A prognostic model for advanced stage nonsmall cell lung cancer. Pooled analysis of North Central Cancer Treatment Group trials

Thrombocytosis and immunohistochemical expression of connexin 43 at diagnosis predict survival in advanced non-small-cell lung cancer treated with cisplatin-based chemotherapy

PURPOSE

Patients with advanced non-small-cell lung cancer (NSCLC) have poor survival, and platinum-based chemotherapy agents are the standard first-line chemotherapy agents for advanced NSCLC. This study aimed to identify predictive factors associated with the response to chemotherapy and survival in 258 patients with advanced NSCLC treated with platinum-based chemotherapy.

METHODS

Stage IIIA-IV NSCLC patients diagnosed in Kaifeng second people's hospital (Henan, China) between March 2002 and September 2011 were retrospectively reviewed. All of the patients had received platinum-based chemotherapy, and patients were followed up to date of death or last follow-up to obtain data of response to chemotherapy and survival. Potential prognostic factors such as gender, age, tumor size, tumor type, histologic stage, anemia, calcium levels, ECOG performance status (PS), thrombocytosis, TTF-1, p63, and connexin 43 were analyzed. Response to chemotherapy, overall survival (OS) and progression-free survival (PFS) were calculated by the Kaplan-Meier method and Cox regression model.

RESULTS

A univariate analysis indicated that thrombocytosis and connexin 43 were found to be significant prognostic factors (p < 0.001) and ECOG PS, Hb levels, and p63 presented a tendency toward association with survival. Kaplan-Meier survival showed that the mean OS and PFS in chemotherapy responders with connexin 43 ≥ +2 were significantly longer than in chemotherapy responders with connexin 43 ≤ 1+. In contrast, thrombocytosis was associated with increased mortality and resistance to chemotherapy in chemotherapy responders. In addition, all 21 patients of the 5-year OS were from chemotherapy responders with connexin 43 ≥ +2 or non-thrombocytosis.

CONCLUSIONS

Thrombocytosis and connexin 43 absence may be reliable surrogate markers for the prediction of chemotherapy response and prognosis for patients with advanced NSCLC, and assessment of these factors may identify a population of patients with advanced NSCLC that is likely to have a prolonged life expectancy.

Post-chemotherapy T-cell recovery is a marker of improved survival in patients with advanced thoracic malignancies

Background:

There is increasing interest in combining chemotherapy with immunotherapy. However, the effects of chemotherapy on the human immune system are largely unknown.

Methods:

Longitudinal changes in peripheral T-cell subsets in 40 patients with malignant mesothelioma (MM) or advanced non-small cell lung cancer (NSCLC) receiving platinum-based chemotherapy were assessed by flow cytometry and evaluated for associations with clinical outcome.

Results:

Proliferating T cells of all subsets were almost entirely depleted at day 8 following chemotherapy, but rapidly recovered above baseline levels. Regulatory T cells (Treg) were most profoundly depleted at this time point. A greater increase in CD8⁺ T-cell proliferation following one treatment cycle was associated with improved overall survival in univariate (hazard ratio (HR)=0.40; P<0.05) and multivariate (HR=0.17; P<0.01) analyses. A greater increase in the ratio of CD8⁺ T cell to Treg proliferation was also predictive of better prognosis.

Conclusion:

Chemotherapy potentially provides a favourable environment for the development of anti-tumour immunity through transient Treg depletion and regeneration of the T-cell pool. Change in CD8⁺ T-cell proliferation after one cycle of chemotherapy may represent a useful prognostic indicator in patients with MM and NSCLC.

Body mass index and lung cancer risk: results from the ICARE study, a large, population-based case-control study

BACKGROUND

The association between body mass index (BMI) and lung cancer is still disputed because of possible residual confounding by smoking and preclinical weight loss in case-control studies. We examined this association using data from the multicenter ICARE study in France, a large, population-based case-control study.

METHODS

A total of 2,625 incident lung cancer cases and 3,381 controls were included. Weight was collected at interview, 2 years before the interview, and at age 30. Lifetime smoking exposure was calculated using the comprehensive smoking index (CSI). Adjusted odds ratios (aORs) and 95 % confidence intervals were estimated by unconditional logistic regression and controlled for age, area, education, CSI, occupational exposure, previous chronic bronchitis, and parental history of lung cancer. We also examined the role of weight change. Analyses were stratified by smoking status and sex.

RESULTS

When compared with that of men with normal BMI 2 years before the interview, lung cancer aORs (95 % CI) among men with BMIs of <18.5, 25-29.9, 30-32.4, and ≥32.5 kg/m(2) were 2.7 (95 % CI 1.2-6.2), 0.9 (95 % CI 0.7-1.1), 0.8 (95 % CI 0.6-1.1), and 0.8 (95 % CI 0.6-1.0), respectively (p(trend) = 0.02). Results were more pronounced among current smokers and were similar in men and women. Weight gain over time was associated with a significant decreased risk of lung cancer.

