Evaluation of infections in non-small cell lung cancer patients treated with radiotherapy

Tobacco smoking influences the side effects of radiation therapy-managed patients with various malignancies: A systematic review

BACKGROUND

Tobacco smoking may decrease the effectiveness of radiation therapy. This is because tobacco smoking can cause inflammation and damage to surrounding tissues, which may interfere with radiation delivery to the tumor. Our aim of this study is to investigate the effect of tobacco smoking use on complications in radiotherapy as a systematic review.

METHOD

The articles searched from the MEDLINE, PubMed, EMBASE, and Web of Science databases. The search terms used were "radiotherapy", "outcome", "radiation therapy", "tobacco", "smoking", "complications", "side effects", "cancer", and "malignancy". PRISMA check list was used to assess the overall quality of evidence for each outcome.

RESULT

The outcomes of radiotherapy-inducing tobacco smoking in smokers are more than non-smokers including; high SPC (second primary cancer), decreased median overall survival, higher infections during treatment, increased fatigue (p = 0.027), increased pain (p = 0.009), poorer cognitive function (0.041), affected mouth opening (0.049), more speech disturbances (p = 0.017), higher metastasis risk (p = 0.031 and 0.019), higher locoregional recurrence risk (p = 0.027), oral mucositis (p = 0.03), mucositis severity related to higher tobacco exposure (p = 0.008), severe acute radiation skin reactions, and myocardial infarction.

DISCUSSION

Tobacco smoking appears to be the most significant modifiable factor influencing cancer treatment outcomes. As such, healthcare providers should take detailed notes on patients' smoking histories during both routine and future clinical studies. Beyond immediate cessation, cancer patients should undertake comprehensive smoking cessation programs. These programs can significantly boost the efficacy of radiotherapy and enhance overall patient outcomes.

Lessons from the history of inorganic nanoparticles for inhalable diagnostics and therapeutics

The respiratory tract is one of the most accessible ones to exogenous nanoparticles, yet drug delivery by their means to it is made extraordinarily challenging because of the plexus of aerodynamic, hemodynamic and biomolecular factors at cellular and extracellular levels that synergistically define the safety and efficacy of this process. Here, the use of inorganic nanoparticles (INPs) for inhalable diagnostics and therapies of the lung is viewed through the prism of the history of studies on the interaction of INPs with the lower respiratory tract. The most conceptually and methodologically innovative and illuminative studies are referred to in the chronological order, as they were reported in the literature, and the trends in the progress of understanding this interaction of immense therapeutic and toxicological significance are being deduced from it. The most outstanding actual trends delineated include the diminishment of toxicity via surface functionalization, cell targeting, tagging and tracking via controlled binding and uptake, hybrid INP treatments, magnetic guidance, combined drug and gene delivery, use as adjuvants in inhalable vaccines, and other. Many of the understudied research directions, which have been accomplished by the nanostructured organic polymers in the pulmonary niche, are discussed. The progress in the use of INPs as inhalable diagnostics or therapeutics has been hampered by their well-recognized inflammatory potential and toxicity in the respiratory tract. However, the annual numbers of methodologically innovative studies have been on the rise throughout the past two decades, suggesting that this is a prolific direction of research, its comparatively poor commercial takings notwithstanding. Still, the lack of consensus on the effects of many INP compositions at low but therapeutically effective doses, the plethora of contradictory reports on ostensibly identical chemical compositions and NP properties, and the many cases of antagonism in combinatorial NP treatments imply that the rational design of inhalable medical devices based on INPs must rely on qualitative principles for the most part and embrace a partially stochastic approach as well. At the same time, the fact that the most studied INPs for pulmonary applications have been those with some of the thickest records of pulmonary toxicity, e.g., carbon, silver, gold, silica and iron oxide, is a silent call for the expansion of the search for new inorganic compositions for use in inhalable therapies to new territories.

Inhalable GSH-Triggered Nanoparticles to Treat Commensal Bacterial Infection in In Situ Lung Tumors

Bacterial infection has been considered one of the primary reasons for low survival rate of lung cancer patients. Herein, we demonstrated that a kind of mesoporous silica nanoparticles loaded with anticancer drug doxorubicin (DOX) and antimicrobial peptide HHC36 (AMP) (MSN@DOX-AMP) can kill both commensal bacteria and tumor cells under GSH-triggering, modulating the immunosuppressive tumor microenvironment, significantly treating commensal bacterial infection, and eliminating in situ lung tumors in a commensal model. Meanwhile, MSN@DOX-AMP encapsulated DOX and AMP highly efficiently via a combined strategy of physical adsorption and click chemistry and exhibited excellent hemocompatibility and biocompatibility. Importantly, MSN@DOX-AMP could be inhaled and accumulate in lung by a needle-free nebulization, achieving a better therapeutic effect. This system is expected to serve as a straightforward platform to treat commensal bacterial infections in tumors and promote the translation of such inhaled GSH-triggered MSN@DOX-AMP to clinical treatments of lung cancer.

