Maior estudo já publicado sobre o tema mostrou que a sobrevida de pacientes com a doença está décadas atrás em relação a outros países
Por Cilene Pereira
Atualizado em 6 dez 2021
Leia mais em: https://veja.abril.com.br/saude/saude-privada-e-pouco-eficiente-no-tratamento-de-cancer-de-pulmao/
O câncer de pulmão é uma das doenças que mais mata no mundo.
Em 2020, foram registradas 1.794.144 mortes, segundo o levantamento Globocan 2020, realizado pela Agência Internacional de Pesquisa em Câncer (IARC), ligada à Organização Mundial da Saúde (OMS).
Esse número pode chegar a 3,01 milhões em 2040 (66,7 % a mais), se nada for feito para mudar o quadro atual.
No Brasil, de acordo com o Instituto Nacional de Câncer (INCA),
- são esperados 30.200 casos em 2021, sendo que,
- anualmente, são registradas cerca de 30 mil mortes por câncer de pulmão no país.
Os números são assustadores e por aqui o futuro não parece muito promissor — mesmo para pacientes da rede privada.
Foi isso que mostrou um estudo publicado no mês passado no jornal JCO Global Oncology (JCO GO).
A pesquisa avaliou como é a trajetória de um paciente com o câncer de pulmão de células não pequenas (responsável por 80% dos casos) no sistema privado de saúde brasileiro no período entre 2011 a 2016.
“Os objetivos principais foram descrever a jornada e as taxas de sobrevida de pacientes com este tipo de câncer de pulmão atendidos na saúde suplementar.
Os resultados mostram um alto número de diagnósticos de doença metastática, baixas taxas de sobrevida e altos custos relacionados à assistência médica”, afirma o oncologista torácico Carlos Gil Ferreira, que liderou o estudo.
É o maior estudo em tamanho de amostra já publicado referente ao tema no Brasil e também um dos maiores de dados do mundo real sobre câncer, conduzidos globalmente em países de renda média.
Foram estudados 5016 pacientes, a maioria tinha entre 60 e 69 anos (33,6%) e ensino fundamental completo (52,2%). Havia uma proporção maior de homens (58,1% x 41,9% mulheres).
Os dados foram retirados de bases administrativas, de registros de instituições privadas de câncer e coletadas ao longo dos anos. “Desses registros constam a data da entrada do paciente, os tratamentos a que foram submetidos e data do desfecho (resposta ao tratamento, progressão ao tratamento ou óbito)”, explica Carlos Gil Ferreira.
O estudo incluiu hospitais e planos de saúde de nível médio, mas não os de elite. “Pacientes com acesso a essas instituições em geral são tratados com medicamentos que nem existem no Brasil. Por isso não foram incluídos.
Queríamos dados da população brasileira do sistema privado de saúde que fosse tratada de forma homogênea por oncologistas não necessariamente torácicos”, completa ele.
Atraso de décadas
O estudo mostrou que o perfil de sobrevida de pacientes com a doença no ambiente privado de saúde é de 6,5 meses nos casos mais graves. Esse número é comparável às taxas de sobrevida de outros países de décadas atrás.
Isso significa que as baixas taxas de sobrevida mostradas na pesquisa são comparáveis com as anteriores à chamada oncologia de precisão, desenvolvida a partir dos anos 2000, cujos recursos, nesses casos, permitem uma sobrevida global mediana de 8–12 meses.
Para o oncologista, os motivos da alta mortalidade devem ser investigados e discutidos para melhorar a sobrevida e a qualidade de vida dos pacientes.
“O que ficou claro é que há espaço para melhorar,
- estimulando a detecção precoce do tumor e a abordagem multidisciplinar
- e fornecendo acesso a testes moleculares, quimioterapia, terapias direcionadas e imunoterapias” diz.
“O que ficou claro é que há espaço para melhorar, (1) estimulando a detecção precoce do tumor e a abordagem multidisciplinar, (2) e fornecendo acesso a testes moleculares, quimioterapia, terapias direcionadas e imunoterapias” diz.
Outra descoberta relevante do estudo foi que entre a primeira consulta até o início do tratamento são decorridos dois meses. “O tempo ideal entre a primeira consulta, diagnóstico e tratamento não deveria ser superior a trinta dias. Em uma doença grave como câncer de pulmão, esse atraso pode ter impacto negativo no tratamento”, afirma Carlos Gil Ferreira.
A equipe de especialistas iniciará um novo estudo para analisar os dados de 2016 a 2021. É torcer por notícias melhores!
Originally published at https://veja.abril.com.br.