CONCLUSIONS

We found an inverse dose-dependent association between lung cancer risk and BMI 2 years prior to interview in current smokers. IMPACT STATEMENT: BMI might be an individual factor impacting the risk of lung cancer related to smoking's carcinogen-induced DNA damage.

Swedish lung cancer radiation study group: the prognostic value of anaemia, thrombocytosis and leukocytosis at time of diagnosis in patients with non-small cell lung cancer

There is a need to improve the prognostic and predictive indicators in non-small cell lung cancer (NSCLC). At present, the main focus is on genetic predictive markers while the prognostic value of the standard blood variables related to haematopoiesis has been subjected to relatively limited attention. To study the prognostic potential of haemoglobin (Hgb), platelet (Plt) and white blood cell (WBC) levels at time of diagnosis in NSCLC patients, 835 NSCLC patients, stage I-IV, who received radiotherapy with curative intention (>50 Gy), were included in the study. WBC, Plt, Hgb, gender, age at diagnosis, stage, surgery and first-line chemotherapy were studied in relation to overall survival. For patients with Hgb < 110 g/L and Hgb ≥ 110 g/L), the median survival was 11.2 and 14.5 months, respectively (p = 0.0032). For WBC > 9.0 × 10(9)/L and < 9.0 × 10(9)/L, the median survival was 11.6 and 15.4 months, respectively (p < 0.0001). For Plt > 350 × 10(9)/L and <350 × 10(9)/L, the median survival was 11.2 and 14.9 months, respectively (p < 0.0001). The median survival in patients with pathological results in all three markers was half of that in patients with normal levels of all three markers (8.0 and 16.0 months, respectively (p < 0.0001). The level of the three studied haematological biomarkers corresponds significantly to outcome in NSCLC. These results indicate that standard haematological variables may be used as guidance for the clinician in the decision-making regarding treatment intensity and patient information.

Pretreatment lifestyle behaviors as survival predictors for patients with nasopharyngeal carcinoma

BACKGROUND

Lifestyle behaviors have been widely reported to influence the survival of patients with head and neck cancer. However, the relationship between pretreatment lifestyle behaviors and survival among patients with nasopharyngeal carcinoma (NPC) is unclear.

METHODS

A prospective cohort study was designed to determine the relationship between lifestyle behaviors and survival in 1,533 NPC patients recruited from October 2005 to October 2007. Pretreatment lifestyle behaviors (such as body-mass index [BMI], smoking, alcohol, diet) of the patients were investigated. Univariate and multivariate proportional-hazards models were used to assess the impact of lifestyle behaviors on patient survival.

RESULTS

Smoking was a predictor of survival; both current smokers (hazard ratio [HR] = 1.88; 95% CI, 1.33 to 2.65) and heavy smokers (≥ 25 Pack-years; HR = 1.84; 95% CI, 1.30 to 2.60) showed associations with poor survival. Higher BMI was significantly associated with a lower risk of death (P(trend) = 0.002). Compared with under/normal-weight patients (BMI less than 22.99 kg/m(2)), the multivariate HR for survival was 0.66 (95% CI, 0.48 to 0.90) and 0.47 (95% CI, 0.23 to 0.97) for overweight and obese patients, respectively. No alcohol intake and high fruit intake were associated with favorable survival in the univariate analysis but lost significance in the multivariate model.

CONCLUSION

Our findings indicate that pretreatment lifestyle behaviors, especially smoking status and BMI, as easily available data, provide prognostic value for survival in NPC patients.

Difference in survival and prognostic factors between smokers and never-smokers with advanced non-small-cell lung cancer

BACKGROUND

Our aims were to investigate whether the association between smoking and survival is significant when adjusted for prognostic factors including use of epidermal growth factor tyrosine kinase inhibitors and the Glasgow Prognostic Score, an established score for inflammation, and to explore prognostic factors.

METHODS

We analyzed 244 patients with stage IIIB or IV non-small-cell lung cancer in a registry, including only chemotherapy-receiving outpatients with performance status zero.

RESULTS

Of 244 patients, 170 had died and the median follow-up time for the 74 surviving patients was 12.0 months. In multivariate Cox regression, smoker (hazard ratio compared to never-smoker: 1.67, P < 0.01), stage IV (hazard ratio compared to IIIB: 1.72, P < 0.01), and elevated C-reactive protein level (hazard ratio per 1 mg/dL increase: 1.08, P < 0.01) were significantly associated with shorter survival. The association between survival and smoking was significant, even after adjustment for the Glasgow Prognostic Score and regimens of chemotherapy (hazard ratio: 1.72, P = 0.02). In never-smokers, increased neutrophils were a major determinant of shorter survival and the interaction test between smoking and neutrophils was significant (hazard ratio per 1,000/mm(3) increase for smokers: 1.01; hazard ratio per 1,000/mm(3) increase for never-smokers: 1.44, P for interaction <0.01).

