Patients With Advanced Non-Small Cell Lung Cancer Requiring Inpatient Medical Oncology Consultation: Characteristics, Referral Patterns, and Outcomes

Prognostic significance of thrombocytosis in lung cancer: a systematic review and meta-analysis

A potential relationship between poor prognosis and thrombocytosis has been suggested by previous studies in lung cancer, but the conclusions continued to be controversial. Here, we performed a meta-analysis to explore the prognostic impact of thrombocytosis in lung cancer. The Cochrane Library, EMBASE and PubMed databases were comprehensively and systematically retrieved from establishment to May 5, 2020. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were applied to evaluate overall effects. Heterogeneity was assessed using I² statistics and Cochran's Q test. Sensitivity and subgroup analyses were performed to analyze the sources of heterogeneity. Publication bias was examined using the Egger's test and pooled HR was regulated using the trim-and-fill approach when publication bias was observed. A total of 37 studies including 14,833 patients were enrolled in the meta-analysis. Thrombocytosis was significantly correlated to poor overall survival (HR 1.033; 95% CI 1.017-1.050), disease-free survival (HR 1.568; 95% CI 1.276-1.928), and progression-free survival (HR 1.653; 95% CI 1.069-2.556). Although publication bias was identified, rectification for this bias using the trim-and-fill approach did not change the combined HR substantially. In conclusion, this meta-analysis result suggested that thrombocytosis is a predictor of poor prognosis in lung cancer.

Prognostic value of pretreatment platelet counts in lung cancer: a systematic review and meta-analysis

Background

The prognostic value of elevated pretreatment platelet counts remains controversial in lung cancer patients. We performed the present meta-analysis to determine its precise role in these patients.

Methods

We employed a multiple search strategy in the PubMed, EMBASE and Cochrane Library databases to identify eligible studies. Disease-free survival (DFS)/progression-free survival (PFS)/time to progression (TTP) and overall survival (OS) were used as outcomes with hazard ratios (HRs) and 95% confidence intervals (CIs). Heterogeneity among the studies and publication bias were also evaluated.

Results

A total of 40 studies including 16,696 lung cancer patients were eligible for the analysis. Overall, the pooled analysis showed that compared with normal platelet counts, elevated pretreatment platelet counts were associated with poorer OS (HR = 1.54, 95% CI: 1.37–1.72, P < 0.001) and poorer DFS/PFS/TTP (HR = 1.62, 95% CI: 1.33–1.98, P < 0.001) in patients with lung cancer. In subgroup analyses, elevated pretreatment platelet counts were also associated with poorer OS and DFS/PFS/TTP in most subgroups. There was no evidence of publication bias.

Conclusions

This meta-analysis revealed that elevated pretreatment platelet counts were an independent predictor of OS and DFS/PFS/TTP in lung cancer patients. Large-scale prospective studies and a validation study are warranted.

Inpatients versus outpatients with advanced non-small cell lung cancer: Characteristics and outcomes

BACKGROUND

Most newly diagnosed advanced NSCLC patients have an initial medical oncology consult as an outpatient. Sometimes, the initial consult occurs as an inpatient. We explored differences among NSCLC patients presenting to medical oncology while hospitalized versus as outpatients.

METHODS

With ethics approval, we performed a retrospective analysis of all stage IIIB and IV NSCLC patients at our institution consulted by medical oncology between 2009 and 2012. The primary analysis is descriptive, exploring differences in baseline characteristics, treatment choices, and overall survival (OS).

RESULTS

In total, 637 patients were included: 123 inpatients and 514 outpatients. Among outpatients, 55% received systemic therapy compared to 21% of inpatients. Among treated patients, inpatients were likely to be younger (81% vs 70% <70 years, p = 0.04), have PS 3-4 (38% vs 5%, p<0.001), have ≥5% weight loss (54% vs 42%, p = 0.01), anemia (19% vs 4%, p = 0.001), leukocytosis (38% vs 32%, p = 0.001), thrombocytosis (27 vs 23%, p = 0.001), renal dysfunction (12% vs 5%, p = 0.01) and more rapid onset of symptoms (27% vs 6% for <2 weeks, 35% vs 11% for 2-6 weeks; p<0.001). Inpatients who received systemic therapy were more likely to have a complete or partial response (42% vs 26%, p = 0.007), however had a shorter median OS than treated outpatients (8.4 vs 10.5 months, p = 0.003).

CONCLUSIONS

Patients initially consulted by medical oncologists while hospitalized were more unwell and fewer received systemic therapy. However, if treated, they had higher response rates than outpatients and reasonable OS. Systemic therapy can be considered in hospitalized advanced NSCLC patients.

MICROABSTRACT

A minority of patients with lung cancer have an initial oncology consultation as an inpatient. We compared the characteristics and outcomes of inpatients with their outpatient counterparts. Inpatients were more unwell at diagnosis and fewer received systemic therapy, but among those who did, they were more likely to respond and their overall survival approached that of the outpatient cohort.

Regional process redesign of lung cancer care: a learning health system pilot project

Background

The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions.

Methods

To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation.

Results

The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days.

Conclusions

The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.