Leia mais em: https://veja.abril.com.br/saude/saude-privada-e-pouco-eficiente-no-tratamento-de-cancer-de-pulmao/
ORIGINAL PUBLICATION
JCO Global Oncology
Demographic and Clinical Outcomes of Brazilian Patients With Stage III or IV Non–Small-Cell Lung Cancer: Real-World Evidence Study on the Basis of Deterministic Linkage Approach
Carlos Gil Ferreira , MD, PhD1; Marcia Datz Abadi, MD2; Paula de Mendonça Batista , BSc2; Fernando Brandão Serra , MD2; Rodrigo Buzzatti Peixoto , MD2; Lucas Miyake Okumura , BSc3; and Erica Regina Cerqueira, MD2
ABSTRACT
PURPOSE
Non–small-cell lung cancer (NSCLC) is the most common type of lung cancer and accounts for 80%-90% of the cases. In Brazil, between 2018 and 2019, lung cancer was ranked as the second most frequent cancer among men and the fourth among women. The primary objectives were to describe the journey and survival rates of patients with advanced NSCLC treated in the Brazilian private health care system (HCS).
MATERIALS AND METHODS
A retrospective cohort study was based on the search in administrative databases to analyze the Brazilian private HCS. Patients with advanced NSCLC diagnosed between 2011 and 2016 were included. The data on demographics, cancer-related information, treatment-related information, and resources used were collected. Survival analyses were performed using the semiparametric Kaplan-Meier method to assess mortality by NSCLC stage, with NSCLC diagnosis as the index date.
RESULTS
A total of 5,016 patients were included. Most patients were between 60 and 69 years old (33.6%) and had completed elementary school (52.2%). There was a greater proportion of men (58.1% v 41.9%), and the majority of patients had stage IV NSCLC (67%). It took an average of 31 days, from the first consultation, to have diagnosis. In 44% of the cases, a clinical oncologist was the first specialist in the HCS that the patient was referred to. After the diagnosis, the median time to start of treatment was 35 days. Chemotherapy alone was the most common treatment regimen (32%). The median overall survival was 11.5 months and 6 months for stage II and IV NSCLC, respectively.
CONCLUSION
This study provides contemporary data on stage III and IV NSCLC in private health care in Brazil, which has shown a high rate of metastatic disease diagnoses, high health care–related costs, and low survival rates.
EXCERPTS FROM THE LONG VERSION
CONTEXT
Key Objective
- How is the journey of a patient with advanced non–small-cell lung cancer in Brazilian private health care system (HCS)?
Knowledge Generated
- Patients with non–small-cell lung cancer (NSCLC) are more commonly diagnosed by a clinical oncologist on stage IV, and it took approximately 2 months from the first consultation to start of treatment.
- Patients with advanced NSCLC are more commonly treated with chemotherapy alone in Brazilian private HCS, and these patients show low survival rates, similar to the public HCS.
Relevance
- Knowledge in advanced NSCLC patient’s journey allows the perception of a necessity for improving NSCLC care by stimulating earlier tumor detection and multidisciplinary approach and by providing access to molecular testing, chemotherapy, targeted therapies, and immunotherapies
INTRODUCTION
According to the WHO, globally, about one in six deaths is due to cancer. In 2018, one of the most common neoplasms was lung cancer, accounting for 2.09 million cases and 1.76 million deaths.1 In Brazil, between 2018 and 2019, 18,740 new cases of lung cancer were estimated among men and 12,530 cases among women, with non–small-cell lung cancer (NSCLC) ranked as the second and fourth most frequent neoplasm in these populations, respectively.2
NSCLC is the most common lung cancer and accounts for 80%-90% of all lung cancers. Squamous cell carcinoma, adenocarcinoma, and large-cell carcinoma are all subtypes of NSCLC, among which adenocarcinoma is the most common one.3,4 Cetin et al5 showed 1-year survival rates of 29.1% for patients with stage IV bronchioloalveolar adenocarcinoma and 12.8% for those with large-cell tumors.5 The age-standardized 5-year survival rate in Brazil is 18%, which is consistent with global rates ranging from 10% to 20%.6 In Brazil, from 1979 to 2004, the lung cancer mortality increased from 10.6 to 31.1 deaths per 100,000 population for men and from 3.0 to 5.4 deaths per 100,000 population for women.7 Although more curative-intent treatment and improved relative survival for NSCLC were seen over time, these benefits were less evident among elderly people; also, differences were less marked among the elderly; also, disparities in treatments and relative survival between age groups were widening for stages III and IV in this group of patients.8
Regarding the availability of diagnostic procedures, in a 2005 survey, the numbers of computed tomography scanners per 1,000,000 population were 4.9 and 30.8 in the public and private health care systems (HCSs) in Brazil, respectively.9 These numbers highlight the difficulties in access to an adequate diagnostic evaluation in the public HCS, whereas the numbers for private health care facilities are similar to those in developed countries, such as the United States and Japan (31.5 and 32.2, respectively).10 In Brazil, 2010 was the year that positron emission tomography was approved for lung cancer staging in the private health care setting; however, the public HCS incorporated the technology only in 2014.10
