Survival among non-small cell lung cancer patients with poor performance status after first line chemotherapy

Abstract

Background Performance status (PS) is a commonly used factor in determining the appropriateness for chemotherapy of patients with non-small cell lung cancer (NSCLC). The prevalence of poor PS and impact of chemotherapy on survival among NSCLC patients has not been studied in community populations. Patients and Methods Insured patients, aged 50+ years, diagnosed with advanced stage NSCLC between 2000 and 2007 were identified via tumor registry (n=292) and linked to electronic medical records, automated medical claims, and Census tract information. A multivariate Cox proportional hazards model was used to determine the factors associated with survival. Results Of 292 stage IIIB-IV patients, 82 (28%) had PS 3 or 4, and 39% of PS 3–4 patients received first line chemotherapy. Those who received chemotherapy lived 4.8 months compared to 2.4 months for those who did not. Factors associated with a reduced likelihood of death included receipt of chemotherapy (hazard ratio [HR], 0.64), and female gender (HR, 0.71). Modern chemotherapy may be associated with positive effects on survival for poor PS patients, as for good PS patients. Further trials, especially randomized trials, in this neglected subgroup are indicated.

Chemotherapy Use, Performance Status, and Quality of Life at the End of Life

“…1,4,10,11 A study of patients with non-small-cell lung cancer (NSCLC) found that 28% of patients had performance status scores of 3 or 4 at presentation and that nearly 40% of these patients were receiving chemotherapy. 12 Available data for patients with NSCLC show a response rate of 2% for third-line and 0% for fourth-line chemotherapy. 13 This situation is not unique to NSCLC.…”

Assessing functional status and the survival benefit of chemotherapy for advanced non-small cell lung cancer using administrative claims data

“…The study included stage II and III lung cancer in which adjuvant or combined modality therapy may have been warranted, and included much younger patients. A later study of 292 stage IIIB-IV NSCLC patients aged 50 years or older, identified via tumor registry, chemotherapy was associated with a significant survival advantage even in poor PS patients but to a lesser degree than good PS patients [19].…”

Immune checkpoint inhibitors in challenging populations

“…Patients who present with advanced cancer and a poor Eastern Cooperative Oncology Group (ECOG) performance status present a challenging conundrum to oncology practitioners and, in many cases, overlap with other populations already discussed. In general, cytotoxic chemotherapy (particularly later lines of therapy) is associated with substantial toxicities, impaired quality of life, and a short lifespan in patients with an ECOG performance status ≥ 2 . By contrast, immune checkpoint inhibitors, particularly anti‐PD1/PD‐L1 monotherapy, often have favorable toxicity profiles, even in patients with a poor performance status.…”

“…In general, cytotoxic chemotherapy (particularly later lines of therapy) is associated with substantial toxicities, impaired quality of life, and a short lifespan in patients with an ECOG performance status 2. [60][61][62][63] By contrast, immune checkpoint inhibitors, particularly anti-PD1/PD-L1 monotherapy, often have favorable toxicity profiles, even in patients with a poor performance status. Moreover, some diseases such as Hodgkin lymphoma, Merkel cell carcinoma, and melanoma have response rates in the range of 40% to 90% (albeit in clinical trial populations), and this further complicates the decision.…”