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Journal of Clinical Oncology, Vol 22, No 24 (December 15), 2004: pp. 4971-4978 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.05.031 Chemotherapy Use, Outcomes, and Costs for Older Persons With Advanced Non–Small-Cell Lung Cancer: Evidence From Surveillance, Epidemiology and End Results–MedicareFrom the Fred Hutchinson Cancer Research Center, Seattle, WA; Bristol-Myers Squibb, New York, NY. Address reprint requests to Scott D. Ramsey, MD, PhD, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, M2-B230, Seattle, WA 98109; e-mail: sramsey{at}fhcrc.org
PURPOSE: There is limited published documentation regarding US community patterns of care for older patients with advanced non–small-cell lung cancer (NSCLC). Using the Surveillance, Epidemiology and End Results (SEER) –Medicare database, we examined community treatment patterns for advanced NSCLC, focusing on chemotherapy. METHODS: Patients with locally advanced or metastatic (TNM system stages IIIb and IV) NSCLC diagnosed between January 1, 1994, and December 31, 1999, were stratified based on chemotherapy agents received during the first 3 months following diagnosis. Cox proportional hazards models were used to compare survival, controlling for age, sex, race, noncancer comorbidity, stage at diagnosis, SEER region, and receipt of cancer-related surgery or radiation therapy in the first 3 months following diagnosis. Lifetime medical costs were calculated for each group.
RESULTS: 14,875 patients met inclusion criteria: 7,411 (49.8%) stage III and 7,464 (50.2%) stage IV at diagnosis. Thirty-one percent received chemotherapy, 8% received surgery, and 53% received radiation therapy either as initial or adjuvant treatment. Persons CONCLUSION: Chemotherapy prolongs survival in community settings, but is underutilized for persons with advanced NSCLC. Reasons for lower use in minorities and variation across regions deserve further study.
Lung cancer is the second most common nonskin malignancy and the leading cause of cancer-related death in the United States. The majority of lung cancer cases are non–small-cell lung cancer (NSCLC), and 50% of these individuals will have locally advanced or metastatic disease at the time of diagnosis.1 Lung cancer is predominantly a disease of older adults: the median age of newly diagnosed lung cancer patients in developed countries is approximately 68 years, and as many as 40% of patients may be older than 70 years at diagnosis.2 Evidence from earlier clinical trials suggests that platinum-based chemotherapy regimens offer patients with advanced NSCLC modest quality of life and survival advantages compared with best supportive care.3 Subgroup analyses of these trials and retrospective studies suggest that the relative survival benefits of chemotherapy are maintained in older age groups.4,5 Chemotherapy-related toxicity is a particular concern in older patients.6,7 The elderly typically have a greater number of noncancer comorbidities and poorer performance status at diagnosis than younger patients with the same extent of disease. Although a consensus is emerging that older patients benefit from chemotherapy, it is less clear whether single-agent or combination therapy is preferable, or whether particular agents have advantages for initial treatment. In clinical trials, single-agent therapy has been shown to offer older patients with advanced NSCLC a survival benefit compared to best supportive care.8 The relative benefit of combination versus single-agent therapy is less clear. The recent Multicenter Italian Lung Cancer in the Elderly study found that the combination therapy was not more effective than a single-agent therapy.9 In contrast, an earlier study demonstrated a statistically significant survival advantage for combination therapy,10 and a subgroup analysis of a large Cancer and Leukemia Group B study found that survival for the combination of paclitaxel plus carboplatin was superior to paclitaxel alone in older patients with advanced NSCLC.2 While awaiting further results from ongoing clinical trials that include older persons, evidence from retrospective population-based studies can be helpful. While prior observational studies have shown that chemotherapy seems to confer a modest survival advantage for older adults with advanced NSCLC,4 no study has examined trends in chemotherapy prescribing over time, or whether particular chemotherapy regimens show differential outcomes in clinical practice. Furthermore, no study has evaluated whether outcomes observed in trials are in fact equivalent to those observed in practice, or whether particular regimens offer equivalent outcomes at lower cost. In addition to providing important information about survival, the cost implications of one regimen versus another are important. Choice of initial therapy has been shown to have significant effects on lifetime cancer-attributable costs of care.11 Given the prevalence of lung cancer, significant differences at the patient level translate into large differences in national expenditures for lung cancer care.12 Using clinical treatment and outcomes data from the Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare claims, the objectives of this study were to determine the most common forms of initial treatment for advanced NSCLC and to determine survival and lifetime medical care costs in relation to initial treatment.
