Underutilization of Radiotherapy for Lung
Cancer in New South Wales, Australia
Shalini K. Vinod, MBBS, MD, FRANZCR1; Leonardo Simonella, BA, MPH2; David Goldsbury, BSc, MPH2; Geoff P. Delaney, MBBS, MD, PhD, FRANZCR1; Bruce Armstrong, MBBS, DPhil, FRACP, FAFPHM, FAA3;
and Dianne L. O’Connell, BMaths, PhD2
BACKGROUND:Lung cancer is the leading cause of cancer death in most developed countries. Radiotherapy is im-portant in its treatment, with an estimated optimal utilization rate between 45% and 68% at initial diagnosis. The objective of this study was to describe radiotherapy practice for lung cancer in New South Wales (NSW), Australia. METHODS: Patients with lung cancer were identified prospectively from the NSW Central Cancer Registry (CCR) from November 1, 2001 to December 31, 2002. Questionnaires were mailed to diagnosing and treating clinicians to obtain detailed information on diagnosis, staging, referrals, and treatment. The authors describe referral for and receipt of radiotherapy treatment. RESULTS: Of 1812 patients with lung cancer patients who were identified, 943 patients (52%) were referred for radiotherapy, 846 patients (47%) received a radiotherapy questionnaire, and 727 patients (40%) received radiotherapy. Compared with optimal radiotherapy, there was less curative radiotherapy to the primary site (20% actual vs 50% optimal), and there was more palliative radiotherapy to metastatic sites (36% actual vs 11% optimal). The greatest shortfall in radiotherapy use was observed in patients who had limited stage small cell lung cancer (46% actual vs 94% optimal). The use of combined-modality treatment for stage III nonsmall cell lung cancer and for limited stage small cell lung cancer was uncommon.CONCLUSIONS:There is underutilization of radiotherapy for lung cancer in NSW, especially in small cell lung cancer. The use of combined-modality treatment for potentially curable lung cancers is suboptimal. These issues have to be addressed to improve survival and quality of life for patients with lung cancer.Cancer2010;116:686–94.VC 2009 American Cancer Society.
KEYWORDS:lung neoplasms, radiotherapy, physician’s practice patterns, small cell lung cancer, nonsmall cell lung cancer.
Lung
cancer is the most common cancer after nonmelanoma skin cancer and is overwhelmingly the leading cause of cancer death in the more developed countries of the world. In 2002, lung cancer accounted for an estimated 22% of all cancer deaths in these countries.1This disproportionately high contribution to cancer death reflects the generally poor outcome of patients with lung cancer. The most recent reports indicate that the 5-year relative survival rate from lung can-cer in the United States was 13.5%, and 18.2% for men and women, respectively (patients diagnosed from 1996 through 2004)2; 13% and 18%, respectively, in Canada (patients diagnosed from 1997 through 1999)3; and 10.7% and 14%, respectively, in Australia (patients diagnosed from 1998 through 2004).4In Europe, the percentage for both sexes was 10.9% (patients diagnosed from 2000 through 2002).5Although these rates are low overall, survival from lung cancer can be maximized by the optimal use of potentially curative therapy.6,7Radiotherapy is an integral component of treatment for lung cancer and can be effective whether it is given with curative or palliative intent.8Many patients who receive radiotherapy also are likely to benefit from chemother-apy. Since the 1990s, evidence has emerged for the use of chemotherapy with radiotherapy in the curative treatment of stage III nonsmall cell lung cancer (NSCLC).9,10 It also has been demonstrated that the addition of thoracic radiotherapy to chemotherapy in limited stage small cell lung cancer (SCLC) is beneficial.11,12 Both of these
DOI: 10.1002/cncr.24762, Received: April 15, 2009; Accepted: May 27, 2009, Published online December 2, 2009 in Wiley InterScience (www. interscience.wiley.com)
Corresponding author:Leonardo Simonella, BA, MPH, Cancer Epidemiology Research Unit, Cancer Research Division, Cancer Council, PO Box 572, Kings Cross NSW 1340, Australia; Fax: (011) 61 2 8302 3550; leonardos@nswcc.org.au
1
Collaboration for Cancer Outcomes, Research, and Evaluation, Liverpool Hospital, University of New South Wales, Liverpool, New South Wales, Australia;2
Cancer Epidemiology Research Unit, Cancer Research Division, Cancer Council, Kings Cross, New South Wales, Australia;3
University of Sydney Cancer Research Network, School of Public Health, University of Sydney-Camperdown Campus, Sydney, New South Wales, Australia
combinations result in superior survival compared with single-modality treatment. If radiotherapy was used optimally in lung cancer, with or without chemother-apy, then it is estimated that some 45% to 68% of patients would receive it at initial diagnosis; and, over-all, 61% to 76% of patients would receive it.13,14
Few attempts have been made to determine the pro-portion of lung cancer patients that receive optimal radiotherapy. Australian studies performed in 1993 and 1996 observed actual overall utilization rates ranging from 39% to 55%.15,16 The reasons why lung cancer patients do not receive optimal radiotherapy have not been explained well, although they are likely to include a variety of patient, clinician, and health service delivery factors.
