Cary P. Gross, Craig S. Meyer, Sarika Ogale, Matthew Kent, and William B. Wong
Background: Evidence suggests that patients with Medicaid experience lower-quality cancer care than those with commercial insurance. Whether this trend persists in the era of personalized medicine is unclear. This study examined the associations between Medicaid (vs commercial) insurance and receipt of biomarker testing, targeted therapy, and overall survival in patients with advanced non–small cell lung cancer (aNSCLC). Methods: We conducted a retrospective study of patients who received an aNSCLC diagnosis from January 2011 to September 2019 using a nationwide US healthcare database. Eligible patients were aged 18 to 64 years with Medicaid or commercial insurance at diagnosis. Receipt of biomarker testing (ALK, EGFR, ROS1, BRAF, and PD-L1) was assessed. The likelihood of testing, biomarker-driven therapy (cancer immunotherapy or tyrosine kinase inhibitor treatment), and mortality were compared by insurance type using adjusted Cox regression. Results: Our sample included 6,145 commercially insured and 865 Medicaid beneficiaries. Medicaid beneficiaries were more likely to be Black or African American (20% vs 9.3%; P <.001) and were less likely to have undergone biomarker testing (57% vs 71%; P <.001). In the adjusted analysis, Medicaid beneficiaries were less likely to have evidence of testing (hazard ratio [HR], 0.81; P <.001), any first-line treatment (HR, 0.72; P <.001), and first-line biomarker-driven therapy (HR, 0.70; P <.001). Medicaid beneficiaries with evidence of biomarker testing had a lower risk of death compared with those without evidence of biomarker testing (HR, 1.27 [95% CI, 1.06–1.52]; P =.010). Higher risk of death was observed in patients with Medicaid versus commercially insured patients (HR, 1.23; P <.001); this result remained unchanged after adjusting for biomarker testing (HR, 1.22; P < .001) but was partially ameliorated after adjustment for testing and treatment type (HR, 1.12; P =.010). Conclusions: Medicaid beneficiaries with aNSCLC were less likely to receive biomarker testing and biomarker-driven therapies, which may in part contribute to a higher observed risk of mortality compared with commercially insured patients.
Alex T. Ramsey, Timothy B. Baker, Faith Stoneking, Nina Smock, Jingling Chen, Giang Pham, Aimee S. James, Graham A. Colditz, Ramaswamy Govindan, Laura J. Bierut, and Li-Shiun Chen
Background: Tobacco cessation after a cancer diagnosis can extend patient survival by improving outcomes for primary cancer and preventing secondary cancers. However, smoking is often unaddressed in cancer care, highlighting the need for strategies to increase treatment reach and cessation. This study examined a low-burden, point-of-care tobacco treatment program (ELEVATE) featuring an electronic health record–enabled smoking module and decision support tools to increase the reach and effectiveness of evidence-based smoking cessation treatment. Methods: This study included adult outpatient tobacco smokers (n=13,651) in medical oncology, internal medicine, and surgical oncology clinics from a large midwestern healthcare system. We examined reach and effectiveness of ELEVATE with 2 comparisons: (1) preimplementation versus postimplementation of ELEVATE and (2) ELEVATE versus usual care. Data were evaluated during 2 time periods: preimplementation (January through May 2018) and postimplementation (June through December 2018), with smoking cessation assessed at the last follow-up outpatient encounter during the 6 months after these periods. Results: The proportion of current tobacco smokers receiving cessation treatment increased from pre-ELEVATE to post-ELEVATE (1.6%–27.9%; difference, 26.3%; relative risk, 16.9 [95% CI, 9.8–29.2]; P<.001). Compared with 27.9% treatment reach with ELEVATE in the postimplementation time period, reach within usual care clinics ranged from 11.8% to 12.0% during this same period. The proportion of tobacco smokers who subsequently achieved cessation increased significantly from pre-ELEVATE to post-ELEVATE (12.0% vs 17.2%; difference, 5.2%; relative risk, 1.3 [95% CI, 1.1–1.5]; P=.002). Compared with 17.2% smoking cessation with ELEVATE in the postimplementation time period, achievement of cessation within usual care clinics ranged from 8.2% to 9.9% during this same period. Conclusions: A low-burden, point-of-care tobacco treatment strategy increased tobacco treatment and cessation, thereby improving access to and the impact of evidence-based cessation treatment. Using implementation strategies to embed tobacco treatment in every healthcare encounter promises to engage more smokers in evidence-based treatment and facilitate smoking cessation, thereby improving care cancer for patients who smoke.