Database and Patient Selection Criteria The data source for this study was the National Cancer Institute's database of the SEER cancer registry linked to Medicare claims.13 The merged database, described in detail elsewhere, includes Medicare claims for 94% of patients 65 and older who were diagnosed with cancer in the SEER regions.14 Patients were included in the study if they were diagnosed with locally advanced or metastatic (TNM system stages IIIb and IV) NSCLC between January 1, 1994, and December 31, 1999. Administrative codes for health care service and chemotherapy claims and vital status were available through December 31, 2001. Exclusion criteria were as follows: NSCLC diagnosed before age 65; diagnosis made by death certificate or autopsy, or occurring in an unknown month; enrollment in hospice before or at the time of diagnosis; prior or simultaneous diagnosis of any noncutaneous malignancy; and/or death within the first month of diagnosis. Individuals were also required to have Medicare parts A (hospital) and B (physician) coverage beginning at least 6 months before diagnosis and extending to at least the duration of initial therapy. Medicare beneficiaries enrolled in a health maintenance organization (HMO) during the month of cancer diagnosis were excluded, because the Centers for Medicare and Medicaid Services (CMS) do not require HMOs to submit individual claims for services. Following diagnosis, patients were followed until death, censoring or until the last date for which Medicare claims data were available (December 31, 2001). Patients were censored if they lost Medicare A/B entitlement, enrolled in a HMO, or enrolled in hospice at any time after their date of diagnosis.
Identification of Treatments Based on evidence from controlled studies and meta-analyses, combination chemotherapy regimens that include a platinum-based agent have been recommended for first-line therapy in advanced NSCLC since the mid-1990s.18,19 More recently, some cooperative groups have adopted platinum + taxane combinations as their reference therapy.20,21 Accordingly, we divided chemotherapy use into five categories: no chemotherapy; cisplatin or carboplatin alone; cisplatin or carboplatin plus a taxane; cisplatin or carboplatin plus any other agent except a taxane; combination or single-agent treatment not including cisplatin or carboplatin. Other single-agent and combination chemotherapy categories were considered, but the numbers of patients in other categories were too small for meaningful analysis. An Appendix lists administrative codes for surgery, radiation therapy, and chemotherapy included in the analysis.
Analysis of Factors Influencing Treatment Choice
Survival Analysis It is possible that factors not identifiable in the database may influence both the decision to use chemotherapy and overall survival. If the chemotherapy and no chemotherapy patients differed in an unmeasured characteristic that also influenced their outcome, the Cox model could give biased estimates. To address this issue, we used a propensity score approach to evaluating survival for persons receiving chemotherapy versus no chemotherapy.24 A propensity score is the probability that a patient will receive a particular treatment (in this case, chemotherapy). Individual scores are derived by logistic regression, controlling for observed demographic and clinical factors. Patients are then stratified based on their propensity score, and outcomes are measured within strata. Prognostic characteristics should be randomly distributed between strata among those who did and did not receive the treatment. The use of a propensity score analysis has been documented in a lung cancer study in which the objective was to determine the effects of chemotherapy on survival in Medicare patients diagnosed through 1996.4 We update that analysis, and, unlike the previous analysis, also adjust for the influence of surgery and radiation therapy on survival. Small numbers prevented a propensity score analysis of single-agent versus combination therapy.
Cost Analysis
A total of 14,875 patients met eligibility criteria and were included in the analysis; 7,411 (49.8%) diagnosed as stage IIIb and 7,464 (50.2%) as stage IV at diagnosis. The mean and median ages at diagnosis were 74.9 and 74.0, respectively; 6,405 patients (43%) were female. Of those meeting eligibility criteria, 4,589 (31%) received chemotherapy, 1,210 (8%) received surgery, and 7,893 (53%) received radiation therapy either as initial or adjuvant treatment. Approximately one third of patients had no record of receiving chemotherapy, surgery, or radiation therapy. Combination therapy was given to 97.4% of those who received any type of chemotherapy. Among those receiving chemotherapy, approximately equal proportions received plantinum/taxane combinations, plantinum/nontaxane combinations, and combinations that did not include platinum therapy (Table 1).