According to National Health Research, performed by Brazilian Institute of Geography and Statistics, 71.1% of the Brazilian population depends on the public healthcare system Sistema Único de Saúde to have access to health services, whereas 28.4% of people have access to the private health service (PNS 2013).11 This inequality in access to health is proportional to access to drug products and molecular testing between public and private HCSs. Approximately two thirds of the epidermal growth factor receptor mutation tests are performed in the private sector for lung cancer, and only one third is performed in public health care institutions.12 In addition, standard third-generation chemotherapy agents were only introduced in the public HCS in the late 2000s and pemetrexed is still unavailable. Targeted therapies, such as monoclonal antibodies (bevacizumab) and first-generation epidermal growth factor receptor tyrosine kinase inhibitors, are available only for patients with private health care coverage.10
The primary objectives of this study were to characterize patients with NSCLC journey in the private health care and to explore the demographics and survival of patients with advanced NSCLC in the Brazilian private HCS. The journey of patients can be defined as the ongoing sequence of care procedures that a patient follows from the point of access into the HCS, continuing toward diagnosis and care and until the completion of outpatient care.13
To achieve these aims, we used database linkage, also known as record linkage at the individual level of the patient, which is the matching of separate database records, combining information from each database into a single observation unit. The challenge is to perform matching so that available data from the same person are not duplicated, whereas information from different people is not combined.14 Record linkage from medical databases such as electronic health records, health insurance company claims, and patient-generated data is becoming increasingly important for delivering high-quality and high-value health care, conducting valid and generalizable research, and evaluating health care policy. Database linkage can help create comprehensive, longitudinal data sets with information on patients’ conditions and treatments over time.15
Database linkage stems from public administration disciplines and is very common in social security sciences and public administration. In the past few decades, linkage methods were adopted in the health sciences (epidemiology and public health) to solve the problem of not having integrated information about the population.16 Nowadays, linkage is a discipline in the public health graduate program in Brazil,17 and many authors have been using it to answer questions about many clinical conditions,16,17 such as cancer and tuberculosis. Using linkage methods is not a common practice in countries with integrated data such as the United Kingdom or even the US Medicare system.
MATERIALS AND METHODS
See the original publication
RESULTS
See the original publication
DISCUSSION
The present study has the largest sample size ever published on patients with NSCLC treated in the private HCS in Brazil. It is also one of the largest cancer real-world data studies globally conducted in middle-income countries.10,26,27 Therefore, it brings a wider perspective on staging, survival, and resource use. This study allowed the elucidation of the survival profile of patients with advanced NSCLC in the private health care setting, which was comparable with survival rates in other countries, but from decades ago.10,26,27
Latin American health care database studies are scarce because of a lack of reliable and unified data sources. For NSCLC, real-world evidence is the ultimate modality of research to strategically assess the private health care market, especially when there is a lack of data published, as is the case with Brazil. The last review on lung cancer10 could not identify as much as 10 studies in the country. The sum of all patients in previous studies might be smaller than our sample size (eg, Barrios et al25 reported 41 patients). After matching the database records using the deterministic approach, we included more than 5,000 patients, which might not represent all patients with NSCLC who were referred to private health care institutions in Brazil, but certainly is the biggest source of information.
The predominance (> 90.0%) of patients > 50 years age in the sample was expected for patients with stage III and IV NSCLC.10 Regarding the assumption of a higher proportion of cases for men, the predominance of the disease in men was described here (58.1%) and confirmed elsewhere, varying from 2:1 to 12:1.28,29
Additionally, a possible explanation for the observed reduction in the number of NSCLC cases over time, in the private health care setting, includes different reasons:
(1) One of the main databases used for cancer identification in Brazil (RHC/INCA) has not been locked (the data on the 2014–2016 cohort are still being collected). This observation was confirmed by the repeated download of databases on July 15, 2018, and September 20, 2018.
(2) NSCLC definitions were changed in 2014–2015: pathologists were oriented to choose non–small-cell cancer, instead of non–small-cell lung cancer since the latter was confirmed after the exclusion diagnosis with or without identification of a pneumocyte marker to confirm a lung-specific disease.30 Per protocol, our mainstay criteria to identify patients with lung cancer were having ICD-10 code C34 and histologic findings compatible with NSCLC. Considering that malignant neoplasm not otherwise specified is a common diagnosis after the introduction of the 2014–2015 WHO Lung Cancer Classification, there was a significant loss of lung cancer registries.
