Complications and long-term survival for alcoholic patients with resectable lung cancer

Survival and prognostic factors of early-stage non-small cell lung cancer in Central and Eastern Europe: A prospective cohort study

BACKGROUND

Although early diagnosis and surgical resection of the tumor have been shown to be the most important predictors of lung cancer survival, long-term survival for surgically-resected early-stage lung cancer remains poor.

AIMS

In this prospective study we aimed to investigate the survival and prognostic factors of surgically-resected early-stage non-small cell lung cancer (NSCLC) in Central and Eastern Europe.

METHODS

We recruited 2052 patients with stage I-IIIA NSCLC from 9 centers in Russia, Poland, Serbia, Czech Republic, and Romania, between 2007-2016 and followed them annually through 2020.

RESULTS

During follow-up, there were 1121 deaths (including 730 cancer-specific deaths). Median survival time was 4.9 years, and the 5-year overall survival was 49.5%. In the multivariable model, mortality was increased among older individuals (HR for each 10-year increase: 1.31 [95% CI: 1.21-1.42]), males (HR:1.24 [1.04-1.49]), participants with significant weight loss (HR:1.25 [1.03-1.52]), current smokers (HR:1.30 [1.04-1.62]), alcohol drinkers (HR:1.22 [1.03-1.44]), and those with higher stage tumors (HR stage IIIA vs. I: 5.54 [4.10 - 7.48]). However, education, chronic obstructive pulmonary diseases (COPD), and tumor histology were not associated with risk of death. All baseline indicators of smoking and alcohol drinking showed a dose-dependent association with the risk of cancer-specific mortality. This included pack-years of cigarettes smoked (p-trend = 0.04), quantity of smoking (p-trend = 0.008), years of smoking (p-trend = 0.010), gram-days of alcohol drank (p-trend = 0.002), frequency of drinking (p-trend = 0.006), and years of drinking (p-trend = 0.016).

CONCLUSION

This study shows that the 5-year survival rate of surgically-resected stage I-IIIA NSCLC is still around 50% in Central and Eastern Europe. In addition to non-modifiable prognostic factors, lifetime patterns of smoking and alcohol drinking affected the risk of death and disease progression in a dose-dependent manner in this population.

Patterns of cigarette smoking and alcohol drinking among Canadian adults with cancer in a contemporary national cohort

OBJECTIVE

To evaluate the patterns of cigarette smoking and alcohol drinking among Canadian adults with cancer in a contemporary national cohort.

METHODS

Canadian Community Health Survey (CCHS) annual surveys (2007-2016) were accessed, and cancer patients (identified by the question: Do you have cancer?) with complete information regarding smoking and alcohol drinking were included in the current analysis. Multivariable logistic regression analyses were conducted to evaluate factors associated with current smoking and alcohol drinking habits.

RESULTS

A total of 15,168 adult patients with cancer with complete information about smoking history and alcohol drinking in the past 12 months were included in the current analysis. Fifteen percent of patients were current smokers at the time of survey completion, and 3.2% exceed national limits for alcohol drinking. The following factors were associated with current smoking: younger age (OR: 2.42; 95% CI: 1.54-3.82), common-law partnership (OR versus single status: 2.61; 95% CI: 1.62-4.18), lower income (OR for patients with income <20,000 versus patients with income >80,000: 3.19; 95% CI: 2.26-4.49), poor self-perceived health (OR for excellent versus poor self-perceived health: 0.52; 95% CI: 0.33-0.83), poor self-perceived mental health (OR for excellent versus poor self-perceived mental health: 0.47; 95% CI: 0.29-0.78), heavy alcohol drinking (OR for no heavy alcohol drinking versus heavy alcohol drinking: 0.41; 95% CI: 0.29-0.58), and illicit drug use (OR: 2.42; 95% CI: 1.96-2.98). The following factors are associated with alcohol drinking beyond recommended levels: male sex (OR: 1.59; 95% CI: 1.18-2.14), heavy smoking status (OR for non-smokers versus heavy smokers: 0.30; 95% CI: 0.19-0.48), and illicit drug use (OR: 2.71; 95% CI: 1.96-3.74).

