Management of Metastatic Non-Small-Cell Lung Cancer and a Consideration of Cost

The 12 percent five-year survival rate for patients with non-small-cell lung cancer (NSCLC) has not changed in several decades. However, four randomized trials have shown a modest increase in the mean survival time of patients with advanced NSCLC who received systemic chemotherapy vs best supportive care (BSC), and two others have demonstrated a statistically significant survival advantage (average increase, 12 weeks). Whereas the objective response rate to chemotherapy ranges from 30 to 40 percent, relief of cancer-related symptoms as well as improved performance status and weight gain typically occur in 70 percent of patients. Treatment-related adverse effects have been markedly reduced with new antiemetics. Concerns regarding costs have been lessened by the National Cancer Institute of Canada's observation that at least some chemotherapy regimens may be less costly than BSC. Direct-care costs of managing all stages of NSCLC in Canada were estimated at $102 million (1984 Canadian dollars), assuming that stage IV patients received only BSC. The average incremental cost of the most expensive chemotherapy would be $5,000 per case. If this cost were incurred by 50 percent of stage IV cases (good performance status, symptomatic patients), total care costs would be increased by about 10 percent ($10.5 million). This is less than half the cost of the introduction of neoadjuvant chemotherapy, which is rapidly being adopted as standard practice in the absence of data from randomized controlled clinical trials.