Post-Operative Chemotherapy for Patients with Stage II or IIIA Non-Small Cell Lung Cancer

  • Charts and Tables

    Charts and Tables

    Figure 4.27

    Percentage of Stage II or IIIA non-small cell lung cancer patients who received chemotherapy following surgical resection, by province — from 2009 to 2012 diagnosis years

    “—” Data not available.
    AB: All Alberta Cancer Registry coded surgeries were included for complete lung resection.
    MB: Oral chemotherapy included if available but may not be complete.
    PE: Data for 2010 represent 2009–10 combined. Data for 2011 represent 2010–11 combined. Data for 2012 represent 2011–12 combined.
    Data include chemotherapy started within 120 days following surgery.
    Data source: Provincial cancer agencies.

    Data Table

    ProvinceDiagnosis yearNumber of patients who received post-operative chemotherapyPercent (%)Lower bound of 95% confidence intervalUpper bound of 95% confidence interval
    BC2009----
    BC2010----
    BC2011----
    BC2012----
    AB20092745.833.158.5
    AB20104150.039.260.8
    AB20114945.836.455.2
    AB20125841.433.349.6
    SK2009950.026.973.1
    SK2010736.815.258.5
    SK20111747.230.963.5
    SK20121743.628.059.2
    MB20092143.829.757.8
    MB20102340.427.653.1
    MB20112548.134.561.7
    MB20122344.230.757.7
    ON200919658.052.763.3
    ON201033253.950.057.8
    ON201133253.950.057.8
    ON201236856.152.359.9
    QC2009----
    QC2010----
    QC2011----
    QC2012----
    NB2009----
    NB2010----
    NB2011----
    NB2012----
    NS2009----
    NS20102541.028.653.3
    NS20111850.033.766.3
    NS2012----
    PE2009----
    PE2010861.535.188
    PE2011746.721.471.9
    PE2012750.023.876.2
    NL2009----
    NL2010----
    NL2011----
    NL2012----

    “—” Data not available.
    AB: All Alberta Cancer Registry coded surgeries were included for complete lung resection.
    MB: Oral chemotherapy included if available but may not be complete.
    PE: Data for 2010 represent 2009–10 combined. Data for 2011 represent 2010–11 combined. Data for 2012 represent 2011–12 combined.
    Data include chemotherapy started within 120 days following surgery.
    Data source: Provincial cancer agencies.

    Figure 4.28

    Percentage of Stage II or IIIA non-small cell lung cancer patients who received chemotherapy following surgical resection, by age group — from 2009 to 2012 diagnosis years

    Data included AB, SK, MB and PE (provinces submitted comparable data for all four years).
    AB: All coded surgeries were included for complete lung resection.
    MB: Oral chemotherapy included if available but may not be complete.
    Data included chemotherapy started within 120 days following surgery.
    Data source: Provincial cancer agencies.

    Data Table

    Patient age groupDiagnosis yearNumber of patients who received post-operative chemotherapyPercent (%)Lower bound of 95% confidence intervalUpper bound of 95% confidence interval
    18-5920091965.548.282.8
    60-6920092554.340.068.7
    70-7920091634.020.547.6
    80+200900.00.00.0
    18-5920102754.040.267.8
    60-6920103251.639.264.1
    70-7920101534.920.649.1
    80+201000.00.00.0
    18-5920112761.447.075.8
    60-6920113751.439.862.9
    70-7920113142.531.153.8
    80+201100.00.00.0
    18-5920123063.850.177.6
    60-6920124257.546.268.9
    70-7920122929.920.839.0
    80+201200.00.00.0

    Data included AB, SK, MB and PE (provinces submitted comparable data for all four years).
    AB: All coded surgeries were included for complete lung resection.
    MB: Oral chemotherapy included if available but may not be complete.
    Data included chemotherapy started within 120 days following surgery.
    Data source: Provincial cancer agencies.

  • About this indicator

    About this indicator

    Key message

    Patients with Stage II or IIIA NSCLC aged 18–59 were twice as likely as patients aged 70–79 to receive guideline-concordant post-operative chemotherapy.

    Indicator definition

    The percentage of patients diagnosed with Stage II or IIIA non-small cell lung cancer (NSCLC) in 2010, 2011 and 2012 who received post-operative chemotherapy. Results are presented by province, age group and sex.

    Measured since

    The 2011 Cancer System Performance Report.

    Why measure this?

    The delivery of chemotherapy following resection has been shown to improve outcomes (i.e., disease-free and overall survival) and prevent recurrences in patients with Stage II or IIIA NSCLC, compared with surgery alone.1-4 Clinical practice guidelines therefore recommend post-operative chemotherapy for patients with Stage II or IIIA NSCLC.5 Measuring national practice patterns relative to this evidence-based guideline can help to identify variations, which could be addressed through quality improvement initiatives.

    What are the key findings?

    • In the 2012 diagnosis year, the percentage of patients with Stage II or IIIA NSCLC who received post-operative chemotherapy ranged from 41.4% in Alberta to 56.1% in Ontario, of the five reporting provinces (Figure 4.27).
    • Use of post-operative chemotherapy decreased with age: 63.8% of NSCLC patients aged 18–59 received postoperative chemotherapy, compared with 29.9% of those aged 70–79 (Figure 4.28).
    • There were no notable sex-related differences (data not shown).

    Why do these findings matter?

