Lung Cancer in Women: The Past, Present, and Future

Sex disparities in advanced non-small cell lung cancer survival: A Danish nationwide study

BACKGROUND

Historically, cancers often exhibit sexual dimorphism. However, following the introduction of immune checkpoint inhibitors and targeted therapies into routine clinical practice, the association of sex on patient and tumour characteristics, as well as survival remains largely unexplored in advanced NSCLC.

PATIENTS AND METHODS

In this observational study, we identified adults diagnosed with advanced NSCLC from January 1, 2017, to December 31, 2023, using Danish nationwide health registries and clinical databases. We compared females to males across demographic, social, socioeconomic, patient and tumour characteristics (including PDL-1 expression and driver mutations), treatments, and overall survival (OS) from diagnosis and initiation of the first line of treatment (LOT1). Cox proportional hazards regression was employed, adjusting for key covariates in the overall cohort and stratified by stage, histological subtype, PD-L1 expression level, and treatment type. Propensity score matching was conducted as a sensitivity analysis.

RESULTS

Among 14,635 included individuals, males comprised 50 % (n = 7,322). Patient and tumour characteristics differed between sexes. The crude and adjusted female-to-male mortality hazard ratio (HR) was 0·82 (95 % confidence interval [CI]: 0·79-0·85) and 0·84 (0·81-0·88) from diagnosis and 0·80 (0·76-0·84) and 0·80 (0·75-0·84) from initiation of LOT1. Median OS for females and males was 8·8 months (95 % CI 8·4-9·2) and 7·0 months (6·7-7·3) from diagnosis and 14·1 months (13·5-15·1) and 10·9 months (10·3-11·5) from initiation of LOT1. Stratified analyses revealed that across all strata, females consistently demonstrated either favourable or comparable outcomes compared to males.

CONCLUSIONS

This study increases our understanding of sex-based disparities in advanced NSCLC. Adjusted analyses addressing previously suggested explanations for sex disparities in survival still demonstrated a longer survival for females, indicating yet-unidentified sex differences with potential clinical implications. Our results underscore the critical role of acknowledging sex as a key variable in oncology trials, research, and clinical practice.

Current insights into the clinico-pathologic characteristics of lung cancer in women

INTRODUCTION

Lung cancer is responsible for premature cancer deaths in women and is the first cause of cancer deaths in women in many countries. The problem of lung cancer in women seems to be underestimated in many aspects, including low participation in clinical trials and screening tests.

AREAS COVERED

Current research progress has contributed to a better understanding of the issue and makes it possible to describe the problem in a new light. In our paper, the problem of lung cancer in women was discussed in a broad aspect, taking into account women's health, the harmful effects of smoking and the current diagnostic and treatment process. The results of treatment also differ in relation to sex. All these aspects of the diversity of women's lung cancer were presented on the basis of newest and most comprehensive literature.

EXPERT OPINION

Lung cancer in women is and will remain an important health problem worldwide, which is justified by epidemiological data, basic research and treatment results.

Lifestyle, Environmental, Occupational, and Dietary Risk Factors in Small-Cell vs. Non-Small-Cell Advanced Lung Cancer Patients: Is There a Connection?

OBJECTIVES

(i) To evaluate the possible exposure of newly diagnosed lung cancer patients to selected lifestyle, environmental, occupational, and dietary risk factors and (ii) to assess the differences in exposures of small-cell (SCLC) and non-small-cell (NSCLC) lung cancer patients to those risk factors.

METHODS

In this study, 205 newly diagnosed patients with IIIB/IV stage of either SCLC or NSCLC (111 men vs. 94 women) from Vojvodina, Serbia, were surveyed for selected demographic characteristics, dietary and lifestyle habits, and environmental factors.

RESULTS

Most patients were long-term heavy smokers. The body mass index values of SCLC patients were higher than those of NSCLC patients. Women reported higher stress levels compared to men. Women diagnosed with lung adenocarcinoma were more often exposed to traffic pollution compared to men. Individual indoor coal combustion systems were more often used by SCLC patients of both sexes compared to other cancer types. Men were more frequent consumers of canned foods, which are potential sources of endocrine disruptors. Occupational exposure to lung cancer risk factors, in addition to tobacco smoking, may be crucial in lung cancer development with specific occupations.

CONCLUSIONS

Further research on environmental and occupational risk factors for lung cancer is urgent in order to unveil the etiopathogenesis of specific lung cancer types.

Sex-based differences in the lung immune microenvironment are associated with an increased risk of lung cancer in women

OBJECTIVE

Lung cancer remains a major cause of mortality worldwide, necessitating further understanding of carcinogenesis and its driving factors, including those influenced by sex-dependent variables. We hypothesized that sex-specific lung immune composition may contribute to a greater risk of lung cancer in women.

METHODS

Data from 1056 lung cancer screenings were examined for an association between sex and lung cancer risk using time-to-event analyses. Immune profiling by flow cytometry was performed on male and female lungs of 3 independent mouse models: nontumor bearing, KRAS mutated, and urethane-exposed carcinogenic. A comparable analysis was performed on human bronchoalveolar lavage samples (n = 81) from patients with lung cancer.

RESULTS

Of the high-risk screening cohort examined, 60 patients (5.7%) developed lung cancer during median follow-up of 43.4 months. Multivariable stepwise modeling retained female sex (hazard ratio, 1.56; P < .01) and age (P < .01) as prognostic indicators for lung cancer development. Female lung immune profiles in patients included T-cell phenotypes consistent with exhaustion (eg, higher proportions of PD-1+ Ki67-; P = .02), an expanded pool of regulatory T-cells (P = .03), reduced effector T-cell frequencies (P = .008), and enhancements in suppressive myeloid populations (P = .02) versus male patients, and this is recapitulated in mouse studies.