Besides, our linkage method detected an underestimated but assertive number of NSCLC cases, which is preferable to overestimation. Considering the updated histologic classification from WHO, the current cancer registries might be subject to criticism on how accurate they are for estimating 34,000 new cases per year of lung or bronchus cancer in Brazil (public plus private systems).10 On the other hand, if the previous estimation is correct, the burden of NSCLC might be around 23,800 new cases per year (70% of all lung cancers, according to local experts17). Another relevant finding in the present study was access to health care services from the first consultation. We found an average 31-day interval to establish a diagnosis, which was corroborated by previous studies that suggested about 30 days to diagnose NSCLC.29 The median time to start treatment (35 days) was close to the findings from Abrao and Abreu,31 who suggested that the median time to start treatment was 1 month.10 In a sample of patients with stage III and IV disease, access to treatment in 30 days cannot be considered a standard of care and might affect mortality in Brazil. A later law, recently published (№13896/2019), stipulates that cancer treatment must start not later than 30 days after diagnosis. Although we have found that the timing is slightly above the legal limit, 30 days is still a long period to wait for a life-changing piece of news and it should be improved.31
Our analyses on resource use showed a profile similar to the private health care setting in Brazil, and these data could be used in the future as an important parameter for budget impact models.
Finally, the median survival for patients with stage IV NSCLC was 6.5 months, which is considerably lower than an American population cohort study that showed a median survival of 11 months.32
Additionally, a retrospective cohort study using data collected by the National Cancer Institute’s SEER(from 1998 to 2003) Program described a median survival ranging from 4 to 6 months, according to the histologic subtype for patients diagnosed with stage IV NSCLC.5 The benchmark values for projecting survival analysis in Brazil are 8 and 7 months of life for stages III and IV, respectively.10 Variables that affect NSCLC survival rate, such as access to health services and the time to treatment start, might be considered before incorporating new technology. This has been associated with a decreased overall survival rate in studies conducted in Brazil and the United States.33 The introduction of new technologies, such as overcoming opportunities on immunobiology, which have been demonstrated to improve overall survival and progression-free survival compared with chemotherapy alone, is expected to improve the prognosis in the country. Nevertheless, knowing the survival rate, it is possible to design appropriate prospective studies and perform an economic analysis.34
Strengths and limitations may be found when working with secondary data, such as the databases used in this study. There is plenty of data to be analyzed, and, sometimes, they might be the only source available. On the other hand, the quality of the study will depend on the quality of the collected data and the format of their entry into the database may vary over time.
The core limitations of real-world data analysis include retrospective data collection, the administrative nature of the databases, and multiple individuals involved with data handling. To minimize the impact of the latter, we made sure that data were double-checked by different researchers. Our data might be confirmed by screening for logical associations (quality assurance of data, as we did by confirming logical assumptions, such as mortality, sex, and staging information).
In conclusion, this study provides contemporary real-world evidence on stage III and IV NSCLC in the private health care setting in Brazil and is the largest sample size observational study in lung cancer ever conducted in the country. The results show a high number of metastatic disease diagnoses, low survival rates, and high health care–related costs. The low survival rates are comparable with the pretargeted therapy era (median overall survival of 8–12 months). The reasons for the described high mortality should be investigated and discussed to improve the patients’ survival and their quality of life. Timely access to more effective drug products must be sought to provide enhanced treatment and, therefore, improve the survival rates. Clearly, there is room for improving NSCLC care by stimulating earlier tumor detection and multidisciplinary approach and by providing access to molecular testing, chemotherapy, targeted therapies, and immunotherapies.
REFERENCES
See original publication
PRIOR PRESENTATION
Presented at the ISPOR Latin America 2019, Bogotá, Colombia, September 12–14, 2019 (poster), and the International Association for the Study of Lung Cancer (IASLC), Barcelona, Spain, September 7–10, 2019 (poster).
SUPPORT
Supported by Merck Sharp & Dohme Corp, a subsidiary of Merck & Co, Inc, Kenilworth, NJ, which provided financial support for the study.
AUTHOR CONTRIBUTIONS
Conception and design: Marcia Datz Abadi, Paula de Mendonça Batista, Fernando Brandão Serra, Rodrigo Buzzatti Peixoto, Erica Regina Cerqueira
Administrative support: Paula de Mendonça Batista
Collection and assembly of data: Lucas Miyake Okumura
Data analysis and interpretation: All authors
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
See the original publication
About the authors & affiliations
Carlos Gil Ferreira , MD, PhD1;
Marcia Datz Abadi, MD2;
Paula de Mendonça Batista , BSc2;
Fernando Brandão Serra , MD2;
Rodrigo Buzzatti Peixoto , MD2;
Lucas Miyake Okumura , BSc3; and
Erica Regina Cerqueira, MD2
1Instituto Oncoclínicas, São Paulo, Brazil
2MSD Brazil, São Paulo, Brazil
3Techtrials, São Paulo, Brazil