To determine how lung cancer patients were being managed, we conducted a patterns of care study in the Australian state of New South Wales (NSW). The key findings from that study have been published.17In this report, we describe patterns of care in patients who were referred for radiotherapy, in particular to document radio-therapy use and to compare it with the estimated optimal radiotherapy management of lung cancer.
MATERIALS AND METHODS
New South Wales is the most populous state in Australia with a population of 6.3 million in 2001.18A Lung Can-cer Patterns of Care Study was performed there covering residents who were diagnosed with primary lung cancer between November 1, 2001 and December 31, 2002. Eli-gible patients were ascertained from notifications to the population-based NSW Central Cancer Registry (CCR). Patients provided informed consent for their treatment details to be obtained from their physicians. If a patient had died, then ethics approval allowed treatment informa-tion to be obtained with the physician’s consent. This study was approved by the required human research ethics committees. The methods have been described else-where.17At the time of the study, there were 14 individual radiotherapy facilities in NSW.
Four separate treatment questionnaires were devel-oped by an expert advisory group to collect information on 1) patient demographics, clinical characteristics, inves-tigations, referrals, and management; 2) surgery; 3) radio-therapy; and 4) chemotherapy. The sample in this report comprises patients who were referred to a radiation oncol-ogist for whom a completed radiotherapy questionnaire was obtained.
Disease stage for SCLC was assigned using the Vet-erans Administration staging system.19NSCLC and can-cers with no pathologic confirmation (NPC) were staged using the TNM classification.20Performance status was scored using the Eastern Cooperative Oncology Group (ECOG) scale.21 Each patient’s place of residence was coded according to the distance to major service centers using the Accessibility and Remoteness Index for Australia.22
Collected data were entered into an Access database and analyzed using SAS statistical software version 9.1. Chi-square tests of association were used to identify fac-tors related to the intent of radiotherapy. Multivariate logistic regression was used to analyze the following fac-tors associated with treatment intent: age, sex, disease stage, pathology, weight loss, ECOG performance status, comorbidities, and lung cancer specialist caseload. Odds ratios adjusted for all of these variables are reported.
RESULTS
Patient Referral Characteristics
There were 2931 potentially eligible patients registered by the CCR, and 2126 of those patients (73%) participated in the study. Patients were excluded because of a lack of patient or physician consent (n¼483), inability to con-tact patient or physician (n¼198), or delayed notifica-tion to the CCR (n¼124). Diagnosis and treatment data were available for 1812 patients. Of these, 943 patients were referred to a radiation oncologist (Fig. 1). We obtained a completed radiotherapy questionnaire for 846 (89%) patients who were referred to radiotherapy.
Patients who were referred had a median age at diag-nosis of 69 years, and 67% were men (Table 1). Seventy-two percent of these patients had at least 1 comorbid condition that was likely to affect management, most commonly chronic airflow limitation or cardiovascular disease. Despite this, 81% of patients had a good perform-ance status (ECOG 0-2).
