Best supportive care in stage I–III non-small cell lung cancer: survival by reason for curative treatment omission in a real-world study population

Background: Despite advances in stage I–III non-small cell lung cancer (NSCLC) treatment, curative-intent therapy is withheld in patients deemed ineligible or preferring no treatment. Limited real-world data exist on overall and cancer-related survival outcomes in patients receiving primary best supportive care (BSC). The main aim of this study was to compare median overall survival (OS) by reason for BSC (patient preference versus other factors).

Methods: We retrospectively analyzed overall and lung cancer-specific survival (LCSS) in patients with stage I–III NSCLC diagnosed between 2015 and 2019 in the Netherlands. Patients received primary BSC or curative treatment (surgery, radiotherapy or chemoradiation). The BSC cohort was categorized by main decisive factor: (I) patient preference; (II) insufficient performance status; or (III) relevant comorbidities. Survival data were compared using log-rank tests and Cox regression models.

Results: Out of 1,895 patients, 234 (12%) received primary BSC, including 82 based on patient preference. Median OS was 5.9 months in the total BCS cohort and 9.6 months in the patient-preference cohort, compared to 54.1 months in the curative treatment cohort [hazard ratio (HR) 0.17; 95% confidence interval (CI): 0.13–0.22; P<0.001]. Median LCSS was 8.9 and 16.4 months in the total BSC and patient-preference cohort, respectively, versus not reached in the curative treatment cohort (HR 0.15; 95% CI: 0.11–0.21; P<0.001). These survival differences remained significant after adjusting for relevant confounders.

Conclusions: In routine clinical practice, primary BSC was provided in a substantial proportion of patients with stage I–III NSCLC, due to medical reasons or patient preference. In either case, omission of curative treatment resulted in significantly reduced survival outcomes. Our data offer targeted evidence to guide treatment decisions in the outpatient oncology clinic.