Adjuvant chemotherapy after resection of N1 non-small cell lung cancer: differential impact of new evidence on physician and patient decisions.
BACKGROUND
Adjuvant cisplatin-based chemotherapy (ACT) after resection of stages II-IIIA non-small cell lung cancer (NSCLC) modestly increased survival in several clinical trials. This study evaluated the subsequent impact of those trials on ACT use in clinical practice.


METHODS
Patients who underwent lobectomy or more extensive lung resection without induction chemotherapy for pathologically confirmed N1 positive NSCLC between 2000 and 2012 were reviewed. Referrals to medical oncology, oncologist recommendations for ACT, and initiation of ACT were evaluated. Because major trials supporting ACT were published in 2004 and 2005, analysis was stratified into two eras: 2000-2005 and 2006-2012.


RESULTS
During the study period, 272 patients met inclusion criteria (110 in the 2000-2005 cohort, 162 in the 2006-2012 cohort). Referrals to medical oncology increased from 74.5% (n=82) in the 2000-2005 cohort to 90.1% (n=146) in the 2006-2012 cohort (P=0.002). Due to lack of referral or missed appointments, 35.5% (n=39) of the 2000-2005 patients and 17.9% (n=32) of the 2006-2012 patients did not have a documented conversation with an oncologist regarding ACT. The proportion of patients recommended for ACT increased from 61% (n=50) to 81.5% (n=119) between the eras (P<0.001). Of patients recommended for chemotherapy, 14% (7/50) in 2000-2005 and 13.4% (16/119) in 2006-2012 declined ACT (P=0.666).


CONCLUSIONS
Publication of supporting evidence increased recommendations for ACT but did not change the percentage of patients who ultimately agreed to receive ACT. Additional research is needed to better understand patient decision-making in this situation.
1 Duke Clinical Research Institute, 2 Department of Medicine, 3 Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Brooke K
BK
Coleman
1 Duke Clinical Research Institute, 2 Department of Medicine, 3 Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Lesley H
LH
Curtis
1 Duke Clinical Research Institute, 2 Department of Medicine, 3 Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Mark W
MW
Onaitis
1 Duke Clinical Research Institute, 2 Department of Medicine, 3 Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Thomas A
TA
D'Amico
1 Duke Clinical Research Institute, 2 Department of Medicine, 3 Department of Surgery, Duke University Medical Center, Durham, NC, USA.
Mark F
MF
Berry
Lung neoplasms; adjuvant; chemotherapy; guideline adherence; patient compliance; referral and consultation