Between 1994 and 1999, the proportion of patients who received chemotherapy rose from 21% to 43%. Differences in the demographic characteristics and proportion of stage IIIb and IV patients diagnosed in 1994 and 1999 were statistically significant, though absolute differences were generally small. Those treated in 1999 were significantly and substantially more likely to receive either chemotherapy alone or combination therapy with radiation and chemotherapy, and significantly and substantially less likely to receive radiation therapy alone (Table 1). Compared with those treated with chemotherapy in 1994, those treated in 1999 were significantly and substantially more likely to receive combination therapy with cisplatin or carboplatin plus paclitaxel or docetaxel, and less likely to receive platinum therapy plus a nontaxane agent. In the multivariate logistic regression model, several factors were significantly correlated with the likelihood of receiving chemotherapy (Table 2). In particular, being male, having stage IV disease and higher comorbidity levels at diagnosis, and receiving surgery were substantially less likely to receive chemotherapy. Those receiving radiation therapy were more likely to receive chemotherapy. African American patients were half as likely to receive chemotherapy as white patients. Chemotherapy use varied widely among the 11 SEER regions. Compared with San Francisco (chosen as the reference SEER region because it was in the middle of all sites for prescribing rates), patients diagnosed in Hawaii had the lowest likelihood (odds ratio, 0.74) of receiving chemotherapy, and patients diagnosed in Georgia had the highest likelihood (odds ratio, 2.45) of receiving chemotherapy.
Unadjusted survival times were significantly higher for those receiving chemotherapy compared with those who did not receive chemotherapy (Fig 1). Median survival from the date of diagnosis was 5 months for those who did not receive chemotherapy versus 8 months for those who received at least one agent (P < .01).
In the multivariate analysis using the Cox proportional hazards model, survival was significantly prolonged for those receiving at least one chemotherapy agent. Surgery was associated with a significantly and substantially increased likelihood of survival, while radiation was associated with a modestly poorer survival (Table 3). After controlling for sociodemographic variables, comorbidities, and individual treatments, there was no significant association between residing in a particular SEER region and likelihood of survival.
In a separate multivariate Cox model comparing survival among different chemotherapy agent combinations, there were significant differences in likelihood of survival among the different combinations, though the absolute differences were relatively modest. In particular, therapies that did not include cisplatin or carboplatin were associated with poorer outcomes than combination therapies that included one of these agents (hazard ratio, 1.16; 95% CI, 1.08 to 1.26; P < .01). Survival analysis revealed that a significant proportion of individuals died within 3 months of the date of initial treatment (1,683 of 14,875). It is likely that treatment had little impact on survival time for those who died shortly after initial therapy. Including these individuals could mask longer-term benefits of treatment. To determine whether chemotherapy influenced longer-term survival, we reran the Cox survival analysis after excluding those who died within 3 months of initial therapy. In this case, combination therapy with a platinum agent was associated with improved survival compared with a single-agent therapy with a platinum agent or therapy that did not include a platinum agent. Surgery was still associated with significantly improved survival, while radiation therapy was still associated with modest but statistically significant modest survival. For the propensity score analysis, the logistic regression model showed a hazard ratio of 0.74 (95% CI, 0.72 to 0.77) for those who receive any chemotherapy compared with ther or no treatments. Propensity scores were stratified into quintiles based on likelihood of receiving chemotherapy, with good balance of observed factors between the chemotherapy and no chemotherapy groups (data not shown). The hazard ratio associated with chemotherapy varied from 0.75 (95% CI, 0.67 to 0.84) in the lowest quintile, to 0.71 (95% CI, 0.66 to 0.77) for the highest quintile. Medical care costs were substantially higher for those receiving chemotherapy than for those who did not receive chemotherapy, with highest costs for those who received both radiation therapy and chemotherapy (Table 4). Among those receiving chemotherapy, the group treated with cisplatin or carboplatin alone were most costly; however, a small number of persons with very high costs (10% with lifetime costs averaging > $250,000) greatly influenced overall costs for this small cohort of patients. For the other three chemotherapy groups, the group treated with cisplatin or carboplatin plus a taxane were most costly, with lifetime expenditures about $10,278 higher than the next platinum-containing doublet combination (P < .01).