Patients who were referred to a radiation oncologist were younger, had a better performance status, and were less likely to have comorbidities than older patients. They were more likely to live in areas that were highly accessible to service centers and were more likely to have pathologic confirmation of their lung cancer. Patients with stage III and IV NSCLC and limited stage SCLC were overrepre-sented in the radiotherapy group.
The majority of referrals to a radiation oncologist occurred at initial diagnosis (61%), and the remaining
referrals occurred after another treating clinician was con-sulted (30%) (Table 2). A large proportion of patients who were referred at initial diagnosis had stage III or IV NSCLC/NPC (78%) and extensive stage SCLC (71%). This pattern was similar after a treating clinician was con-sulted, with the exception of patients with limited stage SCLC, in which a larger proportion was referred to a radi-ation oncologist after a treating clinician was consulted compared with the proportion referred at initial diagnosis (47% vs 29%).
Investigations
Pulmonary function tests were performed in less than half of all patients who were seen by a radiation oncologist (44%). Chest computed tomography (CT) scans were obtained in 95% of patients, brain CT scans were obtained in 40%, bone scans were obtained in 46%, and positron emission tomography scans were obtained in 21%. Fifty-three percent of patients had a bronchoscopy. Patients with NPC histology were less likely to have most investigations, whereas patients with SCLC had propor-tionally almost twice as many brain CT scans and bone scans as patients who were diagnosed with NSCLC. Pathway to Radiotherapy Treatment
Of the patients who were seen by radiation oncologists (n¼846), 86 (10%) were not suitable for radiotherapy.
The reasons recorded were no clinical indication in 31 patients, poor performance status in 16 patients, patient decision in 16 patients, other reasons in 21 patients, and unknown in 2 patients. Of the 760 patients who were suitable for radiotherapy, 708 actually commenced radio-therapy. An additional 19 patients had radiotherapy treat-ment indicated in other treattreat-ment questionnaires, but no radiotherapy questionnaire data were available. Thus, up to 727 patients received some form of radiotherapy. Of the 708 patients with questionnaire data available, 638 (90%) completed their planned course. The reasons for not commencing radiotherapy were death (n ¼ 19), patient decision (n¼17), disease progression or deterio-ration in the patient’s condition (n¼8), and other rea-sons (n ¼ 8). The reasons for not completing radiotherapy were patient’s death (n¼ 13), disease pro-gression or deterioration in the patient’s condition (n ¼ 30), treatment toxicity (n¼7), patient decision (n¼4), and other reasons (n¼16).
Radiotherapy Intent and Dose
Among the 708 patients who had questionnaire data and received radiotherapy, the objective of treatment was palliative in 72%, curative in 21%, and adjuvant in 7% (Table 3). Only 2 patients received neoadjuvant radiotherapy. Among the patients with good perform-ance status (ECOG 0-2), curative radiotherapy was given to 76 out of the 230 patients (33%) with stage I through III NSCLC and to 29 out of the 43 patients (67%) with limited stage SCLC. The most common sites of radiotherapy were the primary and/or regional lymph node areas (n ¼ 414 patients; 58%), followed by bone metastases (n ¼ 157 patients; 22%), and brain metastases (n¼ 120 patients; 17%) (Table 4).
The median dose of curative thoracic radiotherapy was 60 grays (Gy) (interquartile range [IQR], 50-60 Gy) for NSCLC and 50 Gy (IQR, 45-50 Gy) for SCLC. The median dose for adjuvant thoracic radiotherapy for NSCLC was 50 Gy (IQR, 45-54 Gy). For both patholo-gies, the median dose for palliative thoracic radiotherapy was 30 Gy (IQR, 20-37.5 Gy). The median dose for palli-ative radiotherapy for both bone and brain metastases was 20 Gy in 5 fractions. The median dose for prophylactic cranial irradiation was 30 Gy in 10 fractions.
The median time from diagnosis to radiotherapy treatment was 29 days for patients who received radiother-apy only and 39 days for those who received combination treatment. The median radiotherapy course duration was 14 days.
