Influence of medical comorbidities on the presentation and outcomes of stage I-III non-small-cell lung cancer

Real-World Efficacy and Safety of Durvalumab Administration Following Chemoradiotherapy in Elderly Patients With Unresectable Locally Advanced Nonsmall Cell Lung Cancer: A Multicenter, Retrospective Study

BACKGROUND

The PACIFIC trial established durvalumab administration after chemoradiotherapy as the standard of care for unresectable locally advanced nonsmall cell lung cancer (LA-NSCLC). However, the efficacy and safety of durvalumab in elderly patients aged 75 years or above remains unclear. This study aimed to investigate the real-world efficacy and safety of durvalumab for LA-NSCLC, with a specific focus on elderly patients.

PATIENTS AND METHODS

We reviewed 214 patients who received durvalumab out of 278 patients with unresectable LA-NSCLC who underwent chemoradiotherapy at 7 institutions between July 2018 and March 2022. Propensity score matching (PSM) analysis was performed to evaluate the efficacy of durvalumab in elderly patients.

RESULTS

The 2-year progression-free survival (PFS) and 2-year overall survival (OS) rates were 42.2% (95% confidence interval [CI], 34.7%-49.5%) and 77.1% (95% CI, 70.1-82.7%), respectively. Grade ≥ 3 immune-related adverse events (irAEs) occurred in 8.2% of patients. PSM analysis revealed that OS was significantly shorter in elderly patients (≥ 75 years) than in younger patients (< 75 years) (hazard ratio [HR]; 95% CI, 1.39-8.99; P = .008), whereas PFS did not differ significantly between the 2 groups (HR: 1.50, 95% CI, 0.84-2.68, P = .169). The frequency of irAEs did not differ between these groups.

CONCLUSIONS

The real-world efficacy and safety of durvalumab administration following chemoradiotherapy for LA-NSCLC coincided with the PACIFIC trial's findings. Disease control achieved with this protocol did not differ significantly between elderly and younger patients but had acceptable tolerability, demonstrating its benefit even in elderly LA-NSCLC patients aged 75 years or above.

Lung cancer, comorbidities, and medication: the infernal trio

Most patients with lung cancer are smokers and are of advanced age. They are therefore at high risk of having age- and lifestyle-related comorbidities. These comorbidities are subject to treatment or even polypharmacy. There is growing evidence of a link between lung cancer, comorbidities and medications. The relationships between these entities are complex. The presence of comorbidities and their treatments influence the time of cancer diagnosis, as well as the diagnostic and treatment strategy. On the other hand, cancer treatment may have an impact on the patient's comorbidities such as renal failure, pneumonitis or endocrinopathies. This review highlights how some comorbidities may have an impact on lung cancer presentation and may require treatment adjustments. Reciprocal influences between the treatment of comorbidities and anticancer therapy will also be discussed.

Comorbidity in limited disease small-cell lung cancer: Age-adjusted Charlson comorbidity index and its association with overall survival following chemoradiotherapy

Background

Combined, platinum-based thoracic chemoradiotherapy (TCR) is the current state-of-the-art treatment for patients with limited disease (LD) small-cell lung cancer (SCLC). There is only limited data available regarding the effect of comorbidities on survival following TRC. The purpose of this study is to assess the age-adjusted Charlson comorbidity index (ACCI) as a predictor of overall survival in LD-SCLC patients undergoing TCR.

Patients and methods

We retrospectively analyzed 367 SCLC patients diagnosed with LD-SCLC who received TCR between 2003 and 2017. We evaluated the ACCI (n = 348) as a predictor of overall survival (OS). In this cohort, 322 patients (88%) received platinum-based TCR (either cisplatin or carboplatin), and 37 (10%) patients received vincristine based TCR. Median radiation dose was 60 Gy (range 24-66 Gy). Additionally, 83% of patients (n = 303) received prophylactic cranial irradiation (PCI, 30 Gy in 2 Gy fractions). Kaplan-Meier survival analysis was performed for OS. For comparison of survival curves, Log-rank (Mantel-Cox) test was used. Univariate and multivariate Cox proportional-hazards ratios (HRs) were used to assess the influence of cofactors on OS.

Results

Patients with an ACCI > 6 had a significantly shorter OS compared with patients with an ACCI ≤ 6 (median 11 vs. 20 months; p = 0.005). Univariate analysis for OS revealed a statistically significant effect for ACCI > 6 (HR 1.7; 95% CI 1.2-2.4; p = 0.003), PCI (HR 0.5; 95% CI 0.3-0.7; p < 0.001), and Karnofsky performance status ≤ 70% (KPS) (HR 1.4; 95% CI 1.1-1.90; p = 0.015). In multivariate analysis, OS was significantly associated with PCI (HR 0.6; 95% CI 0.4-0.9; p = 0.022) and ACCI > 6 (HR 1.5; 95% CI 1.0-2.1; p = 0.049).

Conclusion

Comorbidity is significantly associated with survival in patients with LD-SCLC undergoing TCR. The ACCI may be a valuable tool to identify patients with a shorter survival and thus might be used for risk stratification and oncological decision making.