In several clinical trials, chemotherapy has been shown to modestly prolong survival and reduce morbidity for patients with advanced NSCLC. To address the use and effectiveness of chemotherapy as prescribed in community settings, we conducted a longitudinal analysis of treatment patterns, outcomes, and costs for Medicare enrollees with advanced stage NSCLC diagnosed between 1994 and 2001. We note several important findings. First, about one third of patients received no treatment within the first three months of diagnosis. Survival for this group was poorer than for those who received chemotherapy or surgery during this initial treatment period. Second, about two thirds of patients received no chemotherapy, and survival time was 2 to 4 months shorter for this group compared to those who received one or more chemotherapeutic agents within 3 months of diagnosis. Third, there was wide variation in use of chemotherapy agents, with approximately one third of patients receiving either doublet with cisplatin or carboplatin plus paclitaxel or docetaxel, one third receiving cisplatin or carboplatin plus a nontaxane agent, and one third receiving single agent therapy or a doublet that did not include cisplatin or carboplatin. Very few patients received single-agent therapy with cisplatin or carboplatin alone. Survival varied significantly depending on the initial choice of agents, though absolute differences in survival between regimens were generally modest. Regimens containing platinum and a taxane were the most costly. Perhaps the most striking finding of this analysis is the substantial increase in the proportion of patients who receive chemotherapy. The greatest increases were in use of taxane-based combinations, followed by combinations that did not include a platinum-containing agent. In addition, the likelihood that a newly diagnosed patient would receive chemotherapy varied substantially by geographic region. The increase in use of non–platinum-containing regimens is cause for concern. Doublet chemotherapy that included a platinum agent—recommended by clinical practice guidelines and supported by meta-analyses—was associated with significantly improved survival compared with other regimens. In this analysis, adjuvant radiation was associated with poorer survival, in contrast to evidence from several previous clinical trials.28-32 There may be several explanations for this finding. First, radiation may have been preferentially given to those with poorer performance status or more advanced disease within stage, something we were not able to control for in the regression models. Radiation is also an option for those with tumors that pose imminent threats to survival, such as those obstructing the mainstem bronchus. Excluding those who died within 3 months of initial therapy (presumably including those with such issues) did not improve survival odds for radiation therapy. Second, it is difficult to distinguish concurrent from sequential radiation, and evidence suggests that the latter is associated with poorer survival.33 Survival was observed to be superior for patients who received surgery; however, lung cancer patients receiving surgery are generally carefully selected based on clinical criteria related to survival. Because we could not identify these criteria with the available data, the results likely reflect a selection bias in favor of those receiving surgery, and against those who do not. Lifetime care costs were significantly higher for those receiving chemotherapy regimens that included platinum plus a taxane, without apparent survival benefit compared with platinum plus nontaxane regimens. This finding is similar to that found in a recent clinical trial comparing cisplatin plus vinorelbine versus carboplatin plus paclitaxel.11 We note several limitations of our analysis. First, we are unable to assess performance status of patients at the time of treatment. Guidelines generally recommend that chemotherapy should be administered to those with better performance status. We have captured and accounted for noncancer comorbidities, but the relationship between comorbidity and overall performance status is not clear. Second, some patients who were prescribed chemotherapy but did not live long enough to receive treatment would be counted in the no chemotherapy arm of the study. If survival after diagnosis predicts chemotherapy use, it will lead to different points for starting the survival analysis across treatment groups. This could bias outcomes in favor of chemotherapy versus no chemotherapy, although we feel it is unlikely to influence differences between chemotherapy regimens. Third, it is not possible to determine doses of individual agents, and it is difficult to determine duration of therapy from SEER-Medicare records. Those who were not able to complete planned cycles of chemotherapy may have worse outcomes that those who complete treatment. If the suboptimal dosing was correlated with particular regimens, this could account for the poorer outcomes seen in our analysis. Our analysis raises several questions that deserve future study. First is the question of why so few patients with advanced NSCLC receive chemotherapy. There were substantial differences in rates of use of adjuvant therapy across SEER regions, suggesting considerable variation in physician and possibly patient preferences for chemotherapy nationwide. Surveys of physicians (and patients) would help to identify barriers to chemotherapy use in cases where such use has been shown to have benefit. Second, there appears to be marked variation in prescribing patterns for initial chemotherapy. Although some variation is certainly a function of clinical circumstances, much may be driven by physician preferences or patient factors. It is of particular concern that blacks were less than half as likely to receive chemotherapy as whites, controlling for other factors. A multicenter study of cancer care patterns and preferences sponsored by the National Cancer Institute, the Cancer Care Outcomes Research Consortium Study (CanCORS), has been initiated to help address these issues.34 Third, although it was not a primary focus of this study, our findings suggest that radiation therapy does not provide a survival benefit as utilized in community settings. Further evaluation of administrative and other observational data sources from community settings, focusing on timing, duration, and sequencing of radiation with chemotherapy is needed before conclusions can be drawn about this issue.