CONCLUSIONS

Known factors including treatment response or inflammatory process are not responsible for the fact that advanced non-small-cell lung cancer patients without any history of smoking have better survival than those who have smoked.

The absolute monocyte and lymphocyte prognostic score predicts survival and identifies high-risk patients in diffuse large-B-cell lymphoma

Despite the use of modern immunochemotherapy regimens, almost 50% of patients with diffuse large-B-cell lymphoma will relapse. Current prognostic models, including the International Prognostic Index, incorporate patient and tumor characteristics. In contrast, recent observations show that variables related to host adaptive immunity and the tumor microenvironment are significant prognostic variables in non-Hodgkin lymphoma. Therefore, we retrospectively examined the absolute monocyte and lymphocyte counts as prognostic variables in a cohort of 366 diffuse large-B-cell lymphoma patients who were treated between 1993 and 2007 and followed at a single institution. The absolute monocyte and lymphocyte counts in univariate analysis predicted progression-free and overall survival when analyzed as continuous and dichotomized variables. On multivariate analysis performed with factors included in the IPI, the absolute monocyte and lymphocyte counts remained independent predictors of progression-free and overall survival. Therefore, the absolute monocyte and lymphocyte counts were combined to generate a prognostic score that identified patients with an especially poor overall survival. This prognostic score was independent of the IPI and added to its ability to identify high-risk patients.

A front-line window of opportunity phase 2 study of sorafenib in patients with advanced nonsmall cell lung cancer: North Central Cancer Treatment Group Study N0326

BACKGROUND

The current study was conducted to assess the efficacy and toxicity of sorafenib as front-line therapy in patients with stage IIIB (pleural effusion) or IV nonsmall cell lung cancer (NSCLC).

METHODS

Patients received sorafenib 400 mg twice daily by mouth continuously, and were evaluated every 2 weeks during the first 8 weeks. Patients who manifested clinical progression during this period proceeded to receive standard of care. The primary endpoint was confirmed objective tumor response. A 2-stage Fleming design was used such that if at most 1 confirmed partial response (PR) or complete response was observed in the first 20 patients (stage 1), the treatment would be considered ineffective, and further enrollment would be discontinued.

RESULTS

Only 1 PR was observed in the first 20 patients. By the time of study closure, 5 additional patients who were already being screened for study inclusion were enrolled. Of the 25 patients (15 women, 10 men; 4 stage IIIB, 21 stage IV; median age, 67 years [range, 45-85 years]), there were 3 (12%) PRs and 6 (24%) cases with stable disease observed. The median time-to-progression and progression-free survival was 2.8 months. Seven (28%) patients remained progression-free at 24 weeks. No grade 3 or higher hematologic adverse events were observed. Thirteen (52%) patients had a grade 3 nonhematologic adverse event, with fatigue (20%), diarrhea (8%), and dyspnea (8%) being the most common.

CONCLUSIONS

Sorafenib is not effective as front-line therapy in the general unselected NSCLC population. The window of opportunity design is feasible for estimating the activity of novel compounds.

Smoking and prognostic factors in an observational setting in patients with advanced non-small cell lung carcinoma

BACKGROUND

This prospective observational study estimated the effect of prognostic factors, particularly continued smoking during therapy, on survival in advanced non-small cell lung cancer (NSCLC) patients receiving gemcitabine-platinum. Further, prognostic factors were used to build a survival model to improve prognosis prediction in naturalistic clinical settings.

METHODS

Eligibility criteria included: Stage IIIB/IV NSCLC, no prior chemotherapy, and Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1. A Cox regression model was constructed and validated by randomizing patients into two datasets (Construction [C]:Validation [V]; 3:1 ratio). Country, disease stage, hypercalcemia, "N" factor, weight reduction, performance status, and superior vena cava obstruction were pre-defined variables forced into the model. Continued smoking was tested with adjustment for these variables.

RESULTS

One thousand two hundred and fourteen patients (C=891 and V=323) were enrolled. The final predictive model, established in the Construction dataset, identified four significant (p≤0.05) and independent predictors of survival, which were disease stage, performance status, gemcitabine-platinum regimen, and T-stage. Smoking during therapy was not significantly associated with survival (Hazard Ratio [95% CI]: 0.955 [0.572, 1.596], p=0.8618; versus never smokers).

CONCLUSIONS

Although continued smoking during therapy was not significantly associated with shorter survival, the model developed in this study forms an evidence-based approach to assessing prognosis in advanced stage NSCLC.

Meta-analysis of neutropenia or leukopenia as a prognostic factor in patients with malignant disease undergoing chemotherapy

PURPOSE

We performed a systematic review and meta-analysis to determine the impact of neutropenia or leukopenia experienced during chemotherapy on survival.