CONCLUSIONS

Current smoking and alcohol drinking are not uncommon among Canadian adults with cancer. Further efforts focusing on smoking cessation and alcohol moderation are needed.

IMPLICATIONS FOR CANCER SURVIVORS

Coordinated national and provincial efforts are needed to address cigarette smoking and heavy alcohol drinking among individuals with history of cancer.

Effect of preoperative psychiatric morbidity on postoperative outcomes of lung cancer surgery: A nationwide cohort study in South Korea

OBJECTIVE

Lung cancer is the leading cause of cancer-related mortality worldwide, and cancer is associated with severe psychological distress. We aimed to investigate whether preoperative psychiatric morbidities affect clinical outcomes of lung cancer surgery in South Korea.

METHODS

Using the National Health Insurance Service database, all adult patients who were diagnosed with lung cancer and underwent lung cancer surgery from January 1, 2011, to December 31, 2018, were included in this retrospective, population-based cohort study. Depression, anxiety disorder, schizophrenia, alcohol abuse, non-alcohol substance abuse, and post-traumatic stress disorder were considered as preoperative psychiatric morbidities.

RESULTS

Overall, 60,031 adult patients who underwent lung cancer surgery were included in the final analysis. Of these, 17,255 (28.7%) patients had preoperative psychiatric morbidity before lung cancer surgery. Multivariable logistic regression modeling revealed patients with preoperative alcohol abuse (odds ratio [OR]: 2.51, 95% confidence interval [CI]: 1.24, 5.08; P = 0.011) and those with bipolar disorder (OR: 2.91, 95% CI: 1.94, 4.53; P &lt; 0.001) to be associated with increased in-hospital mortality. Moreover, patients with preoperative psychiatric morbidities were associated with longer length of hospitalization (LOS), higher cost of hospitalization, and increased 1-year all-cause mortality.

CONCLUSION

In South Korea, patients with preoperative alcohol abuse and bipolar disorder were associated with increased in-hospital mortality after lung cancer surgery. Moreover, they were associated with increased 1-year all-cause mortality, longer LOS, and higher total costs for lung cancer surgery.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Sex and Survival After Surgery for Lung Cancer: A Swedish Nationwide Cohort

BACKGROUND

Prior reports on a possible female survival advantage in both surgical and nonsurgical cohorts of patients with lung cancer are conflicting. Previously reported differences in survival after lung cancer surgery could be the result of insufficient control for disparities in risk factor profiles in men and women.

RESEARCH QUESTION

Do women who undergo pulmonary resections for lung cancer have a better prognosis than men when taking a wide range of prognostic factors into account?

STUDY DESIGN AND METHODS

We performed a nationwide population-based observational cohort study analyzing sex-specific survival after pulmonary resections for lung cancer. We identified 6356 patients from the Swedish National Quality Register for General Thoracic Surgery and performed individual-level record linkage to other national health-data registers to acquire detailed information regarding comorbidity, socioeconomic status, and vital status. Inverse probability of treatment weighting was used to account for differences in baseline characteristics. The association between female sex and all-cause mortality was assessed with Cox regression models, and flexible parametric survival models were used to estimate the absolute survival differences with 95% CIs. We also estimated the difference in restricted mean survival time.

RESULTS

We observed a lower risk of death in women compared with men (hazard ratio, 0.73; 95% CI, 0.67-0.79). The absolute survival difference at 1, 5, and 10 years was 3.0% (95% CI, 2.2%-3.8%), 10% (95% CI, 7.0%-12%), and 12% (95% CI, 8.5%-15%), respectively. The restricted mean survival time difference at 10 years was 0.84 year (95% CI, 0.61-1.07 years). The findings were consistent across several subgroups.

INTERPRETATION

Women who underwent pulmonary resections for lung cancer had a significantly better prognosis than men. The survival advantage was evident regardless of age, common comorbidities, socioeconomic status, lifestyle factors, physical performance, type and extent of surgery, tumor characteristics, and stage of disease.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03567538; URL: www.clinicaltrials.gov.