The following authors or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Employment: Bonnie Donato, Bristol-Myers Squibb. Consultant/Advisory Role: Scott D. Ramsey, Bristol-Myers Squibb. Stock Ownership: Bonnie Donato, Bristol-Myers Squibb, Pfizer. Other Remuneration: Scott D. Ramsey, Bristol-Myers Squibb. For a detailed description of these categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration form and the "Disclosures of Potential Conflicts of Interest" section of Information for Contributors found in the front of every issue.
Supported by Bristol-Myers Squibb and NCI NCI-PC-67009. Presented in part by the corresponding author at the Annual Meeting of the American Society for Clinical Oncology, Chicago, IL, May 31-June 3, 2003. Authors' disclosures of potential conflicts of interest are found at the end of this article.
1. National Cancer Institute Surveillance, Epidemiology, and End Results Web site: Incidence, Lung and Bronchus Cancer, 2004. http://www.seer.cancer.gov/faststats/html/inc_lungb.html
2. Bunn PA Jr, Lilenbaum R: Chemotherapy for elderly patients with advanced non-small-cell lung cancer. J Natl Cancer Inst 95:341-343, 2003
3. Non-small Cell Lung Cancer Collaborative Group: Chemotherapy in non-small cell lung cancer: A meta-analysis using updated data on individual patients from 52 randomised clinical trials. BMJ 311:899-909, 1995
4. Earle CC, Tsai JS, Gelber RD, et al: Effectiveness of chemotherapy for advanced lung cancer in the elderly: Instrumental variable and propensity analysis. J Clin Oncol 19:1064-1070, 2001
5. Billingham LJ, Cullen MH: The benefits of chemotherapy in patient subgroups with unresectable non-small-cell lung cancer. Ann Oncol 12:1671-1675, 2001 6. Rocha Lima CM, Herndon JE 2nd, Kosty M, et al: Therapy choices among older patients with lung carcinoma: An evaluation of two trials of the Cancer and Leukemia Group B. Cancer 94:181-187, 2002[CrossRef][Medline]
7. Langer CJ, Manola J, Bernardo P, et al: Cisplatin-based therapy for elderly patients with advanced non-small-cell lung cancer: Implications of Eastern Cooperative Oncology Group 5592, a randomized trial. J Natl Cancer Inst 94:173-181, 2002
8. Gridelli C: The ELVIS trial: A phase III study of single-agent vinorelbine as first-line treatment in elderly patients with advanced non-small cell lung cancer: Elderly Lung Cancer Vinorelbine Italian Study. Oncologist 6:4-7, 2001 (suppl 1)
9. Gridelli C, Perrone F, Gallo C, et al: Chemotherapy for elderly patients with advanced non-small-cell lung cancer: The Multicenter Italian Lung Cancer in the Elderly Study (MILES) phase III randomized trial. J Natl Cancer Inst 95:362-372, 2003
10. Frasci G, Lorusso V, Panza N, et al: Gemcitabine plus vinorelbine versus vinorelbine alone in elderly patients with advanced non-small-cell lung cancer. J Clin Oncol 18:2529-2536, 2000
11. Ramsey SD, Moinpour CM, Lovato LC, et al: Economic analysis of vinorelbine plus cisplatin versus paclitaxel plus carboplatin for advanced non-small-cell lung cancer. J Natl Cancer Inst 94:291-297, 2002
12. Ramsey SD, Kessler LG: Does economics matter when treating advanced non-small cell lung cancer? Oncologist 7:179-180, 2002 13. National Cancer Institute: Surveillance, Epidemiology and End Results (SEER), 2004. http://seer.cancer.gov/ 14. Potosky AL, Riley GF, Lubitz JD, et al: Potential for cancer related health services research using a linked Medicare-tumor registry database. Med Care 31:732-748, 1993[Medline] 15. Warren JL, Harlan LC, Fahey A, et al: Utility of the SEER-Medicare data to identify chemotherapy use. Med Care 40:IV-55-61, 2002 16. Virnig BA, Warren JL, Cooper GS, et al: Studying radiation therapy using SEER-Medicare-linked data. Med Care 40:IV-49-54, 2002 17. Cooper GS, Virnig B, Klabunde CN, et al: Use of SEER-Medicare data for measuring cancer surgery. Med Care 40:IV-43-48, 2002 18. National Comprehensive Cancer Network: Clinical Practice Guidelines in Oncology, Non-Small Cell Lung Cancer, Version 1, 2004, 2004. http://www.nccn.org/physician_gls/f_guidelines.html 19. Socinski MA, Morris DE, Masters GA, et al: Chemotherapeutic management of stage IV non-small cell lung cancer. Chest 123:226S–243S, 2003