    The data suggest that the use of post-operative chemotherapy for Stage II or IIIA NSCLC is relatively consistent among the reporting provinces, but is not consistent across age groups. Patients aged 18–59 with Stage II or IIIA NSCLC are much more likely to receive post-operative chemotherapy than are patients aged 70–79. While older patients are more likely to have conditions that reduce their ability to tolerate chemotherapy, evidence does suggest that use of post-operative chemotherapy can improve survival for patients up to age 80.6-8 Given that, it is important to understand why treatment practices may vary based on patient age. Factors that may influence use of post-operative chemotherapy in patients with Stage II or IIIA NSCLC include medical conditions that preclude its use, refusal of treatment after being referred to a medical oncologist and lack of referral to a medical oncologist.

    References

    1. Pignon JP, Tribodet H, Scagliotti GV, Douillard JY, Shepherd FA, Stephens RJ, et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol. 2008 Jul 20;26(21):3552-9.
    2. Douillard JY, Rosell R, De Lena M, Carpagnano F, Ramlau R, Gonzales-Larriba JL, et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB-IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol. 2006 Sep;7(9):719-27.
    3. Winton T, Livingston R, Johnson D, Rigas J, Johnston M, Butts C, et al. Vinorelbine plus cisplatin vs. observation in resected non-small-cell lung cancer. N Engl J Med. 2005 Jun 23;352(25):2589-97.
    4. Arriagada R, Bergman B, Dunant A, Le Chevalier T, Pignon JP, Vansteenkiste J. Cisplatin-based adjuvant chemotherapy in patients with completely resected non-small-cell lung cancer. N Engl J Med. 2004 Jan 22;350(4):351-60.
    5. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer Version 4.2016. 2016.
    6. Cuffe S, Booth CM, Peng Y, Darling GE, Li G, Kong W, et al. Adjuvant chemotherapy for non-small-cell lung cancer in the elderly: a population-based study in Ontario, Canada. J Clin Oncol. 2012 May 20;30(15):1813-21.
    7. Pallis AG, Gridelli C, Wedding U, Faivre-Finn C, Veronesi G, Jaklitsch M, et al. Management of elderly patients with NSCLC; updated expert's opinion paper: EORTC Elderly Task Force, Lung Cancer Group and International Society for Geriatric Oncology. Ann Oncol. 2014 Jul;25(7):1270-83.
    8. Wisnivesky JP, Smith CB, Packer S, Strauss GM, Lurslurchachai L, Federman A, et al. Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study. BMJ. 2011;343:d4013.
  • Data specifications

    Data specifications

    Definition: The percentage of patients diagnosed with stage II or IIIA non-small cell lung cancer (NSCLC) who received post-operative chemotherapy

    Numerator: Stage II and IIIA non-small cell lung cancer cases that had a resection within one year of diagnosis and started adjuvant chemotherapy within 120 days of resection

    Denominator: Stage II and IIIA non-small cell lung cancer cases having a lung resection within one year of diagnosis

    Data source: Provincial cancer agencies

    Measurement timeframe: 2009, 2010, 2011 and 2012 diagnosis years

    Stratification variables: Province, age group, sex

    Provinces submitting data: AB, SK, MB, ON, NS, PE

    Province specific notes:

    • AB: For 2009, resections not necessarily limited to the specified types (lobectomy, pneumonectomy or segmentectomy). For 2010/2011/2012, treatment information is based on initially planned treatment to the primary site (ACR data). The CCI codes are not identified in the ACR, as such all coded surgeries were included for complete lung resection. If more than one surgical procedure is performed, the most definitive procedure is documented. The definition of definitive is the surgical procedure with the intent to care. This indicator excludes case with stage=”III”. Chemotherapy before surgery were excluded. There are some other procedures in which the margins could not be identified as negative.
    • SK: For 2011, data included squamous cell carcinoma cases. For 2012, all surgeries are included where margins could not be identified as negative, and oral and IV chemotherapy were not included.
    • MB: For 2009, oral drugs given at Cancer Care Manitoba are included. However, patients who received oral chemotherapy through prescription may be missed in the reported data. For 2010, oral chemotherapy was included but might not be complete. For 2012, all surgeries are included where margins could not be identified as negative.
    • ON: most oral chemotherapy were excluded since those data were not reliably reported to Cancer Care Ontario. 2009 data are for 2009/2010, 2010 data are for 2010/2011. 2011 data are for 2011/2012, 2012 data are for 2012/2013.
    • NS: For 2010/2011, collaborative stage variables were used to identify those having resections. Individual chart were reviewed to obtain resection date.
    • PE: For 2009, treatment intent filter was used to identify adjuvant therapy. It didn’t apply for 2010 data as it was only entered part way through the year so data is missing for half of the applicable cases. For 2011, data included squamous cell carcinoma cases.

    Notes:

    1. Non-small cell lung cases defined as ICDO3 codes: C34.0 to C34.9, AJCC group stage at diagnosis = II or IIIA.
    2. Lung resections defined as CCI codes 1GR87, 1GR89, 1GR91, 1GT59, 1GT87, 1GT89 or 1GT91 or list of descriptors in Appendix 1.
    3. Excluded lymphoma codes M-95 to M-98. For 2010/2011/2012, data also excluded sarcoma codes (see Appendix 1), neuroendocrine carcinoma. For 2010/2011, squamous cell carcinomas was also excluded, but included in 2012.
    4. Excluded histology codes: 8002, 8041, 8043, 8044, 8045, 8073 and 8803 in 2010/2011/2012 data.
    5. Resected cases included regardless of margin status (due to data limitations).
    6. Included cases where last resection data (if multiple)-diagnosis date<=365 days, chemotherapy start date – last resection date (if multiple) <=120 days.
    7. Chemotherapy includes oral (as available in data) and IV chemotherapy for 2010/2011/2012.
    8. Cases for patients under 18 years of age were excluded.
    9. No filter for treatment intent was used, unless specified by province for 2009.
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