Despite breakthroughs, many go without treatment for metastatic lung cancer

About half of people diagnosed with metastatic non-small-cell lung cancer never receive treatment, despite advances in options over recent decades that have created meaningful improvements in lifespan and quality of life for many patients.  

Although it’s difficult to know how many were too sick to be treated by the time they were diagnosed, a significant minority appeared to be suitable candidates for treatment – meaning that people who could possibly have had more good years with family and friends simply didn’t receive the systemic therapies that could have made that happen. 

This startling reality was quantified and characterized for the first time in a paper published May 7 in JAMA Oncology. Gerard Silvestri, M.D., and Adam Fox, M.D., both lung cancer pulmonologists at MUSC Hollings Cancer Center and the Thoracic Oncology Research Group, led the study team on behalf of the American Cancer Society National Lung Cancer Roundtable (ACS NLCRT), which funded the study.  

“Funding from the American Cancer Society for this study was critical since the findings are a loud wake-up call to the clinical community that an alarming number of patients with advanced lung cancer are not receiving an opportunity to benefit from modern therapies,” said Robert Smith, Ph.D., the American Cancer Society co-chair of the ACS NLCRT and a co-author on the study. 

The statistic floored Fox and Silvestri, whose research had started with a different question.  

“The thing we really wanted to look at was the prevalence of biomarker testing,” Fox said. Many of the new treatments for lung cancer are targeted toward specific genetic mutations, and biomarker testing allows doctors to match the treatment to the patient. 

“And we said, ‘Well, before we look at how many people get tested, we should start to know how many people even get treated.’” 

Talking to colleagues from across the country, they got the sense that most oncologists thought that 80% to 90% of patients get treated.  

And from an oncologist’s perspective, that’s probably about right, Fox said.  

“If you make it to a medical oncologist, especially to one who specializes in lung cancer, like at a cancer center or a specialty referral center, then your odds of getting treated are going to be much higher,” he said.  

Unfortunately, the numbers showed that many people never even see an oncologist.  

“The take-home message for physicians is get patients to an oncologist – quickly – so that we can see if they’re eligible for one of these new treatments,” Silvestri said.  

These new treatments include targeted therapies for specific genetic mutations. But even without one of these genetic mutations, nearly all lung cancer patients should be able to receive immunotherapy.  

Many patients, though, are too sick with advanced lung cancer at the time of diagnosis and die before treatment can be selected and used. About 40% of patients in the study were deceased within 90 days of diagnosis. That points to the importance of screening so that lung cancer can be discovered at an earlier stage and also of getting patients referred promptly so a full workup can be performed and treatment administered. For those who are not eligible for screening based on the guidelines, it is important not to ignore persistent and unexplained respiratory symptoms. 

Silvestri and Fox are planning new research to delve into the reasons why people aren’t treated. Although this paper doesn’t answer that question, they have some ideas based on their experience.  

• Outdated expectations. “Gerard and I have patients all the time saying, ‘Oh, I remember my father or mother got diagnosed with lung cancer. And man, as soon as they got chemotherapy, they were gone,’” Fox said. Those patients aren’t wrong – lung cancer treatment in the past came with harsh side effects and little benefit. But that’s not the case for newer therapies, which in some cases have extended survival by almost seven years. That message may not be getting out, though – either to patients or to clinicians.  

• Lack of social support. The paper posits that a lack of transportation or receiving care at under-resourced medical facilities could also be contributing. The study did find that married patients were more likely to be treated, which fits with existing research.   

• Poor health. Guidelines for treatment come from clinical trials that usually involve patients who are in relatively good health, aside from the lung cancer, on the theory that people with multiple health problems are less able to handle toxic side effects.  

The paper calls for including people in poorer health in clinical trials, given that immunotherapies have fewer side effects than traditional chemotherapies. There’s potentially a larger pool of patients who could benefit from these new therapies.  

There’s a lot of work to do to change perceptions, the researchers said. The paper looked at data from 2006 to 2021, meaning it covered a time when chemotherapy was the primary treatment, through a time when immunotherapies and targeted therapies became available. And yet, the increase in people who received treatment over time was “unimpressive.”  

“I think everyone is really excited about all the advances,” Fox said. “Still, we think there's gaps in the implementation, and there's certainly more work to be done.” 

To put that in perspective, Silvestri noted that more than 200,000 people will be diagnosed with lung cancer in the U.S. this year. About 100,000 of those cases will have metastatic disease at diagnosis, but only half will receive treatment.  

“Lung cancer remains the leading cause of cancer-related deaths in this country, with more Americans dying of this disease than the next two cancer types combined,” he said. “The onus is on the medical community to diagnose disease early, refer to an oncologist quickly and recognize and communicate to patients that there are available treatment options that can improve both quality of life and survival.”