METHODS

Eligible studies included prospective or retrospective analyses that evaluated neutropenia or leukopenia as a prognostic factor for overall survival or disease-free survival. Statistical analyses were conducted to calculate a summary hazard ratio and 95% confidence interval (CI) using random-effects or fixed-effects models based on the heterogeneity of the included studies.

RESULTS

Thirteen trials were selected for the meta-analysis, with a total of 9,528 patients. The hazard ratio of death was 0.69 (95% CI, 0.64-0.75) for patients with higher-grade neutropenia or leukopenia compared to patients with lower-grade or lack of cytopenia. Our analysis was also stratified by statistical method (any statistical method to decrease lead-time bias; time-varying analysis or landmark analysis), but no differences were observed.

CONCLUSIONS

Our results indicate that neutropenia or leukopenia experienced during chemotherapy is associated with improved survival in patients with advanced cancer or hematological malignancies undergoing chemotherapy. Future prospective analyses designed to investigate the potential impact of chemotherapy dose adjustment coupled with monitoring of neutropenia or leukopenia on survival are warranted.

Prediction of residual metabolic activity after treatment in NSCLC patients

PURPOSE

Metabolic response assessment is often used as a surrogate of local failure and survival. Early identification of patients with residual metabolic activity is essential as this enables selection of patients who could potentially benefit from additional therapy. We report on the development of a pre-treatment prediction model for metabolic response using patient, tumor and treatment factors.

METHODS

One hundred and one patients with inoperable NSCLC (stage I-IV), treated with 3D conformal radical (chemo)-radiotherapy were retrospectively included in this study. All patients received a pre and post-radiotherapy fluorodeoxyglucose positron emission tomography-computed tomography FDG-PET-CT scan. The electronic medical record system and the medical patient charts were reviewed to obtain demographic, clinical, tumor and treatment data. Primary outcome measure was examined using a metabolic response assessment on a post-radiotherapy FDG-PET-CT scan. Radiotherapy was delivered in fractions of 1.8 Gy, twice a day, with a median prescribed dose of 60 Gy.

RESULTS

Overall survival was worse in patients with residual metabolic active areas compared with the patients with a complete metabolic response (p=0.0001). In univariate analysis, three variables were significantly associated with residual disease: larger primary gross tumor volume (GTV(primary), p=0.002), higher pre-treatment maximum standardized uptake value (SUV(max), p=0.0005) in the primary tumor and shorter overall treatment time (OTT, p=0.046). A multivariate model including GTV(primary), SUV(max), equivalent radiation dose at 2 Gy corrected for time (EQD(2, T)) and OTT yielded an area under the curve assessed by the leave-one-out cross validation of 0.71 (95% CI, 0.65-0.76).

CONCLUSION

Our results confirmed the validity of metabolic response assessment as a surrogate of survival. We developed a multivariate model that is able to identify patients at risk of residual disease. These patients may benefit from an individualized and more adequate therapeutic approach, thereby improving local control and survival.

[The International Association for the Study of Lung Cancer Staging Project. Prognostic factors and pathologic TNM stage in surgically managed non-small cell lung cancer]

目的

本研究的目的是在国际肺癌研究协会国际分期数据库中采用外科治疗的Ⅰ-ⅢA期非小细胞肺癌病例中，评价除肿瘤原发灶、病理淋巴结和转移（TNM）分期外，细胞类型、年龄和性别的影响。

材料和方法

从提交至分期数据库的67 725例非小细胞肺癌（NSCLC）病例中，筛选出9 137例采用外科治疗的病例，这些病例的病理分期、年龄、性别和特殊组织细胞类型等信息均可获得。在亚组中分析记录行为状态和吸烟史。检验方法采用Cox比例风险回归和递归分割及合并（RPA）分析。

结果

病理TNM分期、年龄以及性别均为生存的独立预后因素。尽管细支气管肺泡癌（BAC）亚型间存在潜在的异质性，其相对于其它细胞类型仍具有生存优势。修正比较提示罹患鳞癌相对于非BAC腺癌及大细胞癌具有微弱的生存优势，尽管此优势仅限于男性患者。RPA结果提示TNM分期为首要因素，年龄是各分期分组的预后因素。在RPA分析中未发现细胞类型具有预后价值。依据RPA的结果形成预后分组，诸分组的预后价值得到北美监视、流行病学、结局结果注册机构的认可。在资料可得的亚组中，行为状态和吸烟史均为预后因素。在回归模型中，吸烟状态的纳入未影响其它变量的效果。

结论

年龄和性别已被证实为外科切除的非小细胞肺癌的重要预后因素。细胞类型的重要性次之，尽管归类于BAC的少部分病例相对于其它组织学类型具有生存优势，且鳞癌相对于非BAC腺癌具有微弱的生存优势。在未修正分析中，分期、年龄、性别和细胞类型间的不平衡可能会导致有关细胞类型的误导结果。在该分析中，病理TNM分类是最重要的预后因素。