Figure 1.This chart illustrates the referral, questionnaire data, and radiotherapy (RT) treatment pathway.
Table 1.Characteristics of Lung Cancer Patients Referred to a Radiation Oncologist Compared With Those Not Referred in New South Wales, Australia 2001-2002
Radiotherapy Referral: No. of Patients (%)
Characteristic Yes, n5943 No, n5869 Pa
Sex .19 Male 635 (67) 560 (64) Female 308 (33) 309 (36) Age, y <.001 0-59 220 (23) 133 (15) 60-69 274 (29) 204 (23) 70-79 336 (36) 365 (42) ‡80 111 (12) 164 (19) Unknown/missing 2 (0) 3 (0)
ECOG performance status <.001
0-2 762 (81) 574 (66) 3-4 136 (14) 196 (23) Unknown 45 (5) 99 (11) Comorbidity .03 No 193 (20) 138 (16) Yes 681 (72) 653 (75) Unknown 69 (7) 78 (9) Accessibility to services .05b Highly accessible 761 (81) 665 (77) Accessible 161 (17) 173 (20) Moderately accessible 15 (2) 25 (3) Remote 5 (1) 5 (1) Very remote 1 (0) 1 (0) Pathology <.001 SCLC 141 (15) 137 (16) NSCLC 727 (77) 536 (65) No pathologic confirmation 75 (8) 169 (19) Stage at diagnosis NSCLC <.001 I 105 (14) 181 (32) II 50 (7) 40 (7) III 218 (30) 90 (16) IV 333 (46) 194 (34) Unknown 21 (3) 58 (10) SCLC .02c Limited 54 (38) 29 (21) Extensive 85 (60) 104 (76) Unknown 2 (1) 4 (3) NPC .003 I 16 (21) 41 (24) II 6 (8) 6 (4) III 15 (20) 16 (9) IV 27 (36) 46 (27) Unknown 11 (15) 60 (36)
ECOG indicates Eastern Cooperative Oncology Group; SCLC, small cell lung cancer; NSCLC, nonsmall cell lung can-cer; NPC, no pathologic confirmation.
aPvalues are for comparison of proportions of patients who were referred and patients who were not referred for
radiotherapy.
bBecause of small patient numbers, the categories moderately, remote, and very remote accessibility to services
were combined for the analysis.
Factors Associated With Treatment Intent Factors associated with the use of radiotherapy with cura-tive intent were localized stage (vs extensive stage: adjusted odds ratio [OR], 23.2; 95% confidence interval [CI], 13.9-38.5), weight loss (none vs some: OR, 2.9; 95% CI, 1.8-4.9), pathology (SCLC vs NSCLC: OR, 2.7; 95% CI, 1.4-5.2), and ECOG performance status (good vs poor: OR, 3.1; 95% CI, 1.3-7.4). There was no associa-tion with comorbidities, lung cancer specialist caseload, sex, or age.
Chemoradiotherapy
Most patients with stage III NSCLC received palliative radiotherapy. The reasons for this, as opposed to curative
intent radiotherapy, were not recorded. However, of the 52 patients with stage III NSCLC who received radiother-apy with curative intent, 65% (34 of 52 patients) received chemotherapy. Because the chemotherapy was palliative for 5 patients, only 56% (29 of 52 patients) received chemotherapy as part of their curative treatment.
Of the 32 patients with limited stage SCLC who received radiotherapy with curative intent (including ad-juvant radiotherapy), 30 patients (94%) received chemo-therapy, which was concurrent in 12 patients and neoadjuvant in 18 patients. Six patients with limited stage SCLC received palliative radiotherapy; thus, most patients with SCLC who were given radiotherapy received potentially curative chemoradiotherapy. However, there Table 3.Intent of Lung Cancer Radiotherapy Treatment by Pathology and Stage in New South Wales, Australia 2001-2002
Intent: No. of Patients (%)
Disease Stage/Pathology Curative Palliative Adjuvant Neoadjuvant Unknown Total No.
