INITIAL SYSTEMIC TREATMENT IN STAGE IV NON-SMALL CELL LUNG

CANCERFran Maguire, MPH, PhD candidate

California Cancer Reporting and Epidemiologic Surveillance (CalCARES) ProgramNAACCR Annual Conference

June 20, 2017

Objectives

1. Use California Cancer Registry data to describe the use of systemic treatments in stage IV non-small cell lung cancer (NSCLC)

Emphasis on targeted therapy/immunotherapy

2. Identify disparities in treatment

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BACKGROUND

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LUNG CANCER

• Second most common cancer

• Leading cancer killer

• Non-small cell lung cancer (NSCLC) - 83%• Approximately 50% diagnosed at stage IV

• 5 year survival rate of 4%• No cure for stage IV NSCLC

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NSCLC BY STAGE AT DIAGNOSIS, 2012-2014 N=37,211

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Source: California Cancer Registry

22%

8%

18%

47%

5%

23%

8%

17%

47%

4%

24%

8%

17%

46%

4%

Stage I Stage II Stage III Stage IV Unknown

2012 2013 2014

Survival Plot of NSCLC by Stage, 2012-20146

Source: California Cancer Registry

Survival Plot of NSCLC by Stage, 2012-20147

0.5

4 months

Source: California Cancer Registry

Survival Plot of NSCLC by Stage, 2012-20148

0.22

12 months

Source: California Cancer Registry

Treatments

Two main treatments:

1. Chemotherapy

2. Targeted therapy/Immunotherapy• Driver mutations• Important molecules for cancer cell proliferation• Immune checkpoints

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Treatments

Two main treatments:

1. Chemotherapy

2. Targeted therapy/Immunotherapy• Driver mutations• Important molecules for cancer cell proliferation• Immune checkpoints

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Treatments

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Targeted Therapy Immunotherapy

Small Molecules Monoclonal Antibodies Monoclonal Antibodies

Treatments

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Targeted Therapy Immunotherapy

Small Molecules Monoclonal Antibodies Monoclonal Antibodies

Erlotinib (Tarceva)Crizotinib (Xalkori)Gefitinib (Irresa)Atatinib (Gilotrif)Ceritinib (Zykadia)Osimertinib (Tagrisso)Alectinib (Alecensa)Brigatinib (Alungbrig)

Bevacizumab (Avastin)Ramucirumab (Cyramza)Necitumumab (Portrazza)

Nivolumab (Opdivo)Pembrolizumab (Keytruda)Atezolizumab (Tecentriq)

Treatments

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Targeted Therapy Immunotherapy

Small Molecules Monoclonal Antibodies Monoclonal Antibodies

Erlotinib (Tarceva)Crizotinib (Xalkori)Gefitinib (Irresa)Atatinib (Gilotrif)Ceritinib (Zykadia)Osimertinib (Tagrisso)Alectinib (Alecensa)Brigatinib (Alungbrig)

Bevacizumab (Avastin)Ramucirumab (Cyramza)Necitumumab (Portrazza)

Nivolumab (Opdivo)Pembrolizumab (Keytruda)Atezolizumab (Tecentriq)

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Treatment• 45%-50% do not receive systemic treatment

• Elderly (>75)• Differences by insurance type and race/ethnicity• Many not tested for biomarkers/mutations

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METHODS

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Methods• Identified stage IV NSCLC patients diagnosed 2012-2014 in California Cancer Registry data

• Reviewed text fields from all reporting facilities, categorized systemic treatment into:• Targeted therapy/immunotherapy• Chemotherapy

• Used logistic regression to identify predictors of targeted therapy/immunotherapy

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RESULTS

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Results• 17,314 people diagnosed with stage IV NSCLC 2012-2014• 24,873 records from all reporting facilities reviewed

• Focused on treatment text fields:• Text_chemo (chemotherapy)• Text_immuno (immunotherapy)

• Other text fields:• Text_other_rx (other medication)• Text_lab (laboratory)• Text_op_proc (operating procedures)• Text_path (pathology)• Text_phys_ex (physical exam)• Text_rad (radiation)• Text_remarks (remarks)• Text_scopes (scope procedures)• Text_surg_1 (surgical procedures)

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Systemic Treatment, n=17,314

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17%

32%

51%

5%

38%

8%

11%

Unknown

No Treatment

Treatment Any

Chemo NOS

Chemotherapy

Monoclonal antibody

Small molecules

Systemic Treatment, n=17,314

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17%

32%

51%

5%

38%

8%

11%

Unknown

No Treatment

Treatment Any

Chemo NOS

Chemotherapy

Monoclonal antibody

Small molecules

Targeted Therapy/Immunotherapy 18%

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 21

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 22

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 23

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 24

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 25

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 26

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 27

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Adjusted ORs Predicting Receipt of Targeted Therapy/Immunotherapy 28

Variable OR 95% CIRace/ethnicity

NH white (reference) 1.00NH black 0.68 0.56-0.84Hispanic 1.15 0.99-1.33API 2.76 2.46-3.10

InsurancePrivate/Military (reference) 1.00Medicare 0.90 0.76-1.07Medicaid 0.70 0.63-0.77

Charlson Comorbidity Score0 (reference) 1.001 0.59 0.53-0.66>=2 0.44 0.39-0.49

SexMale (reference) 1.00Female 1.46 1.33-1.60

Rural/Urban ResidenceRural (reference) 1.00Urban 1.15 1.00-1.32

NCI ProgramNo (reference) 1.00Yes 1.55 1.37-1.75

Age (5 year increments) 0.90 0.88-0.92NH: non-Hispanic; API: Asian/Pacific Islander; NCI: National Cancer Institute

Strengths/Limitations• Strengths:

• Population based study• Using existing registry data

• Limitations:• Tedious• High percentage of missing• No information about dosing or treatment length

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Conclusions• Cancer Registry data can be used to further characterize treatment• There are disparities in uptake of targeted therapy/immunotherapy and

underutilization

• Next Steps:• Compare manual text field review to an automated process• Further study targeted treatments and patient outcomes

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AcknowledgmentsCyllene MorrisUniversity Of California Davis Health System, Institute for Population Health ImprovementArti Parikh-PatelUniversity Of California Davis Health System, Institute for Population Health ImprovementKen KizerUniversity Of California Davis Health System, Institute for Population Health ImprovementTheresa KeaganUniversity Of California Davis Health System, Department of Hematology and OncologyChin-Shang LiUniversity Of California Davis, Division of BiostatisticsRosemary CressPublic Health Institute, Cancer Registry of Greater CaliforniaPatrick LinUniversity Of California Davis Health System, Department of Hematology and Oncology

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Contact Information

Fran Maguirefbmaguire@ucdavis.edu

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Questions

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CCR Summary Fields vs Text Fields

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3%

49%

3%

8%

38%

17%

Immuno Sum Chemo Sum Unknown

CCR summaryCCR text fields

Use of Targeted Therapy/Immunotherapy 2012-2014

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17.8%

18.0%

18.7%

2012 2013 2014

Receipt of Targeted Therapy/Immunotherapy by Histologic Type

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11%

3%

24%

Non-Small Cell Carcinoma NOS

Squamous Cell Carcinoma

Adenocarcinoma

NOS = Not otherwise specified