The Spectrum of Infections in Patients with Lung Cancer

Although diagnostic and therapeutic advances in lung cancer (LC) have increased the survival of patients, infection and its complications are still among the most important causes of mortality. The disruption of tissue caused by tumor mass, management of cancer therapy and alteration in the humoral/cellular immune systems due to both cancer itself and therapy considerably increase susceptibility to infection in cancer patients. Particularly, opportunistic microorganisms should be considered, then applying rapid and sensitive diagnostic methods for them. Thus, cancer patients who are already exposed to difficult, long-term and expensive treatments can be prevented from dying from complications related to infections.

Impact of Tobacco Smoking on Outcomes of Radiotherapy: A Narrative Review

The carcinogenic role of tobacco smoking is well recognized, but the detrimental effects of continued smoking after a cancer diagnosis have been underestimated. Radiotherapy is among the main treatment modalities for cancer. We reviewed the literature data concerning the impact of tobacco smoking on treatment outcomes in radiotherapy-managed patients with various malignancies. Most of the analyzed studies demonstrated the detrimental effect of smoking on overall survival, tumor control, quality of life, treatment toxicity, and the incidence of second primary malignancies. Healthcare professionals should use the cancer diagnosis and treatment as a teachable moment and recommend their patients to immediately cease smoking. Wherever possible, cancer patients should undergo an intensive smoking-cessation program, including behavioral and pharmacologic therapy.

A novel use for routine CBCT imaging during radiotherapy to detect COVID-19

INTRODUCTION

Thoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection.

METHODS

A tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January-June 2020 to assess the efficiency of the tool and process.

RESULTS

Three patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs. Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process.

CONCLUSION

The preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers.

IMPLICATIONS FOR PRACTICE

This process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.

Worse lung cancer outcome in patients with lower respiratory tract infection confirmed at time of diagnosis

Background

Pulmonary malignancy is one of the most frequent and fatal cancers in older patients. As data on lower respiratory tract infection (LRTI) and the outcome of lung cancer are scarce, our objective was to determine the impact of LRTI on therapeutic possibilities and one‐year mortality.

Methods

Patients undergoing bronchoscopy in 2017 who had bronchial microbial sampling at the time of the lung cancer diagnosis (n = 143) were included. Group 1 (LRTI+) included patients with confirmed infection (n = 74) while Group 2 (LRTI‐) included patients without infection (n = 69). Clinical characteristics, pathogen profile and one‐year survival were analyzed.

Results

Age, gender, TNM stage, histology type, comorbidities or underlying lung disease did not differ among groups. The most common LRTI pathogens included aerobic (n = 49), anaerobic (n = 14) and fungal (n = 26) infections. Chemo/immune/target therapy alone, or in combination with radiotherapy were significantly less frequently used, whilst palliative care was more common in Group 1 (LRTI+). Multiple pathogen LRTI patients were significantly older, less frequently diagnosed with adenocarcinoma and had worse performance status compared to solitary pathogen LRTI patients. One‐year median survival was 274 days (235 vs. 305 days Group 1 vs. Group 2). Risk factors for increased one‐year mortality included performance status ≥2 (OR 30.00, CI 95% 5.23–313.00), performance status 1 (OR 11.87, CI 95% 4.12–33.78), male gender (OR 4.04, CI 2.03–8.04), LRTI with multiple pathogens (OR 2.72, CI 1.01–6.81) and nonadenocarcinoma histology (OR 2.26, CI 1.15–4.56).

Conclusion

LRTIs in lung cancer patients, especially multiple pathogen infections, are associated with less oncotherapeutic possibilities and significant risk for lower one‐year median survival.

Supportive care in the era of immunotherapies for advanced non-small-cell lung cancer

PURPOSE OF REVIEW

The therapeutic armamentarium for advanced non-small-cell lung cancer has evolved considerably over the past years. Immune checkpoint inhibitors targeting programmed cell death-1 such as pembrolizumab and nivolumab or programmed cell death ligand 1 such as atezolizumab, durvalumab and avelumab have shown favorable efficacy results in this patient population in the first-line and second-line setting. These immunotherapies are associated with a distinct toxicity profile based on autoimmune organ toxicity which is a new challenge for supportive care during treatment with these drugs.