NSCLC stage I 28 (37) 30 (39) 16 (21) 1 (1) 1 (1) 76 II 15 (43) 15 (43) 4 (11) 0 (0) 1 (3) 35 III 52 (31) 104 (61) 13 (8) 1 (1) 0 (0) 170 IV 5 (2) 250 (97) 2 (1) 0 (0) 1 (0) 258 Unknown 7 (41) 7 (41) 3 (18) 0 (0) 0 (0) 17 SCLC stage Limited 27 (71) 6 (16) 5 (13) 0 (0) 0 (0) 38 Extensive 3 (5) 55 (90) 2 (3) 0 (0) 1 (2) 61 Unknown 1 (100) 0 (0) 0 (0) 0 (0) 0 (0) 1 NPC stage I 5 (42) 5 (42) 2 (17) 0 (0) 0 (0) 12 II 0 (0) 4 (100) 0 (0) 0 (0) 0 (0) 4 III 1 (9) 10 (91) 0 (0) 0 (0) 0 (0) 11 IV 0 (0) 20 (100) 0 (0) 0 (0) 0 (0) 20 Unknown 2 (40) 2 (40) 1 (20) 0 (0) 0 (0) 5 Total 146 (21) 508 (72) 48 (7) 2 (0) 4 (1) 708 NSCLC indicates nonsmall cell lung cancer; SCLC, small cell lung cancer; NPC, no pathologic confirmation.
Table 2.Referrals to a Radiation Oncologist at Initial Diagnosis and by Treating Clinicians According to Stage, Pathology, and Type of Lung Cancer
No. of Patients (%)
NSCLC/NPC Stage SCLC Stage
Referral I II III IV Total ED LD Total Stage Unknown Total Referrals
At initial diagnosis 70 (15)a 36 (7) 151 (31) 225 (47) 482 32 (71)b 13 (29) 45 13 (2)c 540 (61) By treating clinician 39 (23) 13 (8) 50 (29) 69 (40) 171 39 (53) 35 (47) 74 19 (7) 264 (30) At both times 8 (12) 5 (7) 19 (28) 35 (52) 67 8 (62) 5 (38) 13 1 (1) 81 (9) Total 117 (16) 54 (8) 220 (31) 329 (46) 720 79 (60) 53 (40) 132 33 (4) 885d
NSCLC indicates nonsmall cell lung cancer; NPC, no pathologic confirmation; SCLC, small cell lung cancer; ED, extensive disease; LD, limited disease.
aCalculated as the proportion of referrals at initial diagnosis among patients with NSCLC/NPC. bCalculated as the proportion of referrals at initial diagnosis among patients with SCLC. cCalculated as the proportion of all referrals at initial diagnosis.
were 43 more patients with limited stage SCLC who were not referred to a radiation oncologist, including 22 patients who received chemotherapy and 21 patients who received no treatment.17Thus, of all patients with limited stage SCLC, only 37% (30 of 81 patients) received che-moradiotherapy with curative intent. On the basis of clin-ical evaluation by radiation oncologists, 35 patients were candidates for prophylactic cranial irradiation, which was received by 23 patients.