A systematic review of genetic ancestry as a risk factor for incidence of non-small cell lung cancer in the US

Background: Non-Small Cell Lung Cancer (NSCLC), the leading cause of cancer-related death in the United States, is the most diagnosed form of lung cancer. While lung cancer incidence has steadily declined over the last decade, disparities in incidence and mortality rates persist among African American (AA), Caucasian American (CA), and Hispanic American (HA) populations. Researchers continue to explore how genetic ancestry may influence differential outcomes in lung cancer risk and development. The purpose of this evaluation is to highlight experimental research that investigates the differential impact of genetic mutations and ancestry on NSCLC incidence. Methods: This systematic review was conducted using PubMed and Google Scholar search engines. The following key search terms were used to select articles published between 2011 and 2022: "African/European/Latin American Ancestry NSCLC"; "Racial Disparities NSCLC"; "Genetic Mutations NSCLC"; "NSCLC Biomarkers"; "African Americans/Hispanic Americans/Caucasian Americans NSCLC incidence." Systematic reviews, meta-analyses, and studies outside of the US were excluded. A total of 195 articles were initially identified and after excluding 156 which did not meet eligibility criteria, 38 were included in this investigation. Results: Studies included in this analysis focused on racial/ethnic disparities in the following common genetic mutations observed in NSCLC: KRAS, EGFR, TP53, PIK3CA, ALK Translocations, ROS-1 Rearrangements, STK11, MET, and BRAF. Results across studies varied with respect to absolute differential expression. No significant differences in frequencies of specific genetic mutational profiles were noted between racial/ethnic groups. However, for HAs, lower mutational frequencies in KRAS and STK11 genes were observed. In genetic ancestry level analyses, multiple studies suggest that African ancestry is associated with a higher frequency of EGFR mutations. Conversely, Latin ancestry is associated with TP53 mutations. At the genomic level, several novel predisposing variants associated with African ancestry and increased risk of NSCLC were discovered. Family history among all racial/ethnic groups was also considered a risk factor for NSCLC. Conclusion: Results from racially and ethnically diverse studies can elucidate driving factors that may increase susceptibility and subsequent lung cancer risk across different racial/ethnic groups. Identification of biomarkers that can be used as diagnostic, prognostic, and therapeutic tools may help improve lung cancer survival among high-risk populations.

A New Approach to Simplifying and Harmonizing Cancer Clinical Trials-Standardizing Eligibility Criteria

Importance

Clinical trial sponsors rely on eligibility criteria to control the characteristics of patients in their studies, promote the safety of participants, and optimize the interpretation of results. However, in recent years, complex and often overly restrictive inclusion and exclusion criteria have created substantial barriers to patient access to novel therapies, hindered trial recruitment and completion, and limited generalizability of trial results. A LUNGevity Foundation working group developed a framework for lung cancer clinical trial eligibility criteria. The goals of this framework are to (1) simplify eligibility criteria, (2) facilitate stakeholders' (patients, clinicians, and sponsors) search for appropriate trials, and (3) harmonize trial populations to support intertrial comparisons of treatment effects.

Observations

Clinicians and representatives from the pharmaceutical industry, the National Cancer Institute, the US Food and Drug Administration (FDA), the European Medicines Agency, and the LUNGevity Foundation undertook a process to identify and prioritize key items for inclusion in trial eligibility criteria. The group generated a prioritized library of terms to guide investigators and sponsors in the design of first-line, advanced non-small cell lung cancer clinical trials intended to support marketing application. These recommendations address disease stage and histologic features, enrollment biomarkers, performance status, organ function, brain metastases, and comorbidities. This effort forms the basis for a forthcoming FDA draft guidance for industry.

Conclusions and Relevance

As an initial step, the recommended cross-trial standardization of eligibility criteria may harmonize trial populations. Going forward, by connecting diverse stakeholders and providing formal opportunity for public input, the emerging FDA draft guidance may also provide an opportunity to revise and simplify long-standing approaches to trial eligibility. This work serves as a prototype for similar efforts now underway for other cancers.

Quantifying the impact of pre-existing conditions on the stage of oesophagogastric cancer at diagnosis: a primary care cohort study using electronic medical records

BACKGROUND

Pre-existing conditions interfere with cancer diagnosis by offering diagnostic alternatives, competing for clinical attention or through patient surveillance.

OBJECTIVE

To investigate associations between oesophagogastric cancer stage and pre-existing conditions.

METHODS

Retrospective cohort study using Clinical Practice Research Datalink (CPRD) data, with English cancer registry linkage. Participants aged ≥40 years had consulted primary care in the year before their incident diagnosis of oesophagogastric cancer in 01/01/2010-31/12/2015. CPRD records pre-diagnosis were searched for codes denoting clinical features of oesophagogastric cancer and for pre-existing conditions, including those providing plausible diagnostic alternatives for those features. Logistic regression analysed associations between stage and multimorbidity (≥2 conditions; reference category: no multimorbidity) and having 'diagnostic alternative(s)', controlling for age, sex, deprivation and cancer site.

RESULTS

Of 2444 participants provided, 695 (28%) were excluded for missing stage, leaving 1749 for analysis (1265/1749, 72.3% had advanced-stage disease). Multimorbidity was associated with stage [odds ratio 0.63, 95% confidence interval (CI) 0.47-0.85, P = 0.002], with moderate evidence of an interaction term with sex (1.76, 1.08-2.86, P = 0.024). There was no association between alternative explanations and stage (odds ratio 1.18, 95% CI 0.87-1.60, P = 0.278).

CONCLUSIONS

In men, multimorbidity is associated with a reduced chance of advanced-stage oesophagogastric cancer, to levels seen collectively for women.

