title: Referral patterns in advanced non-small cell lung cancer: impact on delivery of treatment and survival in a contemporary population based cohort.
abstract: BACKGROUND
  Chemotherapy improves overall survival (OS) in advanced non-small cell lung cancer (NSCLC), yet low rates of chemotherapy utilization have been observed. We sought to characterize the clinical effectiveness of chemotherapy in the general population by evaluating referral patterns, predictors of chemotherapy receipt and outcomes.
  
  
  METHODS
  All referred cases of stage IIIB/IV NSCLC in British Columbia from January 1 to December 31, 2009 were retrospectively reviewed. Patient demographics, tumor characteristics and treatments were extracted. OS was estimated using the Kaplan-Meier method. Cox Proportional Hazards modeling was used to control for confounding variables. Multiple logistic regression was used to assess factors that predicted for chemotherapy treatment.
  
  
  RESULTS
  1373 patients were identified. Median age 70 years, 53% male, 37% ECOG ≥ 3.
  
  
  RESULTS
  34% non-squamous, 21% squamous and 46% NOS. 748 (54%) patients were assessed by medical oncology and 417 (30%) received chemotherapy. Predictors of chemotherapy treatment were younger age, ECOG 0-2, living in a rural area and not receiving radiotherapy. There was an improvement in OS in patients who received chemotherapy at 13.1 months versus best supportive care 5.4 months (p<0.0001). This remained statistically significant when controlling for ECOG, sex, age, histology (HR 0.68, CI 0.59-0.78).
  
  
  CONCLUSIONS
  In this population-based setting, 37% of patients had an ECOG ≥ 3 at the time of referral, 54% were assessed by a medical oncologist and only 30% received chemotherapy. This is despite the awareness that chemotherapy significantly improves survival. Strategies to optimize appropriate referral such that patients do not miss out on life-prolonging therapy should be evaluated.
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada.
authors.forename: Krista
authors.initials: K
authors.lastname: Noonan
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada.
authors.forename: King Mong
authors.initials: KM
authors.lastname: Tong
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada.
authors.forename: Janessa
authors.initials: J
authors.lastname: Laskin
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada.
authors.forename: Barbara
authors.initials: B
authors.lastname: Melosky
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada.
authors.forename: Sophie
authors.initials: S
authors.lastname: Sun
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada.
authors.forename: Nevin
authors.initials: N
authors.lastname: Murray
authors.affiliation: Department of Medical Oncology, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC, V5Z 4E6 Canada. Electronic address: cho@bccancer.bc.ca.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Ho
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011159:Population Surveillance; D011379:Prognosis; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D012189:Retrospective Studies
keywords: Advanced NSCLC; Population-based analysis; Referral patterns; Treatment delivery