cell lung cancer [SCLC], and breast, kidney, prostate, colon, rectum, cervical, or uterine cancer diagnosed from 2000 to 2008. "No treatment" was defined as refusal of any type of intervention, death prior to treatment initiation, or physician recommendation that no treatment be given.

Physicians generally do not treat these cancers in patients with low ECOG performance status (being bed-bound for more than 50% of the day) because the risks for therapy outweighs the benefits, Dr. Adams explained. In contrast, other tumors, such as ovarian cancer, testicular cancer, and lymphoma, are always treated because 90% of patients achieve tumor shrinkage and get out of bed feeling better, Dr. Adams said.

Log-binomial regression analysis indicated that 25.5% of patients with metastatic renal cancer received no treatment, as did 24.7% of those with NSCLC, 24.4% with uterine cancer, 21.3% with SCLC, 16.5% with rectal cancer, 15.7% with colon cancer, 14.8% with cervical cancer, 12.8% with breast cancer, and 11.1% with prostate cancer.

"On the low extreme, breast and prostate cancer patients were the least likely to remain untreated, which may be related to the high rates of screening for these cancers and the relatively tolerable hormonal therapies available for the treatment of metastatic disease," Small said. At the other extreme, patients with NSCLC and SCLC had the highest rate of being untreated and accounted for 68% of the untreated population. "This is likely due a lack of consensus on screening, aggressive biology of this disease, and relatively more toxic treatment," Small explained.

With respect to socioeconomic factors, 22.7% of those with no insurance remained untreated, compared with 3.1% of those with private insurance, 18.2% with Medicaid, 25.2% with Medicare , and 24.0% with military insurance (prevalence ratio [PR], 1.47 to 2.46; P < .001). Lower income also predicted nontreatment (PR, 0.91 to 0.98 for every additional $10,000 in income; P < .001).

With respect to demographics, black patients were more likely than nonblack patients to remain untreated (PR, 1.05 to 1.32; P < .001), as were older Americans (PR, 1.37 to 1.49; P < .001).

The importance of these factors remains unclear, the researchers note.

"The study doesn't reveal the underlying reason for nontreatment. It could be related to performance status and justifiable and completely okay, but if it's not due to performance status or to refusal of patients, then those causes could be meaningful and should be explored further," Dr. Adams noted.

"Over 20% of patients don't get treated; the importance of this study is that it brings that to light. It identifies the substantial number of patients who do not receive therapy for stage IV cancers with the highest prevalence in the United States," Dr. Adams concluded.

The researchers have disclosed no relevant financial relationships. Dr. Adams reports financial ties to GlaxoSmithKline.

2012 Annual Meeting of the American Society of Clinical Oncology: Abstract 6065. Presented June 4, 2012.

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