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Purpose

Some elderly patients (≥ 65 years old) with small-cell lung cancer (SCLC) do not receive chemotherapy likely because of fear of toxicity and uncertainty regarding benefits. Thus, we aimed to study real-world trends in utilization of antineoplastics over the years and predictors of utilization, survival, and Medicare expenditure in elderly patients with extensive-stage (ES) SCLC.

Patients and Methods

Using the linked SEER and Medicare database, we identified elderly patients with newly diagnosed ES-SCLC between 2001 and 2013. The Wald test was used to determine the significance of trends. Cox proportional hazards models were applied for survival analyses. We used SAS, version 9.4 (SAS Institute, Cary, NC).

Results

We identified 15,763 patients with newly diagnosed ES-SCLC. Approximately 6,838 patients (43.38%) received antineoplastics, and 8,925 patients (56.61%) received supportive care only. Every year since 2001, the percentage of patients receiving antineoplastics has decreased (45.8% vs 36.6% in 2001 and 2013, respectively, P_trend <0.0001). Patients with advanced age (P<0.001), patients from high-poverty areas (P<0.001) or rural areas (P=0.005), patients with Charlson comorbidity index ≥ 3 (P<0.001), and non-Hispanic blacks (P=0.003) and Hispanics (P=0.001) were less likely to receive antineoplastics. Mean Medicare spending per patient decreased over the study period for patients treated with antineoplastics ($45,998 in 2001 and $35,053 in 2013, P_trend <0.001) and for those receiving supportive care only ($34,197 in 2001 and $25,265 in 2013, P_trend <0.001).

Conclusion

Decreasing utilization of antineoplastics in elderly patients with ES-SCLC since 2001 could be partly secondary to higher comorbidities and physiologic age, leading to poor candidacy. Medicare expenditures decreased likely as a result of value-based treatment initiatives by the Centers for Medicare and Medicaid Services. However, expenditures are likely to increase with use of expensive novel agents.

Read an interview with the lead author of the study here and read about the clinical implications of the study here.