Radiotherapy Utilization
The overall rate of radiotherapy utilization for patients with lung cancer in the current study was 40% (727 of 1812 patients). This rate varied from 21% in patients
without pathologic confirmation to 36% and 43% for patients with SCLC and NSCLC, respectively (Table 4). Compared with optimal radiotherapy utilization rates, there was less first use for treatment of disease in the chest and more first use for disease at other sites, particularly bone and brain; and there was less use with curative intent and more use with palliative intent, particularly when it was targeted to metastases (Table 4). For NSCLC, the deficit in use lay mainly in stage III and IV disease; for SCLC, the deficit was present in both limited stage and extensive stage disease but proportionally was greatest in limited stage disease (Table 4). These deficits were present despite relatively high proportions of patients with good performance status (ECOG 0-2): 74% overall, 78% in Table 4.Actual Compared With Estimated Optimal Radiotherapy Use by Site, Intent of
Treatment, and Stage for Lung Cancer Patients in New South Wales, Australia 2001-2002
Actual Estimated
Optimal, %
Variable No. % Delaney
200313
Tyldesley 200114
ECOG 0-2, %a
Site of first radiotherapy episodeb
Chest (primary site) 414 58 88 82
Lymph nodesc 256 36 88
Bone 157 22 3 80
Brain 120 17 7 79
Other 68 10 2 84
Intent of first radiotherapy episodeb
Curative 144 20 50 90 Adjuvant 50 7 1 82 Palliative to chest 254 36 38 78 Palliative to metastases 255 36 11 79 Palliative, other 170 24 — 86 Other/unknown 6 1 — 100 Disease stage NSCLC I 286 27 31 27 81 II 90 39 31 37 84 III 308 55 81 77 83 IV 527 49 83 35 75 Alld 1290 43 68 46 78 SCLC Limited 83 46 94 81 87 Extensive 189 32 49 11 62 Alld 278 36 68 45 69 NPC 244 21 — — 55 Overall 1812 39 68 45 74
ECOG indicates Eastern Cooperative Oncology Group; NSCLC, nonsmall cell lung cancer; SCLC. small cell lung cancer; NPC, no pathologic confirmation.
aRepresents patients in the category that had an ECOG performance status from 0 to 2, and not the proportion
with an ECOG performance status from 0 to 2 who received radiotherapy.
bCategories are not mutually exclusive. c
Includes ipsilateral hilar lymph nodes, mediastinal lymph nodes, and ipsilateral supraclavicular lymph nodes.
NSCLC (rising to 81%-83% in stages I-III NSCLC), and 87% and 62% in limited stage and extensive stage SCLC, respectively.
DISCUSSION
To our knowledge, this is the first Australian study to describe radiotherapy management of lung cancer at a population level. Fifty-two percent of patients in our sam-ple were referred to a radiation oncologist. Of these, 77% (727 of 943 patients) received radiotherapy, and 69% (651 of 943 patients; including 13 of the 19 patients with no radiotherapy questionnaire) completed treatment in full. The majority of referrals were patients who were diagnosed with locoregional or advanced disease (NSCLC/NPC stage III or IV and extensive disease SCLC; 72%). Given this, a large proportion of patients received radiotherapy with palliative intent (72%). How-ever, of those who could have been treated with curative intent (NSCLC stage I-III and limited stage SCLC), a sig-nificant proportion were not treated according to guide-line recommendations.
Compared with optimal estimates of radiotherapy utilization rates at initial diagnosis,13,14 significant gaps were apparent in NSW. Overall, radiotherapy at initial di-agnosis was underutilized by 29% according to Australian standards13and by 6% according to Canadian standards.14 Even if all patients who were referred to a radiation oncolo-gist were treated using radiotherapy, the NSW underutili-zation rate would be 16% according to Australian standards, suggesting a significant lack of consideration of radiotherapy benefits by diagnosing and potentially treat-ing clinicians or nihilistic attitudes about lung cancer. It is well known that clinician attitudes and personal biases affect treatment recommendations in lung cancer.23-25
An exploration of stage-specific radiotherapy utiliza-tion rates at initial diagnosis indicates that the proporutiliza-tions of patients diagnosed with stage I or II NSCLC were treated within acceptable ranges (stage I NSCLC: actual rate, 27%; optimal rate, 27%-31%; stage II NSCLC: actual rate, 39%; optimal rate, 31%-37%). However, sig-nificant gaps were observed for patients who were diag-nosed with potentially curable disease. For stage III NSCLC, 55% of patients received radiotherapy compared with an ideal of from 77% to 81%. Furthermore, of the patients with limited stage SCLC, only 46% were treated (optimal range, 81%-94%). In this study, the majority of these patients had a good performance status (83% and 87% of patients with stage III NSCLC and limited stage
SCLC, respectively). However, poor respiratory function may have precluded curative radiotherapy, although this generally would be reflected in a worse performance sta-tus. Large tumor volume also may have made the safe delivery of curative radiotherapy difficult. Neither of these factors was recorded in this study.
