Real-world program-based lung cancer care.
Authors: Liao Wei , Derrick Anna , Goss Jordan , Shepherd Catherine J , Qureshi Talat , Patel Anita , Fehnel Carrie , Faris Nicholas R , Ray Meredith , Osarogiagbon Raymond U. 
Published: June 2023

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Background: Low dose CT screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordance. The impact of such program-based care on ‘real-world’ population-level lung cancer survival and mortality is uncertain. We evaluated program-based lung cancer care versus care outside structured programs in a large community healthcare system. Methods: We linked prospective observational databases for LDCT, LNP and MDC with the Tumor Registry of Baptist Cancer Center facilities across Mississippi, Arkansas and Tennessee, categorizing all lung cancer patients between 2011 and 2021, according to program- (LDCT, LNP, MDC) versus non-program-based care. We compared stage distribution, care patterns, survival and mortality by standard statistical methods. Results: Of 12,089 patients, 250 (2%), 1236 (10%), 1045 (7%) and 9558 (79%) were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96% in 2011 to 67% in 2021, diagnosis through LDCT increased from 0.3% to 7%, LNP from 0.9% to 21%; and MDC alone decreased from a high of 13% in 2015 to 5% in 2021. Black persons, 28% of the whole cohort, were 13% of LDCT, 25% of LNP, 31% of MDC, and 28% of non-program-based care recipients (p = 0.0005). Median (IQR) tumor size was 20mm (13 – 34), 25mm (17 – 44), 35mm (20 – 55) and 35mm (20 – 55), respectively (p < 0.0001); 40-46% of patients across programs had adenocarcinoma; clinical stage was I or II in 58%, 48%, 38% and 29% and IV in 16%, 27%, 31% and 42% in the respective programs (p < 0.0001). 2609 patients (21.6%) had surgery, including 49.2%, 37.7%, 36.1% and 17.2% in LDCT, LNP, MDC and non-program-based care respectively, among whom aggregate pathologic stage was I in 76%, 71%, 54% and 60% (p = 0.0005). Surgery was the sole treatment modality in 27.6%, 21.5%, 12.9% and 10.6%, respectively (p < 0.0001). Despite higher proportions with more advanced pathologic stage, 30.8% of recipients of non-program-based care received adjuvant therapy, compared to 42% among recipients of program-based care, including 39.0%, 37.1% and 49.3% in LDCT, LNP and MDC, respectively (p < 0.0001); 8.7% of patients in programs received no treatment, compared to 20.1% of non-program-based care. Aggregate 5-year overall survival rates were 60% (95% CI: 52% - 69%), 45% (95% CI: 42% - 49%), 30% (95% CI: 27% - 33%), and 18% (95% CI: 17% - 19%), respectively (p < 0.0001). Adjusting for age, sex, race, patient-level rurality and histology, with non-program-based care as reference, the aHR were 0.3 (95% CI: 0.234 – 0.373), 0.51 (95% CI: 0.464 – 0.556, and 0.66(95% CI: 0.607 – 0.712). Results were consistent even without patients who received no treatment. Conclusions: Program-based care was associated with more favorable lung cancer characteristics, better quality of care and survival. Disseminating program-based care should be explored as a matter of urgent public policy.