Use of comorbidity indices in patients with any cancer, breast cancer, and human epidermal growth factor receptor-2-positive breast cancer: A systematic review

Objective

To identify comorbidity indices that have been validated in cancer populations, with a focus on breast cancer and human epidermal growth factor receptor-2-positive (HER2+) breast cancer.

Study design and setting

A systematic review of the literature on the use of comorbidity indices in any cancer, breast cancer, and HER2+ breast cancer using Ovid and PubMed.

Results

The final data set comprised 252 articles (252 any cancer, 39 breast cancer, 7 HER2+ breast cancer). The most common cancers assessed were hematologic and breast, and the most common comorbidity index used was the Charlson Comorbidity Index (CCI) or a CCI derivative. Most validity testing of comorbidity indices used predictive validity based on survival outcomes. Hazard ratios for survival outcomes generally found that a higher comorbidity burden (measured by CCI) increased mortality risk in patients with breast cancer. All breast-cancer studies that validated comorbidity indices used CCI-based indices. Only one article validated a comorbidity index in HER2+ breast cancer.

Conclusion

CCI-based indices are the most appropriate indices to use in the general breast-cancer population. There is insufficient validation of any comorbidity index in HER2+ breast cancer to provide a recommendation, indicating a future need to validate these instruments in this population.

Effect of prior cancer on survival of hepatocellular carcinoma: implications for clinical trial eligibility criteria

Background

Patients with cancer history are usually excluded from hepatocellular carcinoma (HCC) clinical trials. However, whether previous malignancy affects the oncological outcomes of HCC patients has not been fully assessed. This study aimed to evaluate whether prior cancer compromised the survival of HCC patients.

Methods

Patients with HCC were extracted from the Surveillance, Epidemiology, and End Results database between 2004 and 2015, and then they were classified into groups with and without prior cancer. The Kaplan-Meier and multivariate Cox regression analysis were adopted to evaluate whether prior cancer impacted clinical outcomes after propensity score matching (PSM) adjusting baseline differences. Validation was performed in the cohort from our institution.

Results

We identified 2642 HCC patients with prior cancer. After PSM, the median overall survival (OS) time were 14.5 and 12.0 months respectively for groups with and without prior cancer. Prior cancer did not compromise prognosis in patients with HCC (p = 0.49). The same tendency was found in subgroups stratified by tumor stages and cancer interval period: OS was similar between groups with and without prior cancer (both p values> 0.1). In the multivariate Cox regression model, prior cancer did not adversely impact patients’ survival (HR: 1.024; 95% CI: 0.961–1.092). In the validation cohort from our institution, prior cancer had no significant association with worse outcomes (p = 0.48).

Conclusion

For HCC patients, prior cancer did not compromise their survival, regardless of tumor stage and cancer interval period. Exclusion criteria for HCC clinical trials could be reconsidered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07870-0.

Impact of Prior Cancer History on the Clinical Outcomes in Advanced Breast Cancer: A Propensity Score-Adjusted, Population-Based Study

PURPOSE

Despite the rapid growing of cancer survivors, prior cancer history is a commonly adopted exclusion criterion. Whether prior cancer will impact the survival of patients with advanced breast cancer (ABC) remains uncertain.

MATERIALS AND METHODS

Patients with ABC diagnosed between 2004 and 2010 were identified using Surveillance, Epidemiology, and End Results (SEER) database. Timing, stage, and type were used to characterize prior cancer. Multivariable analyses using propensity score-adjusted Cox regression and competing risk regression were conducted to evaluate the prognostic effect of prior cancer on overall survival (OS) and breast cancer-specific survival (BCSS).

RESULTS

A total of 14,176 ABC patients were identified, of whom 10.5% carried a prior cancer history. The most common type of prior cancer was female genital cancer (32.4%); more than half (51.7%) were diagnosed at localized stage; most were diagnosed more than 5 years (42.9%) or less than 1 year (28.3%) prior to the index cancer. In multivariate analyses, patients with prior cancer presented a slightly worse OS (hazard ratio, 1.18; 95% confidence interval [CI], 1.07 to 1.30; p=0.001) but a better BCSS (subdistribution hazard ratio, 0.64; 95% CI, 0.56 to 0.74; p < 0.001). In subset analyses, no survival detriment was observed in patients with prior malignancy from head and neck or endocrine system, at in situ or localized stage, or diagnosed more than 4 years.

CONCLUSION

Prior cancer provides an inferior OS but a superior BCSS for patients with ABC. It does not affect the survival adversely in some subgroups and these patients should not be excluded from clinical trials.

Comorbidity and stage at diagnosis among lung cancer patients in the US military health system

PURPOSE

We investigated the association between comorbidities and stage at diagnosis among NSCLC patients in the US Military Health System (MHS), which provides universal health care to its beneficiaries.

METHODS

The linked data from the Department of Defense's Central Cancer Registry (CCR) and the MHS Data Repository (MDR) were used. The study included 4768 patients with histologically confirmed primary NSCLC. Comorbid conditions were extracted from the MDR data. Comorbid conditions were those included in the Charlson Comorbidity Index (CCI) and were defined as a diagnosis during a 3-year time frame prior to the NSCLC diagnosis. Multivariable logistic regression was performed to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) of late stage (stages III and IV) versus early stage (stages I and II) in relation to pre-existing comorbidities.