Cancer-associated myeloproliferation: old association, new therapeutic target

The association between malignancy and development of a paraneoplastic leukocytosis, the so-called leukemoid reaction, has long been appreciated. Although a leukemoid reaction has conventionally been defined as a peripheral blood leukocytosis composed of both mature and immature granulocytes that exceeds 50,000/microL, a less profound leukocytosis may be appreciated in many patients harboring a malignant disease. More recent insights have shed new light on this long-recognized association, because research performed in both murine models and cancer patients has uncovered multiple mechanisms by which tumors both drive myelopoiesis, sometimes leading to a clinically apparent leukocytosis, and inhibit the differentiation of myeloid cells, resulting in a qualitative change in myelopoiesis. This qualitative change leads to the accumulation of immature myeloid cells, which due to their immune suppressive effects have been collectively called myeloid-derived suppressor cells. More recently, myeloid cells have been shown to promote tumor angiogenesis. Cancer-associated myeloproliferation is not merely a paraneoplastic phenomenon of questionable importance but leads to the suppression of host immunity and promotion of tumor angiogenesis, both of which play an integral part in tumorigenesis and metastasis. Therefore, cancer-associated myeloproliferation represents a novel therapeutic target in cancer that, decades after its recognition, is only now being translated into clinical practice.

[Management and outcome of French elderly patients with lung cancer: an IFCT survey]

BACKGROUND

Lung cancer in the elderly is considerably increasing in frequency, representing a public health issue. Those patients are underrepresented in clinical trials and probably not optimally treated.

METHODS

We performed a survey of the management and the outcome of lung cancer patients aged 70 and more in France between August 2002 and September 2003 according to age categories (70-74, 75-79 and > or =80 years). One thousand six hundred and twenty-seven patients were analysed for descriptive data and 1595 for survival.

RESULTS

Median age was 75 (70-96) and male:female ratio was 4.26 with a decrease across the age categories from 5.1 to 3.0. Tobacco-linked comorbidities were frequent. The median value of Charlson's index was 2. About 58% had a performance status (PS) 0 or 1, 30% a PS 2 and 12% a PS>2. The proportion of never-smokers (11.6%) increased significantly with age categories. Regarding imaging procedures, as much as 83.3% of the patients had at least a chest CT-scan and a brain CT-scan (or MRI) and an abdominal ultrasound or CT-scan. Best Supportive Care (BSC) as only treatment was administered to 16.1% of the patients. Among patients specifically treated, 22.9% were operated, 21.8% received mediastinal irradiation and 71.5% chemotherapy. Overall, median survival time was 9.14 months with 23.5% deaths occurring before 3 months. Low category of age, good PS, non-smoking and high body mass index (BMI) were favorable independent prognostic factors of survival. Age, PS and tobacco smoking were prognostic of early death.

CONCLUSIONS

A large majority of elderly lung cancer patients in France are managed like younger counterparts regarding diagnostic procedures and treatment. Age remains an independent prognostic factor as well for overall survival as for early death.

Pretreatment quality of life is an independent prognostic factor for overall survival in patients with advanced stage non-small cell lung cancer

HYPOTHESIS

We conducted this pooled analysis to assess the prognostic value of pretreatment Quality of Life (QOL) assessments on overall survival (OS) in advanced non-small cell lung cancer (NSCLC).

METHODS

Four hundred twenty patients with advanced NSCLC (stages IIIB with pleural effusion and IV) from six North Central Cancer Treatment Group trials were included in this study. QOL assessments included the single-item Uniscale (355 patients), Lung Cancer Symptom Scale (217 patients), and Functional Assessment of Cancer Therapy-Lung (197 patients). QOL scores were transformed to a 0 to 100 scale with higher scores representing better status and categorized using the sample median or clinically deficient score (CDS, <or=50 versus >50). Cox proportional hazards models stratified by study were used to evaluate the prognostic importance of QOL on OS alone and in the presence of other prognostic factors such as performance status, age, gender, body mass index, and laboratory parameters.

RESULTS

Pretreatment QOL accessed by Uniscale was significantly associated with OS univariately (p < 0.0001). Uniscale (p < 0.0001; hazard ratio = 1.6 for the sample median and 2.0 for the CDS categorization) and body mass index were the only significant predictors of OS multivariately. The median survival of patients who had a Uniscale score less than or equal to the CDS (<or=50) was 5.7 versus 11.1 months for the >50 group; and 7.8 versus 13 months for the less than or equal to sample median (<or=83) group and >83 group, respectively. The Lung Cancer Symptom Scale and the Functional Assessment of Cancer Therapy-Lung total scores were not significant predictors of OS.