Costs and Cost Drivers Associated with Non-Small-Cell Lung Cancer Patients Who Received Two or More Lines of Therapy in Europe

Purpose

Advanced non-small-cell lung cancer (aNSCLC; stage IIIB/IV) presents a substantial clinical burden to society; reliable estimates of its economic burden are lacking. Therefore, this study aimed to quantify real-world health care resource utilization (HCRU) and costs of patients with squamous (SQ) and non-SQ (NSQ) aNSCLC who received two or more lines of treatment (2L+) in Europe, and to describe cost-predictors.

Methods

The LENS (Leading the Evaluation of Non-squamous and Squamous NSCLC) retrospective chart review study collected data from 2L+ patients with aNSCLC diagnosed between 07/2009 and 08/2011 (wave 1) or 07/2010 and 09/2012 (wave 2) in France, Germany, Italy, Spain, England, the Netherlands, and Sweden. Patients were followed from diagnosis through most recent visit/death. A weighted average of country-specific unit costs (2018 Euro) was applied to systemic anti-cancer therapy usage and HCRU (hospital/emergency department visit, surgery, radiotherapy, ancillary care, biomarker testing) to determine the total cost from aNSCLC diagnosis to death. Generalized linear models (gamma distribution, log link) were used to assess clinical and demographic predictors.

Results

Of 973 2L+ aNSCLC patients, median overall survival (OS) was 1.5 years from advanced diagnosis (range: 0.2-5.3; median OS: 1.4 [SQ], 1.6 [NSQ]), 79.0% died during follow-up. Weighted mean total per-patient costs were €21,273, ranging from €17,761 (England) to €30,854 (Sweden), and €15,446 (SQ) to €26,477 (NSQ). Systemic drug costs comprised 77.4% of total costs. Insurance status, presence of epidermal growth factor receptor (EGFR) mutation, SQ histology, age, alcohol abuse, and year of diagnosis were significant predictors for lower total costs per patient-month, Eastern Cooperative Oncology Group performance status (ECOG PS) ≥1 and country for higher costs.

Conclusion

In the era pre-immunotherapy, HCRU and costs were substantial in aNSCLC 2L+ patients, with most of the costs accrued prior to start of 2L. NSQ patients incurred significantly higher total costs than SQ patients in all participating countries.

Putting the life in lifestyle: Lifestyle choices after a diagnosis of cancer predicts overall survival

BACKGROUND

The aim of this study was to examine predictors of health behaviors over time and the link between health behaviors and survival after a diagnosis of advanced cancer.

METHODS

Patients with a diagnosis of advanced cancer were administered a battery of questionnaires measuring optimism, depressive symptoms, physical activity, intake of fruits and vegetables, and alcohol and tobacco use over an 18-month period. Analyses included generalized linear mixed models and Cox regression survival analyses.

RESULTS

Of the 334 patients enrolled in the study, the mean age at cancer diagnosis was 62 years; the majority were male (62.3%) and white (91%). Twenty percent of the patients reported using alcohol, 19% reported using tobacco, 19% reported eating fewer fruits and vegetables than recommended by the Centers for Disease Control and Prevention and 28% reported physical inactivity after the diagnosis of advanced cancer. Clinical levels of depressive symptoms were associated with lower intake of fruits and vegetables (t = 2.67, P = .007) and physical inactivity (t = 2.11, P = .035). Dispositional optimism was positively associated with physical activity (t = -2.16, P = .031) and a lower frequency of tobacco use (Z = -2.42, P = .015). Multivariate analyses revealed that after adjusting for demographic variables (age and sex), depressive symptoms, and disease-specific factors (diagnosis, tumor size, cirrhosis, vascular invasion, and number of lesions), alcohol use (χ²  = 4.1186, P = .042) and physical inactivity (χ²  = 5.6050, P = .018) were linked to an poorer survival.

CONCLUSIONS

Greater dissemination and implementation of effective interventions to reduce alcohol use and increase physical activity in cancer patients are recommended.