RESULTS

Compared to patients with no comorbidities, those with prior comorbidities tended to be less likely to have lung cancer diagnosed at late stage. When specific comorbidities were analyzed, decreased odds of being diagnosed at late stage were observed among those with chronic obstructive pulmonary disease (COPD) (adjusted OR 0.78, 95% CI 0.68 to 0.90). In contrast, patients with a congestive heart failure or a liver cirrhosis/chronic hepatitis had an increased likelihood of being diagnosed at late stage (adjusted OR 1.30, 95% CI 1.00 to 1.69 and adjusted OR 1.87, 95% CI 1.24 to 2.82, respectively).

CONCLUSIONS

Among NSCLC patients in an equal access health system, the likelihood of late stage at diagnosis differed by specific comorbid diseases.

Timing, Sites, and Correlates of Lung Cancer Recurrence

INTRODUCTION

Understanding temporal and anatomic patterns of lung cancer recurrence could guide disease management and monitoring. However, these data are not available in population-based datasets and are not routinely recorded in clinical trials.

MATERIALS AND METHODS

We identified cases of stage 1 to 3 lung cancer diagnosed January 1, 2000, to December 31, 2017, in the tumor registry of a National Cancer Institute-designated comprehensive cancer center. For cases with documented disease recurrence, we recorded anatomic site(s) and timing. We estimated time to recurrence using Kaplan-Meier methods. Associations between case characteristics and recurrence features were assessed using univariable and multivariable logistic regression models and Cox regression models.

RESULTS

A total of 1619 cases of stage 1 to 3 lung cancer from 1549 patients were included in the analysis. Of these, 466 (30%) patients developed recurrent lung cancer. The most common type of first recurrence was distant disease, most commonly central nervous system (CNS) (37%). In multivariable analyses, race (P = .02) and primary treatment modality (P < .001) correlated with recurrent disease, whereas tumor histology (P = .004) and primary treatment modality (P < .001) were associated specifically with distant recurrence. Patient age (P = .05) and initial TNM stage (P = .001) correlated with timing of recurrence.

CONCLUSION

In this single-center series of stage 1 to 3 lung cancer, recurrent disease was associated with race, histology, and treatment modality, and most commonly occurred in the CNS. Modulation of clinical and radiographic disease monitoring according to recurrence risk, timing, and site may offer a means to identify future lung cancer when it remains asymptomatic and highly treatable.

Comorbid chronic diseases and cancer diagnosis: disease-specific effects and underlying mechanisms

An earlier diagnosis is a key strategy for improving the outcomes of patients with cancer. However, achieving this goal can be challenging, particularly for the growing number of people with one or more chronic conditions (comorbidity/multimorbidity) at the time of diagnosis. Pre-existing chronic diseases might affect patient participation in cancer screening, help-seeking for new and/or changing symptoms and clinicians' decision-making on the use of diagnostic investigations. Evidence suggests, for example, that pre-existing pulmonary, cardiovascular, neurological and psychiatric conditions are all associated with a more advanced stage of cancer at diagnosis. By contrast, hypertension and certain gastrointestinal and musculoskeletal conditions might be associated with a more timely diagnosis. In this Review, we propose a comprehensive framework that encompasses the effects of disease-specific, patient-related and health-care-related factors on the diagnosis of cancer in individuals with pre-existing chronic illnesses. Several previously postulated aetiological mechanisms (including alternative explanations, competing demands and surveillance effects) are integrated with newly identified mechanisms, such as false reassurances, or patient concerns about appearing to be a hypochondriac. By considering specific effects of chronic diseases on diagnostic processes and outcomes, tailored early diagnosis initiatives can be developed to improve the outcomes of the large proportion of patients with cancer who have pre-existing chronic conditions.

QTc Interval-Prolonging Medications Among Patients With Lung Cancer: Implications for Clinical Trial Eligibility and Clinical Care

BACKGROUND

Concomitant medication use, including agents that prolong the corrected QT (QTc) interval, can result in the exclusion of patients with cancer from clinical trials. To estimate the potential effects on accrual, we determined the prevalence of QTc-prolonging medication prescriptions in a national patient cohort.

PATIENTS AND METHODS

We identified adult patients in the Veterans Affairs system with a diagnosis of lung cancer from 2003 to 2016. The use of QTc interval-prolonging medications and risk category were obtained from CredibleMeds. We calculated the prevalence of prescriptions for QTc-prolonging medications with a known or possible risk of torsade de pointes in the 3 months up to and including the date of cancer diagnosis. The rates across patient groups were compared using χ² test.

RESULTS

A total of 280,068 patients were included in the present study. The mean age was 70 years, 98% were male, and 72% were white. Overall, 28.4% had been prescribed a QTc-prolonging medication, and 7.3% had been prescribed ≥2 in the 3 months before the cancer diagnosis. The most commonly prescribed QTc-prolonging medications were antimicrobial agents (14.0%), psychiatric agents (10.2%), antiemetic agents (2.6%), and cardiac medications (1.7%). Excluding the antimicrobial agents, 18.4% of the patients had been prescribed a QTc-prolonging medication.

CONCLUSIONS

A substantial proportion of individuals with lung cancer will be prescribed QTc-prolonging medications. These prescriptions can limit patients' eligibility for clinical trials and complicate the administration of standard cancer therapies. Further research into the actual clinical risks and optimal management of QTc-prolonging medications in cancer populations is warranted.

Prevalence and prognosis significance of cardiovascular disease in cancer patients: a population-based study

BACKGROUND

Cardiovascular disease (CVD) is a heavy burden on cancer patients worldwide. This study aimed to evaluate the prevalence and influence of cardiovascular risk factors (CVRF) and CVD on the all-cause mortality among Chinese cancer patients.

