Nearly half of older adults with metastatic lung cancer never receive systemic therapy, study finds

The treatment arsenal for non-small cell lung cancer (NSCLC) has changed dramatically over the past two decades, with immunotherapies and targeted therapies offering some patients years of additional survival. Yet a new study, published online May 7 in JAMA Oncology, suggests that many older adults never receive any systemic treatment at all. The findings highlight persistent gaps in treatment delivery and suggest that barriers such as delayed diagnosis, lack of specialist referral and the persistence of therapeutic nihilism may be preventing patients from accessing potentially life-extending care.

Metastatic NSCLC accounts for nearly half of all newly diagnosed lung cancer cases and remains associated with high mortality. Historically, treatment options were limited to cytotoxic chemotherapy, which often produced substantial toxicities while offering only modest survival benefits. The arrival of targeted therapies and immune checkpoint inhibitors transformed expectations for many patients, with some now experiencing long-term survival and improved quality of life.

To better understand whether advances in treatment are reaching patients in routine clinical practice, lead author Adam H. Fox, M.D., M.S., and collaborators of the American Cancer Society National Lung Cancer Roundtable analyzed treatment patterns among older adults with metastatic NSCLC. The study included 254,611 adults aged 65 years and older diagnosed between January 2006 and December 2021 using linked SEER-Medicare data. The investigators found that fewer than half of patients received systemic therapy (i.e., body-wide treatments administered by mouth or directly into the bloodstream). Although treatment rates increased modestly over time, the gains were smaller than expected given the rapid expansion of targeted therapies and immunotherapy.

Overall, 119,197 patients (46.8%) received systemic therapy at some point after diagnosis. Among the nearly 40% of patients who died within 90 days of diagnosis, only 13.2% received treatment, compared with 69% of patients who survived longer than 90 days.

Treatment rates increased only modestly over the 15-year study period despite the introduction of highly effective targeted therapies and immunotherapies. Even among patients younger than 80 years with relatively few comorbidities who survived at least 90 days after diagnosis, more than one in five never received systemic therapy.

Referral to an oncology specialist emerged as one of the strongest factors associated with treatment receipt. In adjusted analyses, patients referred to oncology specialists were significantly more likely to receive systemic therapy than those who were not referred. Biomarker testing was also strongly associated with treatment. Patients older than 80 years, those with greater comorbidity burdens and Black or Hispanic patients were less likely to receive treatment.

“We were really surprised to find that only about half of patients with metastatic non-small cell lung cancer ever receive systemic therapy,” Fox told Managed Healthcare Executive in an interview. Fox is a pulmonologist, clinician-scientist, and assistant professor of medicine at the Medical University of South Carolina.

“As more targeted therapies and immunotherapy gained indications over the study period, we expected to see more of an increase in treatment than we found,” he said.

Although the study was able to identify some predictors of treatment, such as marital status and histology, Fox noted that the registry and claims data could not capture all of the factors that may go into clinician and patient decision-making. “For instance, we do not have a good measure of performance status, which would be important from a clinical perspective,” he said.

“Additionally, we have poor insight into how patients may make this decision on whether to be treated,” Fox said, noting that treatment decisions may be influenced by personal values, concerns about toxicity, cost considerations and other factors.

Still, several patterns stood out. “Many patients are presenting within months of their demise… and many never meet an oncologist,” Fox said. Approximately 40% of patients died within 90 days of diagnosis, raising concerns about delayed detection and limited opportunities for intervention. More than a third never had an oncologist visit.

“Clinicians should encourage patients to seek advice from a medical oncologist about their outlook on treatment — such that if they decide to not pursue treatment, it is an informed decision,” Fox said.

A notable strength of the analysis was the inclusion of Medicare Advantage beneficiaries in later years of the study period, when those records became available. While there are potential limitations in how the data is processed differently than traditional Medicare, Fox said this subgroup "behaved similarly to the full cohort," supporting the overall findings.

In their discussion, the authors suggest that improving outcomes will require more than therapeutic innovation alone. Efforts to increase lung cancer screening, reduce delays in diagnosis, accelerate biomarker testing and ensure timely oncology referrals may be just as important as developing new drugs. They also point to the need to address longstanding stigma and therapeutic pessimism surrounding lung cancer, which may discourage both referrals and treatment discussions.

As treatment options continue to expand, the study suggests that one of the greatest challenges may be ensuring that eligible patients are connected to the specialists and resources needed to benefit from them.