Study Finds Risk of Overinvestigation in Patients With Lung Cancer Not Fit for Anticancer Treatment

Despite having poor prognostic factors that result in a recommendation of best supportive care (BCS), a significant proportion of patients with lung cancer still undergo further investigations, say researchers of a new study published in Clinical Medicine (London, England).

Among a group of patients with lung cancer who were not suitable for anticancer treatment, the researchers found that 40% underwent additional investigations after their initial CT scan before eventually receiving BCS. Further investigations included endobronchial ultrasound-guided transbronchial needle aspiration, positron emission tomography, and percutaneous CT-guided lung biopsy.

“Given that the further investigations completed in this study ultimately did not impact patient management, they could be considered futile and raise concerns about the impact on patients undergoing these tests in terms of risk and quality of life, as well as placing additional burden on the cancer diagnostics system,” argued the researchers.

Approximately 80 patients were included in the study and were described as follows:

• Elderly: The average age of patients was 79 years
• Having limited function: 80% of patients had a World Health Organization performance status of 3 or above
• Being frail: 70% of patients had clinical frailty scores (CFS) of 6 or above
• Having advanced disease: 90% of patients had stage 3 or 4 disease

According to the researchers, 55% of the 31 patients who received further investigations did so because they were considered not fit for systemic treatment due to factors that included poor performance status or comorbid status.

“Herein lies the difficulty. It could potentially be argued that a patient might be considered fit for targeted therapy (such as a tyrosine kinase inhibitor in EGFR mutations) but not fit for treatment with platinum-based chemotherapy,” commented the researchers. “Therefore, performing diagnostic sampling procedures are a necessity to identify molecular markers for targeted therapy on the understanding that, in the absence of these markers, the likely management would be BSC.”

However, the researchers noted that a number of the lung cancer samples were not tested for potential targeted therapies and that serum EGFR mutation testing—a less invasive method for screening—was scarcely used in the study population; just 2 of these patients had received the testing. The researchers emphasized the utility of this testing, arguing that early use of the screening method could help guide appropriate decision-making and limit unnecessary investigation.

Use of CFS was also highlighted by the researchers, who noted that widespread use of and adherence to the scoring system can help ensure optimal care decisions for these patients. CFS scores were similar between patients who had early BCS and patients who underwent further investigations.

Kidney function was also similar between the 2 groups. The median estimated glomerular filtration rate was 62 mL/min/1.73 m² among patients who received early BCS and 69 mL/min/1.73 m² among the patients who underwent further investigations.

Sixteen percent of the 31 patients who underwent further investigations did so because they had stage 4 or 5 chronic kidney disease and could not receive system treatment due to inadequate estimated glomerular infiltration. Another 19% died shortly after completing investigations.

The researchers highlighted inadequate attention to incorporation of kidney function as a part of diagnostic work-up in patients with advanced disease, emphasizing that identifying impaired kidney function could help guide decisions for investigations in these patients.

Reference

King J, Shah D, Hewitt K, et al. The diagnostic pathway in lung cancer patients with best supportive care decisions: are there lessons to be learnt? Clin Med. Published online April 20, 2022. doi:10.7861/clinmed.2021-0160