RECENT FINDINGS

The differential diagnosis of events occurring during immune checkpoint inhibitor treatment is broad: they can be due to immune-related or nonimmune-related adverse events, atypical tumor responses (pseudoprogression or hyperprogression) or events related to comorbidities or other treatments.

SUMMARY

The management of these patients includes a thorough baseline clinical, biological and radiologic evaluation, patient education, correct follow-up and management by a multidisciplinary team with a central role for the medical oncologist. Immune-related toxicities should be managed according to available guidelines.

Managing the oncologic patient with suspected pneumonia in the intensive care unit

INTRODUCTION

Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research.

AREAS COVERED

This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.

Gram-negative bacteria facilitate tumor outgrowth and metastasis by promoting lipid synthesis in lung cancer patients

BACKGROUND

Lung cancer is the leading cause of cancer-related death worldwide. Patients with lung cancer are very frequently present with pulmonary infections, in particular with Gram-negative bacteria. Herein, we investigated the effect of the co-presence of Gram-negative bacteria on outgrowth and metastasis of lung cancer cells in clinical patients.

METHODS

Lung cancer cells were isolated from clinical surgical tissues. Heat-inactivated E. coli was used as Gram-negative bacteria. Tumor outgrowth and invasion in vitro was analyzed with MTT assay and Biocoat Matrigel Invasion Chamber. Tumor growth and metastasis in vivo was evaluated in BALB/c nude mice. Lipid synthesis was evidenced by expressions of FASN and ACC1, as well as BODIPY Fluorophores staining. Block lipid synthesis was performed with C75 as a FAS inhibitor and transfection with ACC1 siRNA. Knockdown of TLR4 and TLR9 signaling was achieved by transfection with specific shRNAs and administration of specific antagonists.

RESULTS

Gram-negative bacteria significantly promoted lung cancer development including growth and metastasis in dose dependent manner. Mechanistically, Gram-negative bacteria activate TLR4 and TLR9 signaling and enhance lipid synthesis in human lung cancer cells. Knockdown of TLR4 and/or TLR9 was able to block Gram-negative bacteria mediated lipid synthesis and lung cancer development. Interference with lipid synthesis efficiently abrogated Gram-negative-bacteria-induced lung cancer development. In lung cancer patients, higher expressions of innate immune receptors, TLR4 and TLR9, were observed in those with Gram-negative infections and associated with the aberrant lipid synthesis that was observed in vitro.

CONCLUSIONS

Pulmonary infections with Gram-negative bacteria lead to aberrant lipid synthesis through TLR4 and TLR9 signaling in lung cancer patients and result in rapid proliferation and metastasis of lung cancer cells. These findings reveal a new mechanism for pulmonary infection-trigged caner development and provide clues for exploring therapeutics for lung cancer patients.

Systematic Review of Tobacco Use after Lung or Head/Neck Cancer Diagnosis: Results and Recommendations for Future Research

Tobacco use after cancer diagnosis is associated with adverse cancer outcomes, yet reliable prevalence estimates for this behavior are lacking. We conducted a systematic literature review of the prevalence of current tobacco use among individuals with a history of lung or head/neck cancer (CRD #42012002625). An extensive search of electronic databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, and Web of Science) identified 7,777 potentially relevant articles published between 1980 and 2014 and 131 of these yielded pertinent information. Aggregating results across heterogeneous study designs and diverse patient samples, the overall mean prevalence rate of current tobacco use (mostly cigarette smoking) was 33.0% (median, 31.0%). Among current tobacco users at cancer diagnosis, the mean prevalence rate of current tobacco use (mostly cigarette smoking) was 53.8% (median, 50.3%). In many cases, an operational definition of "current" tobacco use was absent, and biochemical verification of self-reported smoking status was infrequent. These and other observed methodologic limitations in the assessment and reporting of cancer patients' tobacco use underscore the necessity of uniform tobacco use assessment in future clinical research and cancer care.

Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit

Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Growing observational evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation. Despite increasing numbers of (small) randomised controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.This is a qualitative review regarding smoking cessation in patients with COPD and other pulmonary disorders, written by a group of European Respiratory Society experts. We describe the epidemiological links between smoking and pulmonary disorders, the evidence for benefits of stopping smoking, how best to assess tobacco dependence and what interventions currently work best to help pulmonary patients quit. Finally, we describe characteristics and management of any "hardcore" smoker who finds it difficult to quit with standard approaches.

Smoking cessation in lung cancer-achievable and effective

BACKGROUND

Lung cancer is the leading cause of death from cancer in Germany. 90% of cases are due to the inhalation of tobacco smoke. About 40% of patients with newly diagnosed lung cancer are still smokers. A structured smoking cessation program is medically reasonable in this situation but is only rarely offered.