CONCLUSIONS

Pretreatment QOL measured by Uniscale is a significant and an independent prognostic factor for OS, and QOL should be routinely integrated as a stratification factor in advanced NSCLC trials.

Chemotherapy-induced neutropenia as a prognostic factor in advanced non-small-cell lung cancer: results from Japan Multinational Trial Organization LC00-03

Background:

Neutropenia is a common adverse reaction of chemotherapy. We assessed whether chemotherapy-induced neutropenia could be a predictor of survival for patients with non-small-cell lung cancer (NSCLC).

Methods:

A total of 387 chemotherapy-naïve patients who received chemotherapy (vinorelbine and gemcitabine followed by docetaxel, or paclitaxel and carboplatin) in a randomised controlled trial were evaluated. The proportional-hazards regression model was used to examine the effects of chemotherapy-induced neutropenia and tumour response on overall survival. Landmark analysis was used to lessen the bias of more severe neutropenia resulting from more treatment cycles allowed by longer survival, whereby patients who died within 126 days of starting chemotherapy were excluded.

Results:

The adjusted hazard ratios for patients with grade-1 to 2 neutropenia or grade-3 to 4 neutropenia compared with no neutropenia were 0.59 (95% confidence interval (CI), 0.36–0.97) and 0.71 (95% CI, 0.49–1.03), respectively. The hazard ratios did not differ significantly between the patients who developed neutropenia with stable disease (SD), and those who lacked neutropenia with partial response (PR).

Conclusion:

Chemotherapy-induced neutropenia is a predictor of better survival for patients with advanced NSCLC. Prospective randomised trials of early-dose increases guided by chemotherapy-induced toxicities are warranted.

Prognostic factors differ by tumor stage for small cell lung cancer: a pooled analysis of North Central Cancer Treatment Group trials

BACKGROUND

An analysis of 14 small cell lung cancer (SCLC) trials was performed to improve the current understanding of potential prognostic factors for overall survival (OS) and progression-free survival (PFS) in groups of patients with limited-stage disease SCLC (LD-SCLC) and extensive-stage disease SCLC (ED-SCLC) separately.

METHODS

Data on 688 patients with LD-SCLC and 910 patients with ED-SCLC were included. Clinical and laboratory factors were tested for their prognostic significance using Cox regression models that were stratified by protocol. Recursive partitioning and amalgamation (RPA) analyses were used to identify prognostic subgroups.

RESULTS

Poorer performance status (PS) led to worse OS and PFS in the ED-SCLC group but not in the LD-SCLC group. The prognostic impact of PS was strong for men but weak for women in the ED-SCLC group (interaction P value <.012 for OS and PFS). Other negative prognostic factors included increased age and men for the LD-SCLC group and increased age, men, increased number of metastatic sites at baseline, and increased creatinine levels for the ED-SCLC group. In patients with the ED-SCLC, RPA analyses identified 5 subgroups with different prognosis based on baseline PS, creatinine levels, sex, and the number of metastatic sites.

CONCLUSIONS

The current pooled analysis identified baseline creatinine levels and the number of metastatic sites as important prognostic factors in patients with ED-SCLC in addition to the well established factors of sex, age, and PS. There was a significant interaction between sex and PS within the ED-SCLC group, suggesting that PS is highly prognostic in men but has no significant impact in women. Within the LD-SCLC group, only age and sex were identified as important prognostic factors. RPA analyses confirmed many of these findings.

Tumor-related leucocytosis and chemotherapy-induced neutropenia: linked or independent prognostic factors for advanced non-small cell lung cancer?

Tumor-related leucocytosis is a paraneoplastic syndrome that is encountered occasionally in the clinical course of patients with non-small cell lung cancer (NSCLC). Autonomous production of hematopoietic cytokines (granulocyte-colony stimulating factor, granulocyte-macrophage-colony stimulating factor) has been identified in some of the patients presenting with this syndrome. In addition to the widely accepted prognostic factors of performance status and disease stage, recently, leucocytosis has been found to be a significant negative prognostic factor for overall survival and time to progression in patients with advanced-stage NSCLC in a pooled analysis of North Central Cancer Treatment Group trials, with data from about 1000 patients. A pooled analysis of an Italian Group with data from about 1300 patients has recently shown that neutropenia during chemotherapy is associated with increased survival of patients with advanced NSCLC. Similar results on the independent prognostic value of chemotherapy-induced neutropenia, have been reported by the Hellenic Oncology Research Group in a retrospective analysis on 850 patients. The absence of chemotherapy-induced neutropenia can be interpreted as a result of chemotherapy-underdosing. However, considering the negative prognostic value of leucocytosis, another interpretation should be ruled out: a proportion of the patients who do not experience chemotherapy-induced neutropenia may be associated with a worst prognosis because they may be characterized by base-line tumor-related leucocytosis and autonomous production of hematopoietic cytokines protecting them from chemotherapy-induced neutropenia. Prospective trials are needed to assess if NSCLC-related leucocytosis and chemotherapy-induced neutropenia are two linked or independent prognostic factors for NSCLC. This paper is a review of the available retrospective evidence on the aetiology and prognostic value of tumor-related leucocytosis and on the prognostic value of chemotherapy-induced neutropenia in advanced NSCLC. Moreover we try to hypothesize a possible correlation between these two phenomena and to give suggestions on the prospective evaluation of this hypothetical correlation in the next future.

