Abstract

Background Novel anti-cancer treatments (targeted therapies, biologics, and immunotherapies) targeting tumour biology and/or the immune system have improved non-small cell lung cancer (NSCLC) outcomes. However, it is not known if the socio-economic inequalities observed in the utilisation of conventional NSCLC treatments (surgery, chemotherapy, and radiotherapy) are also present with the uptake of NSCLC novel anti-cancer therapies. To investigate, this study examined the associations between deprivation and utilisation of novel anti-cancer therapies, within the national, publicly funded English healthcare system.

Methods A retrospective analysis of 90,785 patients diagnosed between 01/01/2012 – 31/12/2017 with a histologically confirmed stage IV NSCLC, sourced from the English National Cancer Registrations database and linked Systemic Anti-Cancer Therapy (SACT) dataset, was undertaken. Novel systemic anti-cancer therapy utilisation was dichotomised for each patient, based on SACT drug data. The likelihood of novel anti-cancer therapy utilisation by deprivation quintiles of area of residence at diagnosis (Index of Multiple Deprivation income domain) was examined using multivariable logistic regression. Sensitivity analyses were performed for adenocarcinoma and non-squamous histologies. A further exploratory analysis evaluated utilisation by deprivation for targeted treatments (EGFR & ALK), biologics (anti-angiogenics) and immunotherapy. Models were adjusted for the following (where appropriate) covariates: age; sex; diagnosis year; ethnicity; rural/urban residence; multiple tumours; and comorbidities. Analyses were conducted using Stata (v16.1).

Results There are significant treatment inequalities by deprivation in stage IV NSCLC in England. Patients residing in the most deprived areas were more than half as likely to utilise a novel therapy (multivariable odds ratio (mvOR) 0.45 [95% CI] 0.41, 0.49) compared to patients residing in the most affluent areas. Deprivation associations with treatment utilisation were slightly stronger with targeted treatments ((most vs least deprived, mvOR) 0.39 [95% CI] 0.35, 0.43) than immunotherapies (mvOR 0.58 [95% CI] 0.51, 0.66).

Conclusion In the English National Health Service, where treatment is free at the point of delivery, there are marked socio-economic inequalities in NSCLC novel treatment utilisation. Implications of these findings are important for future equitable delivery of drugs which have transformed outcomes in metastatic NSCLC. Further work now needs to explore the underlying causes of this inequality.

Priority and Relevance In an era of biomarker driven cancer treatment, prioritisation of treatment fairness, as well as the integration of novel drugs focused on treatment effectiveness into clinical guidelines, is needed to improve NSCLC outcomes.