RESULTS

Overall, 13.0% of all cancer patients had at least one type of CVRFs and 5.0% with CVDs. Patients with CVRF or CVD presented more frequently at later stages and received higher percentage of oncotherapy. During 1,782,527 person-years of follow-up, the all-cause mortality in cancer patients with CVDs and with CVRFs was higher compared with those without (182.6/1000, 109.5/1000 and 93.3/1000 person-years, respectively). Cox regression analysis showed that patients with heart failure (HR 1.79, 95% CI 1.61-1.99), myocardial infarction (HR 1.50, 95% CI 1.16-1.95), atrial fibrillation (HR 1.30, 95% CI 1.09-1.53), stroke (HR 1.21, 95% CI 1.11-1.32), hypertension (HR 1.10, 95% CI 1.04-1.16) and diabetes (HR 1.16, 95% CI 1.08-1.24) had increased all-cause mortality, whereas dyslipidemia patients had better prognosis (HR 0.73, 95% CI 0.64-0.83). Stratified by cancer type, the prognostic impact of specific CVRF or CVD varied.

METHODS

We consecutively recruited 710,170 cancer patients between Feb. 1995 and Jun. 2018. A stratified Cox proportional hazards model was used to analyze the effect of comorbidities on the overall survival of patients stratified by cancer type.

CONCLUSIONS

Cancer patients are vulnerable to comorbidity related to heart and cerebral disease. The influence of comorbidities on prognosis is noticeable and specific both for the type of cancer and comorbidities.

Chronic obstructive pulmonary disease and comorbidities' influence on mortality in non-small cell lung cancer patients

Background: In Denmark, lung cancer is the most common cause of cancer-related death and chronic obstructive pulmonary disease (COPD) is the most common comorbidity in patients with non-small cell lung cancer (NSCLC). The aim of this study was to investigate the influence of COPD and other common comorbidities on NSCLC mortality. Methods: Patients (n = 534) diagnosed with NSCLC at Aalborg University Hospital from 2008-2010 were included retrospectively in this study. Patient records were assessed and the population was dichotomized in COPD and non-COPD subgroups. Comorbidities i.e., ischemic heart disease, hypertension, diabetes mellitus, apoplexia, former malignancy, interstitial lung disease and psychiatric comorbidity were registered and a comorbidity count were calculated. Survival was assessed with log-rank test and uni- and multivariate regression analysis were performed for COPD-status and comorbidity count adjusting for age, gender, BMI, smoking exposure, cancer stage, method of treatment and eastern cooperative cancer group (ECOG) performance status score. Results: Of 534 NSCLC patients included, 470 were divided into COPD and non-COPD subgroups, 70% with COPD (329/470) and 30% without COPD (141/470). Only 32.5% of the patients in the COPD-group had previously diagnosed COPD. Log-rank test did not show statistically significant difference in survival between the COPD and non-COPD groups (p = .215). Multivariate Cox regression analysis did not show statistically significant association between overall 5-year mortality and the presence of COPD (HR-adj = 0.808, 95% CI = 0.612; 1.068) or other comorbidities (HR-adj = 1.101, 95% CI = 0.979; 1.237) when adjusted for age, BMI, gender, smoking exposure, ECOG performance status, treatment and TNM-stage. Conclusion: Our findings do not suggest that COPD nor other common comorbidities are significantly associated with higher mortality in NSCLC patients.

Effect of prior cancer on trial eligibility and treatment outcomes in nasopharyngeal carcinoma: Implications for clinical trial accrual

OBJECTIVE

In cancer trials, prior cancer is a common exclusion criterion. We evaluated the characteristics of prior cancer exclusion criteria in nasopharyngeal carcinoma (NPC) trials and determined its prognostic effect on patients with NPC.

METHODS

We reviewed NPC trials for prior cancer exclusion criteria. Then we estimated the effect of prior cancer among NPC patients using the Surveillance, Epidemiology, and End Results database.Propensity score-matching was used to compensate for differences in baseline characteristics between patients with and without prior cancer.

RESULTS

There were 109 clinical trials involving 10,437 patients; 49 trials (45%) excluded patients with prior cancer. Prior cancer exclusion was more common in recent or phase III trials. We identified 10,195 NPC patients; 6.2% had prior cancer. More than 70% of these cancers were in situ/localized/regional and diagnosed relatively close to the NPC diagnosis (median 3.3 years). Patients with certain prior cancer type (prostate, breast, gynecological, hematological), time of diagnosis (>5 years ago), or stage (in situ/localized) did not have inferior survival compared with patients with no prior cancer. We tested one form of prior cancer exclusion criteria in an NPC cohort resembling a modern trial population: it did not adversely affect overall and NPC-specific survival.

CONCLUSIONS

Many NPC trials excluded patients with prior cancer, whichimpacts trialaccrual and generalizability. Our findings suggest that broader inclusion in trials of patients with NPC with prior cancer might not affect trial outcomes. More research is needed to understand the appropriateness of this exclusion policy across cancer types and trials.

Short- and long-term outcomes in elderly patients with locally advanced non-small-cell lung cancer treated using video-assisted thoracic surgery lobectomy

BACKGROUND

In recent years, video-assisted thoracic surgery (VATS) lobectomy has been used to treat locally advanced non-small-cell lung cancer (LA-NSCLC). However, VATS has not been reported in elderly patients (≥70 years) with LA-NSCLC. The purpose of this study was to compare short- and long-term outcomes of patients with LA-NSCLC aged ≥70 years and 55-69 years treated with VATS.

