Survival Comparison in Patients with Stage IV Lung Cancer in Academic versus Community Centers in the United States

Abstract

IntroductionAlthough metastatic NSCLC is widely treated in both academic centers (ACs) and community-based centers (CCs), it is unclear whether outcomes are similar across both settings. A growing variety of chemotherapies and targeted agents for an increasingly histology- and molecular-based treatment strategy could provide an advantage to patients treated in ACs. Using the National Cancer Database, we investigated whether treatment at ACs was associated with a survival advantage in metastatic NSCLC. MethodsWe conducted a retrospective analysis of the National Cancer Database after the introduction of novel NSCLC chemotherapy agents from 1998 to 2010. The primary outcome was 2-year survival, which was analyzed by using a multivariable regression model controlling for age, year of diagnosis, sex, primary payer, histologic type, facility type (AC versus CC), and an interaction term allowing a time-based comparison of survival between ACs and CCs. Alpha was set to 0.001 because of the size of the data set. ResultsThere were 193,279 patients included in this study. The percentage of patients achieving 2-year survival was higher in ACs versus in CCs in 1998 (11.5% versus 9.2% [+2.3%]), and by 2010, the difference had increased to 17.4% versus 13.1% (+4.3%). Multivariable analysis confirmed a significant relative increase in 2-year survival associated with ACs versus with CCs from 1998 to 2010 (p = 0.0005). A histology-dependent survival difference was also noted in adenocarcinoma versus in squamous cell carcinoma (10.2% versus 9.9% in 1998 [+0.3%], increasing to 17.3% versus 10.1% in 2010 [+7.2%]). Adenocarcinoma survival also varied by treatment facility, with the difference in 2-year survival in ACs versus in CCs increasing from 12.3% versus 9.1% (+3.2%) in 1998 to 20.5% versus 15.5% (+5%) in 2010, with a trend toward significance in our multivariable model (p = 0.005). ConclusionsA greater increase in survival was noted in ACs than in CCs over this time period, and it was particularly pronounced among patients with adenocarcinoma versus in those with squamous cell carcinoma. Given the known advances in adenocarcinoma treatment compared with in squamous cell lung cancer over this time period, our study suggests that potential treatment-related disparities may exist between ACs and CCs. Further study will be needed to validate this disparity in health care and address opportunities to improve survival in patients with stage IV NSCLC across treatment settings.