14 Background: Stage IV NSCLC is an incurable illness with significant morbidity. Chemotherapy prolongs average survival from 6 to 10 months and targeted therapies further reduce morbidity and prolong survival. These advances pose financial challenges for safety net hospitals, which may also disproportionately feel the impact of racial disparity. Outcomes in advanced lung cancer may thus differ in the underserved population and resources may not be allocated optimally. Methods: A retrospective review was conducted on all patients diagnosed with Stage IV NSCLC between 2005 and 2011 at Boston Medical Center, an urban safety net hospital. Data were collected on survival from time of diagnosis, type and duration of treatment, utilization of healthcare resources, as well as detailed personal characteristics. We calculated costs of treatment for all patients. We assessed the effect of treatment and patient characteristics on survival. Results: Of 198 patients analyzed, 57% were white, 32% were black, 6% were Hispanic. 11% were homeless. 57% did not receive antineoplastic therapy, 24% received cytotoxic chemotherapy, 18% received combined cytotoxic and targeted therapy. Median survival was 5.0 months without therapy, 7.0 months with cytotoxic chemotherapy and 9.2 months with combined therapy. Any therapy was associated with 56% longer survival. Hazard of death in white patients was 0.68 relative to non-white patients. Median total and monthly costs for patients on no therapy were $70,000 and $14,000, on cytotoxic chemotherapy were $112,000 and $19,000 and on combined therapy were $247,000 and $26,000. Cost per month of survival was $12,000 less for white patients and $15,000 more for homeless patients. Conclusions: The majority of patients did not receive antineoplastic therapy, despite robust survival gains associated with its use. Untreated patients nevertheless incurred a high cost of care. White patients showed better survival at a lower cost. Further topics for study and intervention in this population include barriers to therapy, early involvement of palliative and home-based care in patients not suitable for treatment, strategies for cancer care in the homeless, as well as closer inquiry into drivers of racial disparity.
Uncovering Possible Delays in Diagnosis and Treatment in Lung Cancer at an Urban Safety Net Hospital: An Internal NCDB Quality Initiative
