CME
Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™
Released: October 25, 2022
Expiration: October 24, 2023
Wade T. Iams, MD, MSCI:
We have been discussing practice-changing data in early‑stage NSCLC and novel therapy on the horizon for patients with advanced NSCLC and SCLC, but it is always important to think about how these advances are being distributed across society as a whole.
Numerous reports have recently highlighted healthcare disparities, particularly in groups of patients with lung cancer and other types of cancer, such as in various racial and ethnic groups, socioeconomic groups, or older patients. One study at WCLC 2022 suggested how socioeconomics could be underpinning some disparities in novel therapies in patients with NSCLC.20
Wade T. Iams, MD, MSCI:
This retrospective, population‑based study from the United Kingdom assessed the potential association between socioeconomic deprivation and use of novel therapies for patients with NSCLC in a publicly funded healthcare setting.20
In this analysis, 195,387 patients with NSCLC diagnosed between January 2012 and December 2017 from the National Cancer Registration and Analysis Service and the linked Systemic Anti-Cancer Therapy database in the United Kingdom were grouped by socioeconomic deprivation status using the Index of Multiple Deprivation (IMD). Multivariable logistic regression was used to evaluate any association between IMD and treatment use with targeted therapies, biologics, and immunotherapy.
Wade T. Iams, MD, MSCI:
The cohort that was analyzed here consisted of nearly 200,000 patients with a diagnosis of invasive NSCLC, and almost 42,000 had therapies recorded that could be identified as potential novel anticancer therapies up to 2 years after diagnosis.20 Approximately 5% of the overall cohort received novel anticancer therapy, but it is important to think about therapeutic advances and how well we are deploying them among underserved patients.
Wade T. Iams, MD, MSCI:
In this cohort of patients, 92% were White and 85% were older (between 60 and 85 years of age).20 It is important to keep in mind that only 47% of the patients had stage IV disease. At the time of these analyses (2012-2017), stage IV patients were the primary cohort eligible for novel anticancer therapies. Fortunately for our patients, this has changed since that timeframe and patients with earlier-stage NSCLC are also eligible for novel therapies, including adjuvant EGFR inhibitor therapy as well as neoadjuvant and adjuvant immunotherapy.
IMD scores, ranked 1 to 5 with 5 being the most deprived, was somewhat equally distributed at approximately 20% of patients in each group.
Wade T. Iams, MD, MSCI:
One of the biggest takeaways is a clear stepwise difference in novel anticancer therapy use by IMD score in this large dataset. Patients with an IMD score of 1 (the least deprived group) had 6.7% of patients who received novel therapy, whereas only 4% of patients with an IMD score of 5 received a novel therapy (multivariable odds ratio of 0.54).20
It is concerning that patients who were lowest on the socioeconomic spectrum, based on that stepwise pattern, were least likely to receive any novel anticancer therapy, suggesting that socioeconomic status is a predictive biomarker of patients getting appropriate novel therapy, even in a publicly funded healthcare system.
Wade T. Iams, MD, MSCI:
The same trend was observed for targeted therapy or immunotherapy use.20 I think this was a nice way to break out the data and just remind ourselves that it does look like there seems to be a concerning trend in the deployment of these agents that have been so beneficial for so many of our patients with NSCLC.
Wade T. Iams, MD, MSCI:
There are important limitations that the authors of this study highlighted since we do not know about uncontrolled confounding factors.20 Smoking history is a huge factor, although I would posit that the stepwise pattern we are seeing in this large dataset does support this as a valid finding. Other limitations the authors mentioned include the continually evolving treatment paradigm since 2017, changing in quality of data over time, and the role of predictive biomarker testing as a barrier to treatment access. Furthermore, only 1 measure of socioeconomic status was used in this analysis and many other measures exist to try to delineate socioeconomic status.
Wade T. Iams, MD, MSCI:
Unfortunately, these data concur with many other studies suggesting that patients with the greatest economic need are less likely to receive up-to-date care for NSCLC. As we talk about all of these exciting new data and advances in clinical treatment from oncology conferences, it is also important to think about the systemic structures in place to ensure that everybody eligible for these breakthrough therapies has the opportunity to receive them.