Featured Updates to the NCCN Guidelines
Elizabeth A. Griffiths, Vivek Roy, Laura Alwan, Kimo Bachiashvili, John Baird, Rita Cool, Shira Dinner, Mark Geyer, John Glaspy, Ivana Gojo, Ashley Hicks, Avyakta Kallam, Wajih Zaheer Kidwai, Dwight D. Kloth, Eric H. Kraut, Daniel Landsburg, Gary H. Lyman, Anjlee Mahajan, Ryan Miller, Victoria Nachar, Seema Patel, Shiven Patel, Lia E. Perez, Adam Poust, Fauzia Riaz, Rachel Rosovsky, Hope S. Rugo, Shayna Simon, Sumithira Vasu, Martha Wadleigh, Kelly Westbrook, Peter Westervelt, Ryan A. Berardi, and Lenora Pluchino
The NCCN Guidelines for Hematopoietic Growth Factors provide recommendations for the appropriate use of growth factors in the clinical management of febrile neutropenia (FN), chemotherapy-induced thrombocytopenia (CIT), and chemotherapy-induced anemia (CIA). Management and prevention of these sequelae are an integral part of supportive care for many patients undergoing cancer treatment. The purpose of these guidelines is to operationalize the evaluation, prevention, and treatment of FN, CIT, and CIA in adult patients with nonmyeloid malignancies and to enable the patient and clinician to assess management options for FN, CIT, and CIA in the context of an individual patient’s condition. These NCCN Guidelines Insights provide a summary of the important recent updates to the NCCN Guidelines for Hematopoietic Growth Factors, with particular emphasis on the incorporation of a newly developed section on CIT.
David S. Ettinger, Douglas E. Wood, Dara L. Aisner, Wallace Akerley, Jessica R. Bauman, Ankit Bharat, Debora S. Bruno, Joe Y. Chang, Lucian R. Chirieac, Thomas A. D’Amico, Malcolm DeCamp, Thomas J. Dilling, Jonathan Dowell, Scott Gettinger, Travis E. Grotz, Matthew A. Gubens, Aparna Hegde, Rudy P. Lackner, Michael Lanuti, Jules Lin, Billy W. Loo Jr., Christine M. Lovly, Fabien Maldonado, Erminia Massarelli, Daniel Morgensztern, Thomas Ng, Gregory A. Otterson, Jose M. Pacheco, Sandip P. Patel, Gregory J. Riely, Jonathan Riess, Steven E. Schild, Theresa A. Shapiro, Aditi P. Singh, James Stevenson, Alda Tam, Tawee Tanvetyanon, Jane Yanagawa, Stephen C. Yang, Edwin Yau, Kristina Gregory, and Miranda Hughes
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non–Small Cell Lung Cancer (NSCLC) provide recommended management for patients with NSCLC, including diagnosis, primary treatment, surveillance for relapse, and subsequent treatment. Patients with metastatic lung cancer who are eligible for targeted therapies or immunotherapies are now surviving longer. This selection from the NCCN Guidelines for NSCLC focuses on targeted therapies for patients with metastatic NSCLC and actionable mutations.
Joe Y. Chang and Vivek Verma
Metastatic non–small cell lung cancer (NSCLC) is highly heterogeneous, and there are patients with limited areas of metastases (oligometastases) or progression (oligoprogression) whose natural history and prognosis can be considerably more favorable. As a result, local therapy may offer these patients a chance at clinically meaningful disease control and/or cure. This review begins by describing the current status of the existing prospective data, including evidence of overall survival improvements from multiple randomized trials. Given the nascence of this realm, the review then examines ongoing controversies and unresolved issues regarding local therapy for oligometastatic and oligoprogression. First, the role of local therapy in the setting of targeted therapies and immunotherapy is discussed, because most published randomized trials of local therapy have been performed in the context of chemotherapy, which is no longer the standard of care for most patients with metastatic NSCLC. Refining patient selection for local therapy is then reviewed, including clinical factors (such as control of the primary and regional lymph node sites, the heterogeneous definitions of oligometastases/oligoprogression, and the underrepresentation of brain metastases in existing randomized data) and novel pathologic/molecular biomarkers. Next, because there also remains no consensus regarding the optimal modality of local therapy, the advantages and disadvantages of stereotactic radiotherapy, surgery, and other ablative techniques are discussed. Subsequently, methods to optimize radiotherapy are examined, including controversies regarding the optimal dose/fractionation and timing/sequencing scheme. A discussion regarding potentially extending the existing data to polymetastatic NSCLC follows. The review concludes with remarks regarding prudently designing randomized trials of local therapy going forward, including the benefits and drawbacks of specific endpoints meriting further testing in this unique population.