Safety and feasibility of aerobic training on cardiopulmonary function and quality of life in postsurgical nonsmall cell lung cancer patients: a pilot study

BACKGROUND

A feasibility study examining the effects of supervised aerobic exercise training on cardiopulmonary and quality of life (QOL) endpoints among postsurgical nonsmall cell lung cancer (NSCLC) patients was conducted.

METHODS

Using a single-group design, 20 patients with stage I-IIIB NSCLC performed 3 aerobic cycle ergometry sessions per week at 60% to 100% of peak workload for 14 weeks. Peak oxygen consumption (VO(2peak)) was assessed using an incremental exercise test. QOL and fatigue were assessed using the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale.

RESULTS

Nineteen patients completed the study. Intention-to-treat analysis indicated that VO(2peak) increased 1.1 mL/kg(-1)/min(-1) (95% confidence interval [CI], -0.3-2.5; P = .109) and peak workload increased 9 W (95% CI, 3-14; P = .003), whereas FACT-L increased 10 points (95% CI, -1-22; P = .071) and fatigue decreased 7 points (95% CI; -1 to -17; P = .029) from baseline to postintervention. Per protocol analyses indicated greater improvements in cardiopulmonary and QOL endpoints among patients not receiving adjuvant chemotherapy.

CONCLUSIONS

This pilot study provided proof of principle that supervised aerobic training is safe and feasible for postsurgical NSCLC patients. Aerobic exercise training is also associated with significant improvements in QOL and select cardiopulmonary endpoints, particularly among patients not receiving chemotherapy. Larger randomized trials are warranted.

Bortezomib plus gemcitabine/carboplatin as first-line treatment of advanced non-small cell lung cancer: a phase II Southwest Oncology Group Study (S0339)

INTRODUCTION

Bortezomib is a small-molecule proteasome inhibitor with single-agent activity in patients with non-small cell lung carcinoma (NSCLC) and synergy with gemcitabine in preclinical studies. This phase II study of bortezomib in combination with gemcitabine/carboplatin was conducted in chemotherapy-naive advanced NSCLC patients to assess efficacy and safety.

METHODS

Patients with selected stage IIIB/IV NSCLC, performance status 0-1, and no history of brain metastasis received up to six 21-day cycles of gemcitabine 1000 mg/m, days 1 and 8, carboplatin area under curve 5.0, day 1, and bortezomib 1.0 mg/m, days 1, 4, 8, and 11.

RESULTS

One-hundred-fourteen patients (52% adenocarcinoma, 85% stage IV) received a median of 3.6 treatment cycles. Median follow-up was >3 years. Median overall survival was 11 months; 1-year and 2-year survival rates were 47% and 19%, respectively. Median progression-free survival was 5 months; 1-year progression-free survival rate was 7%. Response rate was 23%, and disease control rate (responses + stable disease) was 68%. The most common grade 3/4 toxicities were thrombocytopenia (63%) and neutropenia (52%). One patient experienced febrile neutropenia. Grade 3/4 neuropathy occurred in 4%, and a further 6% experienced grade 2 sensory neuropathy.

CONCLUSIONS

Bortezomib plus gemcitabine/carboplatin resulted in a notable survival benefit in patients with advanced NSCLC, with the anticipated primary toxicity of myelosuppression. Further studies designed to investigate the role of bortezomib in advanced NSCLC are warranted.

Development and external validation of prognostic model for 2-year survival of non-small-cell lung cancer patients treated with chemoradiotherapy

PURPOSE

Radiotherapy, combined with chemotherapy, is the treatment of choice for a large group of non-small-cell lung cancer (NSCLC) patients. Recent developments in the treatment of these patients have led to improved survival. However, the clinical TNM stage is highly inaccurate for the prediction of survival, and alternatives are lacking. The objective of this study was to develop and validate a prediction model for survival of NSCLC patients, treated with chemoradiotherapy.

PATIENTS AND METHODS

The clinical data from 377 consecutive inoperable NSCLC patients, Stage I-IIIB, treated radically with chemoradiotherapy were collected. A prognostic model for 2-year survival was developed, using 2-norm support vector machines. The performance of the model was expressed as the area under the curve of the receiver operating characteristic and assessed using leave-one-out cross-validation, as well as two external data sets.