PATIENTS AND METHODS

From January 2012 to January 2018, a total of 83 patients with LA-NSCLC who were ≥55 years of age underwent VATS. Patients were divided into ≥70 years group (37 cases) and 55-69 years group (46 cases), based on their age at the time of VATS. Short- and long-term outcomes of these two groups of patients were compared.

RESULTS

American Society of Anesthesiologists scores of ≥70 years patients were higher than those of 55-69 years patients. No significant differences were observed when comparing the general preoperative data. For short-term outcomes, there was no significant difference between the two groups of patients in length of surgery, intraoperative blood loss, conversion to thoracotomy, postoperative 30-day complication rate and severity, postoperative 30-day mortality, pathological results, compliance with adjuvant chemotherapy, or other factors. Long-term follow-up results showed that recurrence, overall survival, and disease-free survival were similar in both groups. Furthermore, multivariate analysis showed that age was not an independent predictor of overall and disease-free survival.

CONCLUSIONS

VATS in elderly patients (≥70 years) with LA-NSCLC can result in short- and long-term outcomes similar to those of 55-69 years patients with LA-NSCLC.

Effect of Comorbidity on Lung Cancer Diagnosis Timing and Mortality: A Nationwide Population-Based Cohort Study in Taiwan

The effect of comorbidity on lung cancer patients' survival has been widely reported. The aim of this study was to investigate the effects of comorbidity on the establishment of the diagnosis of lung cancer and survival in lung cancer patients in Taiwan by using a nationwide population-based study design. This study collected various comorbidity patients and analyzed data regarding the lung cancer diagnosis and survival during a 16-year follow-up period (1995-2010). In total, 101,776 lung cancer patients were included, comprising 44,770 with and 57,006 without comorbidity. The Kaplan-Meier analyses were used to compare overall survival between lung cancer patients with and without comorbidity. In our cohort, chronic bronchitis patients who developed lung cancer had the lowest overall survival in one (45%), five (28.6%), and ten years (26.2%) since lung cancer diagnosis. Among lung cancer patients with nonpulmonary comorbidities, patients with hypertension had the lowest overall survival in one (47.9%), five (30.5%), and ten (28.2%) years since lung cancer diagnosis. In 2010, patients with and without comorbidity had 14.86 and 9.31 clinical visits, respectively. Lung cancer patients with preexisting comorbidity had higher frequency of physician visits. The presence of comorbid conditions was associated with early diagnosis of lung cancer.

Association between Charlson comorbidity index score and outcome in patients with stage IIIB-IV non-small cell lung cancer

Background

This retrospective study investigated the association between the Charlson comorbidity index (CCI) score and the survival of patients with stage IIIB-IV (advanced, non-resectable) non-small cell lung cancer (NSCLC) who also did not have gene mutations in epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK).

Methods

The records of 165 patients (28–80 y, median 61 y) who met the above criteria and were admitted to Beijing Friendship Hospital Capital Medical University from 1 May 2010 to 1 October 2014were reviewed. Associations between baseline variables and the CCI score were assessed via univariate and multivariate logistic regression analysis. Overall survival was defined as the time from the first clinic visit to death from any cause, or to the end of follow-up. Survival curves were estimated via the Kaplan-Meier method and compared with the log-rank test.

Results

Logistic regression analyses indicated that smoking and performance status were independently associated with the CCI score. Smoking was associated with an increased risk of mortality (odds ratio (OR) 4.12 (95% confidence interval [CI] 1.92–8.84) compared to non-smokers), as was performance status 2 (ambulatory, capable of self-care, unable to perform any work activities; active for >50% of waking hours) (OR 2.22 (95% CI, 1.14–4.33) compared to performance status 1). Univariate Cox’s regression analyses showed that the hazard ratios were significantly associated with the CCI score (P = 0.009), smoking (P = 0.042), and male gender (P = 0.021).

Conclusion

The CCI score is an important prognostic factor for the prediction of overall survival in patients with stage IIIB-IV NSCLC who are negative for EGFR and ALK gene mutations.

Reproducibility, reliability and validity of population-based administrative health data for the assessment of cancer non-related comorbidities

BACKGROUND

Patients with comorbidities do not receive optimal treatment for their cancer, leading to lower cancer survival. Information on individual comorbidities is not straightforward to derive from population-based administrative health datasets. We described the development of a reproducible algorithm to extract the individual Charlson index comorbidities from such data. We illustrated the algorithm with 1,789 laryngeal cancer patients diagnosed in England in 2013. We aimed to clearly set out and advocate the time-related assumptions specified in the algorithm by providing empirical evidence for them.

METHODS

Comorbidities were assessed from hospital records in the ten years preceding cancer diagnosis and internal reliability of the hospital records was checked. Data were right-truncated 6 or 12 months prior to cancer diagnosis to avoid inclusion of potentially cancer-related comorbidities. We tested for collider bias using Cox regression.

RESULTS

Our administrative data showed weak to moderate internal reliability to identify comorbidities (ICC ranging between 0.1 and 0.6) but a notably high external validity (86.3%). We showed a reverse protective effect of non-cancer related Chronic Obstructive Pulmonary Disease (COPD) when the effect is split into cancer and non-cancer related COPD (Age-adjusted HR: 0.95, 95% CI:0.7-1.28 for non-cancer related comorbidities). Furthermore, we showed that a window of 6 years before diagnosis is an optimal period for the assessment of comorbidities.