METHODS

This review is based on a selective search in the PubMed database combined with a manual search for current publications.

RESULTS

Many cross-sectional and longitudinal studies have shown that patients with lung cancer benefit from smoking cessation. After resection with curative intent, second tumors are 2.3 times more common, and recurrent tumors 1.9 times more common, in patients who continue to smoke than in those who stop. The overall mortality in smokers is 2.9 times higher. Smoking cessation also lowers the rate of radiation pneumonitis and infection during radiotherapy and prolongs the median survival after chemoradiotherapy for small-cell lung cancer (18.0 vs. 13.6 months). For patients with non-small-cell lung cancer, smoking cessation is associated with a better general state of health (77.5% vs. 57.6%). For the many patients with lung cancer who are treated palliatively, smoking cessation offers the advantages of improved pulmonary function, weight gain, and better overall quality of life.

CONCLUSION

Smoking cessation in patients with lung cancer is an important means of increasing the efficacy of treatment and improving their quality of life.

Smoking cessation: an integral part of lung cancer treatment

Lung cancer is the leading cause of cancer death in the US. About 50% of lung cancer patients are current smokers at the time of diagnosis and up to 83% continue to smoke after diagnosis. A recent study suggests that people who continue to smoke after a diagnosis of early-stage lung cancer almost double their risk of dying. Despite a growing body of evidence that continued smoking by patients after a lung cancer diagnosis is linked with less effective treatment and a poorer prognosis, the belief prevails that treating tobacco dependence is useless. With improved cancer treatments and survival rates, smoking cessation among lung cancer patients has become increasingly important. There is a pressing need to clarify the role of smoking cessation in the care of lung cancer patients.

OBJECTIVE

This paper will report on the benefits of smoking cessation for lung cancer patients and the elements of smoking cessation treatment, with consideration of tailoring to the needs of lung cancer patients.

RESULTS

Given the significant benefits of smoking cessation and that tobacco dependence remains a challenge for many lung cancer patients, cancer care providers need to offer full support and intensive treatment with a smoking cessation program that is tailored to lung cancer patients' specific needs.

CONCLUSION

A tobacco dependence treatment plan for lung cancer patients is provided.

Behavioral and psychological predictors of chemotherapy adherence in patients with advanced non-small cell lung cancer

OBJECTIVE

Dose delays and reductions in chemotherapy due to hematologic toxicities are common among patients with advanced non-small cell lung cancer (NSCLC). However, limited data on behavioral or psychological predictors of chemotherapy adherence exist. The goal of this study was to explore the frequency and clinical predictors of infusion dose delays and reductions in this patient population.

METHODS

Fifty patients newly diagnosed with advanced NSCLC of high performance status (Eastern Cooperative Oncology Group Performance Status=0-1) completed baseline assessments on quality of life (Functional Assessment of Cancer Therapy - Lung) and mood (Hospital Anxiety and Depression Scale) within 8 weeks of diagnosis. Participants were followed prospectively for 6 months. Chemotherapy dosing data came from medical chart review.

RESULTS

All patients received chemotherapy during the course of the study, beginning with a platinum-based doublet (74%), an oral epidermal growth factor receptor-tyrosine kinase inhibitor (14%), or a parenteral single agent (12%). Forty percent (n=20) of patients had a dose delay (38%) and/or reduction (16%) in their scheduled infusions. Fisher's Exact Tests and regression analyses showed that patients who experienced neutropenia, smoked at the time of diagnosis, or reported heightened baseline anxiety were significantly more likely to experience dose delays or reductions. There were no associations between chemotherapy adherence and patient demographics, performance status, or quality of life.

CONCLUSION

In this sample, more than one third of patients with advanced NSCLC experienced either a dose delay or reduction in prescribed chemotherapy regimens. Behavioral and psychological factors, such as tobacco use and anxiety symptoms, appear to play an important role in chemotherapy adherence, though further study is required to confirm these findings.

Smoking cessation and lung cancer: oncology nurses can make a difference

OBJECTIVES

To provide an overview of the impact of smoking after a diagnosis of lung cancer, discuss the relationship between smoking cessation and improved outcomes, present information about tobacco-dependence treatments, reimbursement for these treatments, and resources available for patients and health care professionals.

DATA SOURCES

Published articles, reports, websites, and research studies.

CONCLUSION

Prevention of tobacco use and cessation are primary ways to prevent lung cancer. However, even after a diagnosis of lung cancer, smoking cessation is important in improving survival and quality of life. Although effective treatments are available to help smokers quit, persistent efforts over repeated contacts may be necessary to achieve long-term cessation.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nursing action is essential in the identification of and intervention with patients who struggle with tobacco dependence after diagnosis.