For patients who were diagnosed with stage IV NSCLC and extensive spread of SCLC, optimal utiliza-tion rates varied between 35% to 83% and 11% to 49%, respectively.13,14For NSW, the actual rates for radiother-apy for these 2 stages were 49% and 32%, respectively. The large variation within optimal utilization rates for advanced stage lung cancer probably is because of the dif-ferences in the predicted prevalence of symptomatic dis-ease in which radiotherapy can provide clinically meaningful relief. In Australia, 71% of patients with stage IV NSCLC are predicted to have symptomatic, local dis-ease for which radiotherapy is recommended; in Canada, this is estimated at 35%. For patients who are diagnosed with extensive stage SCLC, the Australian optimum sug-gests that 49% of patients would have symptomatic dis-ease and good ECOG status and, thus, likely would benefit from receiving radiotherapy. In contrast, Canada’s optimum rates are based on the small proportion of patients who would respond to chemotherapy (7%) or who have brain metastases at diagnosis (4.4%). One of the limitations of the current study is the lack of data regarding symptomatic presentation and response to chemotherapy. Thus, the proportion of patients with advanced disease who should have been treated is unclear.
The Australian Lung Cancer Guidelines state that the optimal treatment for stage III NSCLC (for nonsurgi-cal patients) is combination chemoradiotherapy.8In the current study, only 38% of patients with stage III NSCLC received concurrent chemotherapy with curative radio-therapy, and another 17% received sequential treatment. For limited stage SCLC, the guidelines state that chemo-therapy with concurrent thoracic radiochemo-therapy is the opti-mal treatment. Although the majority of patients who received radiotherapy also received chemotherapy, overall, only 37% of patients with limited stage SCLC received curative radiotherapy with chemotherapy. The Australian guidelines were published after the current study, but the evidence underlying the recommendations was published in the 1990s, and further international guidelines were available.26-28 Clearly, the use of combined modality treatment is less than expected, and this deficit is more marked in patients with limited stage SCLC. It is unlikely
that a significant proportion of patients were considered fit for chemotherapy but not for radiotherapy.
It might be argued that the data are now 6 years old and, thus, do not reflect current practice. The utilization of radiotherapy in the current study, however, was less than that recorded in Victoria in 1993 (44%) and in South Western Sydney in 1996 (56%).16,29Changes are slow to occur in practice, as evidenced by the similar pro-portion of patients that did not receive any anticancer treatment at all for their lung cancer in 1996 compared with 2002.30NSW is the most populous state in Australia and has the greatest number of radiation oncology facili-ties. Therefore, the findings of this study are likely to be applicable to the rest of Australia.
The findings of this study give cause for concern. The utilization of radiotherapy for lung cancer patients in NSW was less than the estimated optimum. The greatest shortfall occurred in limited stage SCLC and stage III NSCLC, diseases in which radiotherapy, in conjunction with chemotherapy, has been proven to improve survival. For patients who were referred for radiotherapy, curative treatment was given infrequently, and the use of com-bined-modality treatment for appropriate patients was uncommon. Although some of these findings may be explained by factors like changing performance status, inadequate respiratory function, or large tumor volume, these are unlikely to account for all of the observed differ-ences. In addition, patient refusal for treatment appeared to be a minor factor. It is likely that attitudes of referring physicians have an impact on referrals for radiotherapy and, thus, radiotherapy utilization. The profile of radio-therapy for lung cancer needs to be raised, and the message that radiotherapy can improve the survival and quality of life of patients with lung cancer needs to be disseminated to all those involved in the management of this disease.
CONFLICT OF INTEREST DISCLOSURES
The Cancer Council New South Wales (NSW) funded the study. The NSW Central Cancer Registry identified eligible patients while it was operated under contract to the NSW Department of Health at the Cancer Council NSW. It is now operated by the Cancer Institute NSW. The analysis was funded by the Cancer Institute NSW.
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