Unhealthy alcohol use is associated with postoperative complications in veterans undergoing lung resection

Background

Lung resections carry a significant risk of complications necessitating the characterization of peri-operative risk factors. Unhealthy alcohol use represents one potentially modifiable factor. In this retrospective cohort study, the largest to date of lung resections in the Veterans Health Administration (VHA), we examined the association between unhealthy alcohol use and postoperative complications and mortality.

Methods

Veterans Affairs Surgical Quality Improvement Program data recorded at 86 medical centers between 2007 and 2011 were used to identify 4,715 patients that underwent lung resection. Logistic regression models, adjusted for demographics and comorbidities, were fit to assess the association between unhealthy alcohol use (report of >2 drinks per day in the 2 weeks preceding surgery) and 30-day outcomes.

Results

Among 4,715 patients that underwent pulmonary resection, 630 (13.4%) reported unhealthy alcohol use (>2 drinks/day). Overall, postoperative complications occurred in 896 (19.0%) patients, including pneumonia in 524 (11.1%). The rate of mortality was 2.6%. In adjusted analyses, complications were significantly more common among patients with unhealthy alcohol use [odds ratio (OR), 1.42; 95% confidence interval (CI), 1.15-1.74] including, specifically, pneumonia (OR, 1.69; 95% CI, 1.32-2.15). No statistically significant association was identified between unhealthy alcohol use and mortality (OR, 1.27; 95% CI, 0.75-2.02). In secondary analyses that stratified by smoking status at the time of surgery, drinking more than 2 drinks per day was associated with post-operative complications in patients reporting current smoking (OR, 1.51; 95% CI, 1.18-1.91) and was not identified in those reporting no current smoking at the time of surgery (OR, 1.23; 95% CI, 0.79-1.85).

Conclusions

In this large VHA study, 13% of patients undergoing lung resection reported drinking more than 2 drinks per day in the preoperative period, which was associated with increased risk of post-operative complications. Unhealthy alcohol use may be an important target for perioperative risk-mitigation interventions, particularly in patients who report current smoking.

Factors associated with alcohol drinking behavior of cancer survivors: The Korean National Health and Nutrition Examination Survey

BACKGROUND

This study aimed to evaluate the factors associated with drinking behavior of cancer survivors after cancer diagnosis.

METHODS

The study subjects were 906 adult cancer survivors who had reportedly drunk alcohol before cancer diagnosis and participated in the Korean National Health and Nutrition Examination Surveys conducted from 2007 to 2013. Among them, 360 abstained from alcohol drinking after cancer diagnosis. We categorized remaining 546 persistent drinkers into high-risk drinker (consuming≥7 glasses of alcohol for men and≥5 glasses of alcohol for women at one sitting at the frequency of at least once a month) or moderate drinker. We used multiple logistic regression analysis to evaluate risk factors associated with drinking behavior.

RESULTS

The high-risk drinkers occupied 27.1% (148 survivors) of the persistent alcohol drinking survivors. Age increase (OR=0.96; 95% CI 0.93-0.99), female sex (OR=0.15; 95% CI 0.08-0.28), and increase of time lapse (by 1-year) after cancer diagnosis (OR=0.94; 95% CI 0.92-0.97) were associated with a lower risk of high-risk drinking as compared with moderate drinking. Meanwhile,≤9years of education (OR=1.99; 95% CI 1.10-3.60), alcohol-related cancer (OR=2.09; 95% CI 1.23-3.56), and current smoking (OR=1.92; 95% CI 1.03-3.59) were associated with increased risk of high-risk drinking of cancer survivors.

CONCLUSIONS

These findings suggest that greater efforts for preventing high-risk drinking should be laid on the cancer survivors, with consideration of individual sociodemographic characteristics, especially when the survivors had been diagnosed with alcohol-related cancer.

Alcohol exposure as a risk factor for adverse outcomes in elective surgery

BACKGROUND AND AIMS

Alcohol consumption is a well-documented determinant of adverse perioperative outcome. We sought to determine the effect of active alcohol consumption following elective surgery.