Heather Wakelee, MD:
This was an important study to highlight things that we face in practice all the time, but it is important that we keep this in the front of our minds. The best therapies in the world are not helping people if we cannot get the people to the drugs and the drugs to the people. There are still many barriers to care that our medical training did not prepare us for but are so important. It behooves all of us to focus on what we can do to be sure that these incredible scientific advances are benefiting everybody who is grappling with lung cancer or other malignancies, or really any aspects of healthcare.
Heather Wakelee, MD:
Our final study that we will discuss highlighted the importance of talking about smoking cessation when we talk about lung cancer. Fully acknowledging that a large percentage of our patients may develop lung cancer after having never smoked, tobacco smoke still remains the most common cause of lung cancer and whatever we can do to reduce tobacco smoking will have a big impact on reducing lung cancer overall.
Heather Wakelee, MD:
The YESS trial was a randomized, controlled study within the Yorkshire Lung Screening Trial in the United Kingdom. Patients who were currently smoking and went to a lung health clinic were opted in to get immediate consultation for smoking cessation, meeting with a practitioner, getting behavioral support, and given pharmacotherapy as needed to help support smoking cessation. After 4 weeks, patients were then randomized to the intervention group or the usual care group.21 In the usual care group, patients received informed consent to monitor their smoking status using carbon monoxide monitoring after smoking cessation along with ongoing pharmacotherapy and behavioral support. In the intervention group, patients received all of the control group interventions along with personalized risk information and supportive communication. The personalized risk information was developed by CT scan images of each patients’ heart and lungs, which were then annotated and shown to the patient, so the patient could actually see the damage that was done in their own body from tobacco smoking.
The primary endpoint was a 7-day point-prevalent carbon monoxide–validated smoking cessation after 3 months. A 7-day point prevalence is defined by whether a patient has used cigarettes or other forms of tobacco in the past 7 days. Secondary endpoints included carbon monoxide–validated cessation at 4 weeks and 12 months, self-reported continuous cessation at 4 weeks, 3 months, and 12 months, attempts to quit smoking, and changes in psychological variables.
Heather Wakelee, MD:
There were more than 2000 patients who attended the lung cancer screening and were eligible for this program. Of these, 1905 saw a smoking cessation practitioner at the lung screening and 1609 agreed to ongoing smoking cessation support. Overall, 1003 consented to the YESS trial.21
Of the patients who were eligible for referral to a smoking cession practitioner (n = 2150), 12.4% had a 7-day validated point-prevalent abstinence 4 weeks after the lung health check. Of the patients who agreed to ongoing smoking cessation practitioner support (n = 1609), 16.5% had a 7-day validated point prevalent abstinence 4 weeks after the lung health check.
Heather Wakelee, MD:
Baseline characteristics were well balanced between the intervention group and the usual care group.21 The mean age was 65 years in both groups and 50% of patients were men. Most (80%) had a negative lung scan and approximately 50% were extremely or moderately confident that they could quit smoking. The majority had a moderate to high nicotine dependence.
Heather Wakelee, MD:
The percentage of patients with validated 7‑day point-prevalent abstinence at 3 months was slightly higher in the intervention group vs usual care (33.6% vs 30.0%; unadjusted odds ratio of 1.17). The cost per person for smoking cession was a bit higher for the intervention group.21
In addition, the validated 7‑day point-prevalent abstinence at 12 months was lower for both groups, at 29.2% in the intervention group and 28.6% with usual care.
Heather Wakelee, MD:
When we look at 7-day point-prevalent abstinence at 3 months and 12 months by various patient subgroups, the numbers for intervention vs usual care were not drastically different, except in women. At 3 months, the unadjusted odds ratio was 1.70 (95% CI: 1.15-2.53) with a P value of .008 in favor of the intervention group.
For men, the rate of quitting smoking at 3 months in the intervention vs usual care groups was not significantly different at 33.3% vs 37.8%, respectively. In women at 3 months, 33.9% had stopped smoking in the intervention group vs 23.1% in the usual care group.
Similar data were reported after 12 months, although it was not significant.21
Heather Wakelee, MD:
This study emphasizes that we have opportunities for novel interventions to try to encourage more people who are smokers to stop smoking. The more we can continue to focus on that in clinical practice, the better the outcomes for our patients will be.
Wade T. Iams, MD, MSCI:
I agree completely. I think it’s really important to continue to investigate innovative strategies to help patients quit smoking.
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