The Clinical and Economic Implications of Different Treatment Pathways for Patients with Rapidly Recurrent Malignant Pleural Effusion

Background Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been fully evaluated. Research Question What clinical outcomes, complications, healthcare resource use, and costs are associated with various rapidly recurrent MPE treatment pathways? Study Design and Methods This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients aged 66-90 with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis including non-definitive repeated thoracentesis, or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy. Results Among 8,378 patients with MPE, 3,090 (36.9%) had rapidly recurrent MPE (mean [SD] age 75.9 [6.6], 45.6% male, primary cancer 62.9% lung and 37.1% other). Second pleural procedures were non-definitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was more frequently required if the second pleural procedure was non-definitive thoracentesis vs. chest tube, IPC, or thoracoscopy (70.3% vs. 44.1% vs. 17.9% vs. 14.4%, respectively). The mean number of subsequent pleural procedures over the patient’s lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs following the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson Comorbidity Index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube ($40,627; P = .004) vs. thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) had similar costs to patients receiving thoracentesis. Interpretation Early definitive treatment was associated with fewer subsequent procedures and lower costs in rapidly recurrent MPE.