CONCLUSION

To formulate a robust approach for assessing common comorbidities, it is important that assumptions made are explicitly stated and empirically proven. We provide a transparent and consistent approach useful to researchers looking to assess comorbidities for cancer patients using administrative health data.

Revisiting a longstanding clinical trial exclusion criterion: impact of prior cancer in early-stage lung cancer

Background:

Early-stage lung cancer represents a key focus of numerous multicenter clinical trials, but common exclusion criteria such as a prior cancer diagnosis may limit enrollment. We examined the prevalence and prognostic impact of a prior cancer diagnosis among patients with early-stage lung cancer.

Methods:

We identified patients>65 years of age with early-stage lung cancer diagnosed 1996–2009 in the Surveillance, Epidemiology, and End Results-Medicare linked database. Prior cancers were characterized by type, stage, and timing with respect to the lung cancer diagnosis. All-cause and lung cancer specific-survival rates were compared between patients with and without prior cancer using Cox regression analyses and propensity scores.

Results:

Among 42,910 patients with early-stage lung cancer, one-fifth (21%) had a prior cancer. The most common prior cancers were prostate (21%), breast (18%), gastrointestinal (17%), and other genitourinary (15%). Most prior cancers were localized, and 61% were diagnosed within 5 years of the lung cancer diagnosis. There was no difference in all-cause survival between patients with and without prior cancer (hazard ratio [HR] 1.01; P=0.52). Lung cancer specific survival was improved among patients with prior cancer (HR 0.79; P<0.001).

Conclusions:

A prior cancer history may exclude a substantial proportion of patients with early-stage lung cancer from enrollment in clinical trials. Without adverse effect on clinical outcomes, inclusion of patients age >65 years with prior cancer in clinical trials should be considered to improve study accrual, completion rates, and generalizability.

A Prognostic Model to Predict Mortality among Non-Small-Cell Lung Cancer Patients in the U.S. Military Health System

INTRODUCTION

Accurate prognosis assessment after non-small-cell lung cancer (NSCLC) diagnosis is an essential step for making effective clinical decisions. This study is aimed to develop a prediction model with routinely available variables to assess prognosis in patients with NSCLC in the U.S. Military Health System.

METHODS

We used the linked database from the Department of Defense's Central Cancer Registry and the Military Health System Data Repository. The data set was randomly and equally split into a training set to guide model development and a testing set to validate the model prediction. Stepwise Cox regression was used to identify predictors of survival. Model performance was assessed by calculating area under the receiver operating curves and construction of calibration plots. A simple risk scoring system was developed to aid quick risk score calculation and risk estimation for NSCLC clinical management.

RESULTS

The study subjects were 5054 patients diagnosed with NSCLC between 1998 and 2007. Age, sex, tobacco use, tumor stage, histology, surgery, chemotherapy, peripheral vascular disease, cerebrovascular disease, and diabetes mellitus were identified as significant predictors of survival. Calibration showed high agreement between predicted and observed event rates. The area under the receiver operating curves reached 0.841, 0.849, 0.848, and 0.838 during 1, 2, 3, and 5 years, respectively.

CONCLUSIONS

This is the first NSCLC prognosis model for quick risk assessment within the Military Health System. After external validation, the model can be translated into clinical use both as a web-based tool and through mobile applications easily accessible to physicians, patients, and researchers.

Prior cancer does not adversely affect survival in locally advanced lung cancer: A national SEER-medicare analysis

INTRODUCTION

Management of locally advanced non-small cell lung cancer is among the most highly contested areas in thoracic oncology. In this population, a history of prior cancer frequently results in exclusion from clinical trials and may influence therapeutic decisions. We therefore determined prevalence and prognostic impact of prior cancer among these patients.

MATERIALS AND METHODS

We identified patients>65years of age diagnosed 1992-2009 with locally advanced lung cancer in the Surveillance, Epidemiology, and End Results-Medicare linked dataset. We characterized prior cancer by prevalence, type, stage, and timing. We compared all-cause and lung cancer-specific survival between patients with and without prior cancer using propensity score-adjusted Cox regression.

RESULTS

51,542 locally advanced lung cancer patients were included; 15.8% had a history of prior cancer. Prostate (25%), gastrointestinal (17%), breast (16%), and other genitourinary (15%) were the most common types of prior cancer, and 76% percent of prior cancers were localized or in situ stage. Approximately half (54%) of prior cancers were diagnosed within 5 years of the index lung cancer date. Patients with prior cancer had similar (propensity-score adjusted hazard ratio [HR] 0.96; 95% CI, 0.94-0.99; P=0.005) and improved lung cancer-specific (HR 0.84; 95% CI, 0.81-0.86; P<0.001) survival compared to patients with no prior cancer.

CONCLUSIONS

For patients with locally advanced lung cancer, prior cancer does not adversely impact clinical outcomes. Patients with locally advanced lung cancer and a history of prior cancer should not be excluded from clinical trials, and should be offered aggressive, potentially curative therapies if otherwise appropriate.

The impact of comorbidity on cancer and its treatment

Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.