METHODS

We queried discharge records from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP, 2005-2007) for all elective adult admissions. The 7,631 (2.5%) patients with documented alcohol use (active alcohol use of at least two drinks per day within 2 weeks of surgery; ETOH use) underwent elective surgery; 301,994 (97.5%) patients denied ETOH use. Multivariate analysis was performed with adjustments for demographic and comorbid factors. Primary outcome measures included length of stay (LOS), postoperative complications, and death.

RESULTS

ETOH use associated with elective surgery decreased over the course of the study (p < 0.0001). ETOH use was an independent predictor of pneumonia (OR 1.98, 95% CI 1.84-2.13), sepsis (OR 1.19, 95% CI 1.03-1.37), superficial surgical site infection (SSI; OR 1.15, 95% CI 1.02-1.31), wound disruption (OR 1.41, 95% CI 1.11-1.80), and prolonged LOS (OR 1.17, 95% CI 1.08-1.26). Except for SSI, these complications were independent risk factors for postoperative mortality. ETOH use was associated with earlier time to wound disruption (9 vs. 11 days; p = 0.04), longer median hospital stays (5 vs. 3 days; p < 0.0001), and longer LOS after operation (4 vs. 3 days; p < 0.0001).

CONCLUSIONS

Active alcohol consumption is a significant determinant of adverse outcomes in elective surgery; patients with ETOH use who are scheduled to undergo elective surgery should be appropriately educated and counseled.

Alcohol abuse in the critically ill patient

Alcohol abuse and dependence disorders are common in the 10% of hospitalised patients who need admission to the intensive care unit (ICU), but these disorders are often undiagnosed. The systemic effects from the excessive use of alcohol increase susceptibility to, or directly cause various important disorders in the critically ill. Early recognition of alcohol abuse and dependence is necessary and should prompt consideration of several alcohol-specific diagnoses that have important prognostic and therapeutic implications for these patients. We discuss the use of screening tests to improve the identification of alcohol abuse and dependence disorders, the epidemiology and pathogenesis of important alcohol-related disorders, differences in the presentation of several common alcohol-related diagnoses in the ICU, and important alcohol-specific therapies.

Alcohol abuse predicts progression of disease and death in patients with lung cancer

BACKGROUND

Few studies have examined long-term outcomes in alcohol-abusing patients with lung cancer. The purpose of this study was to examine the effect of alcohol abuse on the prognosis of patients with lung cancer.

METHODS

The study was composed of 114 consecutive patients with nonsmall-cell lung cancer treated at a Department of Veterans Affairs Medical Center. An alcohol-abusing group consisted of 36 patients with one of the following at the time of lung cancer diagnosis: positive screening questionnaire, alcohol consumption more than 5 drinks or cans of beer a day, or criteria for a diagnosis of alcohol dependence/abuse according to the Diagnostic and Statistical Manual for Mental Disorders IV. The comparison group consisted of 78 nonabusing patients.

RESULTS

Alcohol abusers, compared with nonabusers, had worse Kaplan-Meier overall survival (median 8.5 versus 17.5 months, p = 0.05) and progression-free survival (median 6.0 versus 15.5 months, p = 0.04). In multivariate analyses including alcohol abuse, Charlson comorbidity, pack-years smoking, performance status, and stage, only stage of disease, performance status, and alcohol abuse (odds ratio = 3.44, 95% confidence interval = 1.17 to 10.1, p = 0.02) predicted progression of disease or death within 12 months of diagnosis. Alcohol abuse was also an independent predictor of disease-specific survival (hazard ratio = 1.65, 95% confidence interval = 1.01 to 2.80, p = 0.05) and progression-free survival (hazard ratio = 1.79, 95% confidence interval = 1.12 to 2.86, p = 0.01) among patients with lung cancer.

CONCLUSIONS

Alcohol-abusing patients with nonsmall-cell lung cancer have worse outcomes than nonabusing patients. The adverse prognosis associated with alcohol abuse is independent of comorbidity, performance status, or smoking history.