RESULTS

The final multivariate model consisted of gender, World Health Organization performance status, forced expiratory volume in 1 s, number of positive lymph node stations, and gross tumor volume. The area under the curve, assessed by leave-one-out cross-validation, was 0.74, and application of the model to the external data sets yielded an area under the curve of 0.75 and 0.76. A high- and low-risk group could be clearly identified using a risk score based on the model.

CONCLUSION

The multivariate model performed very well and was able to accurately predict the 2-year survival of NSCLC patients treated with chemoradiotherapy. The model could support clinicians in the treatment decision-making process.

North Central Cancer Treatment Group--achievements and perspectives

The North Central Cancer Treatment Group (NCCTG) was founded in 1977 as a regional cooperative group to allow cancer patients in the upper Midwest of the United States to gain access to clinical trials in oncology by establishing a network of community oncology practices with one academic research base, the Mayo Clinic. Since then, the NCCTG has grown into an international cooperative group with 43 members in 33 US states and Canada. This article details 30 years of achievements of the NCCTG, including important scientific contributions from disease-specific and treatment modality committees, the cancer control program, patient-reported outcomes and quality-of-life research, and biostatisticians that support the NCCTG's specific aims: to improve the duration and quality of life of cancer patients, to enhance our understanding of the biological consequences of cancer and its treatment, and to improve methods for clinical trial conduct.

Baseline elevated leukocyte count in peripheral blood is associated with poor survival in patients with advanced non-small cell lung cancer: a prognostic model

PURPOSE

We aimed to investigate the prognostic significance of several baseline variables in stage IIIB-IV non-small cell lung cancer to create a model based on independent prognostic factors.

METHODS/RESULTS

A total of 320 patients were treated with last generation chemotherapy regimens. The majority of patients received treatment with cisplatin + gemcitabine or gemcitabine alone if older than 70 years or with an ECOG performance status (PS) = 2. Performance status of 2, squamous histology, number of metastatic sites >2, presence of bone, brain, liver and contralateral lung metastases and elevated leukocyte count in peripheral blood were all statistically significant prognostic factors in univariate analyses whereas the other tested variables (sex, stage, age, presence of adrenal gland and skin metastases) were not. Subsequently, a multivariate Cox's regression analysis identified PS 2 (P < 0.001, hazard ratio 2.57), elevated leukocyte count (P < 0.001, hazard ratio 1.79), squamous histology (P = 0.005, hazard ratio 1.45) and presence of brain metastases (P = 0.035, hazard ratio 1.5) as independent prognostic factors for poor survival. Patients were assigned to one of three risk groups according to the cumulative risk defined as the sum of simplified risk scores of the four independent prognostic factors. Low-, intermediate- and high-risk patients achieved a median survival of 10.2 months (95% confidence interval (CI) 8.9-11.6), 5.1 months (95% CI 4.0-6.2) and 2.8 months (95% CI 0.5-5.2), respectively. The high-risk group encompassed PS 2 patients with two or three adjunctive unfavourable independent prognostic factors.

CONCLUSIONS

Performance status, white blood cells count, histology and brain metastases resulted in our series prognostic factors of survival in NSCLC patients treated with chemotherapy at a multivariate analysis. Leukocyte count resulted the stronger factor after performance status. If prospectly validated, the proposed prognostic model could be useful to stratify performance status 2 patients in specific future trials.

Comparison of limited surgery and three-dimensional conformal radiation in high-risk patients with stage I non-small cell lung cancer

INTRODUCTION

Anatomic resection is currently the standard of care for patients with stage I non-small cell lung cancer (NSCLC). Some stage I patients are unable to tolerate lobectomy because of limited lung function or prohibitive comorbidities. In this study, we retrospectively compared the outcome of patients treated with wedge resection or three-dimensional (3-D) conformal radiation therapy, the most common treatment modalities used for such high-risk patients.

METHODS

All patients with stage I NSCLC from 1988 to 2005 who were not considered candidates for anatomic surgical resection were reviewed. Univariate and multivariate analyses were performed to assess the influence of 3-D conformal radiation and surgery on overall survival and recurrence-free survival. Propensity score-matched analysis and cost assessments were performed to compare outcomes with both modalities. Propensity matching was performed for gender, histology, tumor size, performance status, and age.

RESULTS

Of 160 patients studied, 68 patients received limited resection and 92 patients received 3-D conformal radiation. Univariate and multivariate analyses suggested a trend toward improved outcome in limited resection. Propensity matching was performed with 34 matched pairs and demonstrated no statistically significant difference in overall survival or recurrence-free survival. The mean cost of radiation therapy ($32,735) was not statistically significantly different from surgery ($30,411).

CONCLUSION

In high-risk patients with NSCLC, limited resection has a tendency towards improved outcome. A propensity matched analysis did not show a clear benefit for limited resection, which may be due in part to an inadequate number of patients for analysis and/or increased comorbidities of patients treated with 3-D conformal radiation.