20. Schiller JH, Harrington D, Belani CP, et al: Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer. N Engl J Med 346:92-98, 2002
21. Kelly K, Crowley J, Bunn PA Jr, et al: Randomized phase III trial of paclitaxel plus carboplatin versus vinorelbine plus cisplatin in the treatment of patients with advanced non–small-cell lung cancer: A Southwest Oncology Group trial. J Clin Oncol 19:3210-3218, 2001 22. Klabunde CN, Potosky AL, Legler JM, et al: Development of a comorbidity index using physician claims data. J Clin Epidemiol 53:1258-1267, 2000[CrossRef][Medline] 23. Cox DR: Regression Models and Life Tables. J R Stat Soc B 34:187-220, 1972 24. D'Agostino RB: Propensity Score Methods for Bias Reduction in the Comparison of a Treatment to a Non-Randomized Control Group. Stat Med 17:2265-2281, 1998[CrossRef][Medline] 25. Lin DY: Proportional means regression for censored medical costs. Biometrics 56:775-778, 2000[CrossRef][Medline] 26. Lin DY, Feuer EJ, Etzioni R, et al: Estimating medical costs from incomplete follow-up data. Biometrics 53:419-434, 1997[CrossRef][Medline]
27. Weinstein MC, Siegel JE, Gold MR, et al: Recommendations of the Panel on Cost-effectiveness in Health and Medicine. JAMA 276:1253-1258, 1996
28. Le Chevalier T, Arriagada R, Quoix E, et al: Radiotherapy alone versus combined chemotherapy and radiotherapy in nonresectable non-small-cell lung cancer: First analysis of a randomized trial in 353 patients. J Natl Cancer Inst 83:417-423, 1991 29. Morton RF, Jett JR, McGinnis WL, et al: Thoracic radiation therapy alone compared with combined chemoradiotherapy for locally unresectable non-small cell lung cancer: A randomized, phase III trial. Ann Intern Med 115:681-686, 1991 30. Dillman RO, Seagren SL, Propert KJ, et al: A randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer. N Engl J Med 323:940-945, 1990[Abstract] 31. Schaake-Koning C, van den Bogaert W, Dalesio O, et al: Effects of concomitant cisplatin and radiotherapy on inoperable non-small-cell lung cancer. N Engl J Med 326:524-530, 1992[Abstract]
32. Sause WT, Scott C, Taylor S, et al: Radiation Therapy Oncology Group (RTOG) 88-08 and Eastern Cooperative Oncology Group (ECOG) 4588: preliminary results of a phase III trial in regionally advanced, unresectable non-small-cell lung cancer. J Natl Cancer Inst 87:198-205, 1995 33. Vokes EE, Choy H, Gandara D, et al: Adjuvant and neoadjuvant treatments for NSCLC. Lung Cancer 38:29-35, 2002 (suppl 4) 34. National Cancer Institute: Cancer Care Outcomes Research and Surveillance Consortium (CanCORS), National Cancer Institute, Applied Research Program, Outcomes Research Branch, 2003 Submitted May 6, 2004; accepted September 22, 2004.
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
75 years of age, females, African Americans, and those with more than one comorbidity were significantly less likely to receive chemotherapy (P < .01). Survival was inferior for those who did not receive a platinum-containing agent (P < .01). Lifetime costs were highest for those receiving platinum + taxane combinations, exceeding other regimens by more than $10,000 per patient. 