The impact of patient comorbidity on cancer stage at diagnosis

Background:

It is known that cancer stage is affected by comorbidity, but the evidence regarding the magnitude and even direction of this effect is highly inconsistent and poorly understood. The aims of this study were to establish the impact of comorbidity on cancer stage at diagnosis, using both specific individual comorbid conditions and a global measure of comorbidity; and to assess whether this impact varied by cancer site, level of comorbidity burden and individual comorbidity type.

Methods:

We examined comorbidity among 14 096 patients with breast, colon, rectal, liver, stomach, ovarian, uterine, bladder or kidney cancer. Patients were identified from cancer registry data, and then linked to hospitalisation data to determine the presence of comorbidity in the 5 years preceding cancer diagnosis. Individual comorbid conditions were identified using ICD-10 codes, and overall burden of comorbidity attributed using a cancer-specific measure of comorbidity (C3 Index).

Results:

We observed that the presence of patient comorbidity (a) increases the odds of being diagnosed with distant metastases, (b) does not lead to earlier diagnosis and (c) increases the likelihood of a patient receiving no stage of disease at diagnosis.

Conclusions:

Patient comorbidity has a substantial impact on cancer stage at diagnosis; however, this impact varies considerably by cancer type, individual comorbid condition and overall comorbidity burden.

Comorbidity is independently associated with poor outcome in extremity soft tissue sarcoma

Background

Comorbidity has not been examined as an independent prognostic factor in soft tissue sarcoma (STS). We examined the prognostic impact of comorbidity on oncologic outcome in STS with an adjustment for possible confounding factors.

Methods

A retrospective review was performed on 349 patients who had undergone surgery for high-grade localized STS of extremity at our institute. Conditions known to alter the risk of mortality, as defined in the Charlson comorbidity index, were classified as comorbidities and 43 patients (12%) had at least one comorbidity at the time of surgery. The association of comorbidity and oncologic outcomes of local recurrence-free survival (LRFS) and disease-specific survival (DSS) were tested with adjustment for confounding factors.

Results

Comorbidity was associated with old age, high tumor grade, and large tumor size. The presence of comorbidity was independently associated with poor LRFS and DSS, even after adjusting for confounding factors including age and treatment variables.

Conclusions

Our data suggest that the presence of comorbidity is an independent prognostic factor for extremity STS.

Effect of prior cancer on outcomes in advanced lung cancer: implications for clinical trial eligibility and accrual

BACKGROUND

Prior cancer is a common exclusion criterion in lung cancer trials. This practice reflects concerns that prior cancer may affect trial conduct or outcomes. However, the impact of prior cancer on survival in lung cancer is not known.

METHODS

We identified patients older than age 65 years with stage IV lung cancer diagnosed between 1992 and 2009 in the Surveillance, Epidemiology, and End Results-Medicare linked registry. Prior cancer was characterized by type, stage, and timing. All-cause and lung cancer-specific survival were compared between patients with and without prior cancer using propensity score-adjusted Cox regression.

RESULTS

Overall, 102 929 patients with stage IV lung cancer were identified, of whom 14.7% had a history of prior cancer. More than two-thirds (76.0%) of prior cancers were localized or regional stage; most were diagnosed five or fewer years prior to the lung cancer diagnosis. In propensity score-adjusted analysis, patients with prior cancer had better all-cause (hazard ratio [HR] = 0.93, 95% confidence interval [CI] = 0.91 to 0.94) and lung cancer-specific (HR = 0.81, 95% CI = 0.79 to 0.82) survival. In a simulated clinical trial-eligible population (age <75 years, no comorbidity, treated with chemotherapy), similar trends were noted. In subset analyses according to stage, type, and timing of prior cancer, no group of patients with prior cancer had inferior survival compared with patients without prior cancer.

CONCLUSION

Among patients with stage IV lung cancer, prior cancer does not convey an adverse effect on clinical outcomes, regardless of prior cancer stage, type, or timing. Broader inclusion in clinical trials of advanced lung cancer patients with a history of prior cancer should be considered.

Impact of prior cancer on eligibility for lung cancer clinical trials

BACKGROUND

In oncology clinical trials, the assumption that a prior cancer diagnosis could interfere with study conduct or outcomes results in frequent exclusion of such patients. We determined the prevalence and characteristics of this practice in lung cancer clinical trials and estimated impact on trial accrual.

METHODS

We reviewed lung cancer clinical trials sponsored or endorsed by the Eastern Oncology Cooperative Group for exclusion criteria related to a prior cancer diagnosis. We estimated prevalence of prior primary cancer diagnoses among lung cancer patients using Surveillance Epidemiology and End Results (SEER)-Medicare linked data. We assessed the association between trial characteristics and prior cancer exclusion using chi-square analysis. All statistical tests were two-sided.

RESULTS

Fifty-one clinical trials (target enrollment 13072 patients) were included. Forty-one (80%) excluded patients with a prior cancer diagnosis as follows: any prior (14%), within five years (43%), within two or three years (7%), or active cancer (16%). In SEER-Medicare data (n = 210509), 56% of prior cancers were diagnosed within five years before the lung cancer diagnosis. Across trials, the estimated number and proportion of patients excluded because of prior cancer ranged from 0-207 and 0%-18%. Prior cancer was excluded in 94% of trials with survival primary endpoints and 73% of trials with nonsurvival primary endpoints (P = .06).

CONCLUSIONS

A substantial proportion of patients are reflexively excluded from lung cancer clinical trials because of prior cancer. This inclusion criterion is applied widely across studies, including more than two-thirds of trials with nonsurvival endpoints. More research is needed to understand the basis and ramifications of this exclusion policy.