Elsevier

Lung Cancer

Volume 63, Issue 1, January 2009, Pages 16-22
Lung Cancer

Regional differences in treatment and outcome in non-small cell lung cancer: A population-based study (Sweden)

https://doi.org/10.1016/j.lungcan.2008.05.011Get rights and content

Summary

In the recent decade uniform treatment guidelines for non-small cell lung cancer (NSCLC) have been introduced in Sweden. The objective of this study was to examine time trends and differences in treatment intensity for NSCLC between county clinical centres in Central Sweden. A second aim was to investigate whether any differences in treatment of NSCLC were associated with differences in survival.

4345 patients with a diagnosis of NSCLC between 1995 and 2003 were identified in the population-based Lung Cancer Register of Central Sweden. Multivariate logistic regression was used to estimate odds ratios to analyse the likelihood of receiving different treatment modalities for NSCLC. Cox proportional hazard models estimating relative hazard ratios were used to identify factors related to death (by any cause).

Of all patients, 33.4% received no treatment, and 17.5% underwent surgery. Between 1995 and 2003, the proportion of patients receiving chemotherapy rose from 14.6% to 55%. There were pronounced differences between county centres in treatment policies, especially concerning surgery and radiotherapy. The likelihood of receiving treatment for NSCLC was highest at county centre A where both surgical treatment and chemotherapy were given more often. Compared to this reference county, the risk of death was between 20% and 40% higher in the other counties after adjusting for age, stage, gender, time period, smoking status and histopathological type. When analyses were adjusted for treatment, county of residence was no longer a prognostic factor.

Despite common guidelines there were marked differences in treatment activity between the counties. Treatment activity was associated with survival. Survival benefits may follow improvement in compliance to guidelines.

Introduction

Approximately 80% of new lung cancer cases are of the non-small cell type (NSCLC) with a 5-year survival of 10–18% [1]. Of these patients, about 50% present with locally advanced or metastatic disease. Until recently, surgical resection was the only therapeutic modality with a curative potential in NSCLC [2]. Results from earlier studies indicate that chemotherapy can offer patients with advanced disease improvements in quality of life and survival compared with best supportive treatment. Recent findings, however, indicate that intensive chemotherapy may entail substantial survival benefits in patients of all ages with advanced disease [3], [4], [5].

In Sweden, uniform recommendations for diagnosis and treatment of lung cancer have been endorsed since 1995. These guidelines were revised in 1999–2000, recommending intensified activity for early detection of lung cancer and increased use of chemotherapy in advanced disease [3], [6]. International guidelines continuously evolve following the introduction of new cytotoxic regimens with lesser toxicity and a greater potential to offer palliation and prolonged survival [7], [8]. Few studies to date have examined whether adherence to guidelines translates into improved survival.

The present study examines the management of patients with NSCLC in relation to guidelines in seven counties in Central Sweden. Firstly, we examined time trends and regional differences in treatment intensity for NSCLC. Secondly, we investigated whether any differences in treatment of NSCLC were associated with differences in survival.

Section snippets

Patients and data collection

For the purpose of the present study, 4791 patients with a diagnosis of a primary NSCLC between January 1st 1995 and December 31st 2003, were identified in the Lung Cancer Register (LCR) of Central Sweden. This clinical database started in 1995, covering seven counties with about two million inhabitants representing 21% of the Swedish population. The composition of the population of Central Sweden has a mix of urban and rural inhabitants similar to that of Sweden as a whole. During the period

Results

Of all NSCLC patients, 2587 were men (mean age 69.2 years; range 23–95) and 1758 were women (mean age 66.3 years; range 26–92). The distribution of demographic characteristics of the patients, including smoking history, was very similar between the county centres (Table 1). The lung cancer diagnosis was verified with cytology or histopathology in more than 95% of cases in all counties but two (E and G county had 92% and 88% respectively).

The two most common histopathological tumour types were

Discussion

In this population-based clinical database, comprising all incident cases of NSCLC recorded in Central Sweden over 9-year-period, we found evidence of a wide variation of treatment strategies between county centres, despite consensus management guidelines for lung cancer. In the reference county centre, 83% of patients received any kind of treatment specifically directed towards lung cancer compared with a range of 59–71% for patients managed in the other centres. However, over time the

Contributors

All contributors took part in the conception and design of the study in the acquisition of data or statistical analyses, interpretation of data, and writing and revision of the report.

Conflict of interest

Part of the time of the study, Mats Lambe was employed by AstraZeneca. All other authors declare no conflicts of interest.

Acknowledgements

This study was supported by the Swedish Cancer Society and an unrestricted grant from AstraZeneca.

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