CONCLUSIONS

Female smokers display higher risk for lung cancer. In murine models and humans, female sex is associated with robust immunosuppression within the lung. Further examination of this link will be important in developing immune-based approaches to lung cancer interception and their optimal application across the sexes.

Design, Synthesis, and Mechanistic Anticancer Evaluation of New Pyrimidine-Tethered Compounds

Background: Despite recent breakthroughs in cancer treatment, non-small cell lung cancer (NSCLC) and breast cancer remain major causes of death from all malignancies. The epidermal growth factor receptor (EGFR) is an important mediator of the pathways involved in cell proliferation, apoptosis, and angiogenesis. Thus, its overexpression triggers several types of cancer, including NSCLC and breast cancer. Methods: In the current study, we synthesized new pyrimidine-tethered compounds (chalcone derivative (B-4), pyrazoline-carbothioamide (B-9), and pyrazoline-thiazole hybrids (BH1-7)). These compounds were then tested for cytotoxicity against A549 NSCLC and MCF-7 breast cancer cells. Results: Of these, B-4 displayed significant cytotoxicity against both cells (IC50 = 6.70 ± 1.02 µM for MCF-7; IC50 = 20.49 ± 2.7 µM for A549) compared to the standard agent lapatinib (IC50 = 9.71 ± 1.12 µM for MCF-7; IC50 = 18.21 ± 3.25 µM for A549). The anticancer potential of B-4 between Jurkat leukemic T cells and peripheral blood mononuclear cells (PBMCs) (healthy) was found to be selective. Mechanistically, 11.9% and 10.2% of A549 and MCF-7 cells treated with B-4, respectively, underwent apoptosis and B-4 produced 46% EGFR inhibition at a concentration of 10 μM. The B-4/EGFR complex obtained after induced fit docking was subjected to 300 ns of molecular dynamics simulation, which confirmed the stability of the complex in a mimicked biological environment. On the other hand, B-4 was shown to have drug-like properties by in silico pharmacokinetic estimation. Conclusions: B-4 is an EGFR inhibitor and apoptosis inducer for future NSCLC and breast cancer studies.

Global and China trends and forecasts of disease burden for female lung Cancer from 1990 to 2021: a study based on the global burden of disease 2021 database

BACKGROUND

In recent years, due to various risk factors, the incidence, prevalence, and mortality rates of female lung cancer have been increasing in both China and globally. This has become a significant public health challenge worldwide. Lung cancer not only poses a severe threat to women's health but also places a heavy burden on families and society.

OBJECTIVE

To conduct an in-depth analysis of the trends in disease burden for female lung cancer in China and globally from 1990 to 2021 and to forecast the next 15 years (2022-2037). The aim is to provide a reliable theoretical basis and reference value for clinical research and practice in female lung cancer and offer guidance for resource allocation and policy-making in society.

METHODS

Based on the Global Burden of Disease (GBD) 2021 database, we analyzed the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of lung cancer in China and globally from 1990 to 2021. These metrics were stratified by gender (BOTH, MALE, FEMALE), and the average annual percentage change (AAPC) was calculated for each metric over this period. The JOINPOINT regression model was used to analyze the trends in female lung cancer in China and globally from 1990 to 2021. The ARIMA model was applied to forecast the changes in age-standardized incidence rates (ASIR) and age-standardized mortality rates (ASDR) for the next fifteen years (2022-2037) for female lung cancer in China and globally.

RESULTS

The results indicate an upward trend in incidence, prevalence, mortality, and DALYs for lung cancer in China. Globally, the prevalence of lung cancer showed an increasing trend, while the incidence, mortality, and DALYs demonstrated a declining trend. Both in China and globally, the incidence, prevalence, mortality, and DALY trends for female lung cancer were higher than those for males. From 1990 to 2021, the incidence, prevalence, mortality, and DALYs of female lung cancer in China exhibited an upward trend, with AAPC growth rates of 1.151%, 2.086%, 0.508%, and 0.210%, respectively. Similarly, globally, the incidence, prevalence, and mortality of female lung cancer also showed an upward trend, with growth rates of 0.576%, 1.123%, and 0.276%, respectively, while DALYs showed a slight decline with an AAPC of -0.029%.

CONCLUSION

Although the overall disease burden of female lung cancer is not as high as that of males, the growth rate for female lung cancer is significantly higher than that for males both in China and globally. The overall disease burden and the growth rates of incidence and prevalence of female lung cancer in China are higher than the global average.

A review of the immunomodulatory properties of mesenchymal stem cells and their derived extracellular vesicles in small-cell and non-small-cell lung cancer cells

Among the most challenging diseases to treat is lung cancer (LC). While immunotherapy has a checkered history, it has lately shown great promise in the treatment of LC, and interest in this promising new approach is on the rise around the globe. Immunotherapy using mesenchymal stem cells (MSCs) is gaining popularity. Regenerative medicine, cell therapy, and immune modulation are three areas that have shown significant interest in MSCs. More than that, MSCs have recently attracted attention as potential anti-cancer drug delivery vehicles due to their inherent ability to go home to tumor locations. Making MSCs a double-edged sword in the fight against neoplastic illnesses, they are also known to impart pro-oncogenic properties. Additionally, multiple studies have proposed extracellular vesicles (EVs) secreted by MSCs as a potential therapeutic agent or method for delivering anti-cancer drugs. However, there has been conflicting evidence regarding the impact of MSCs or MSC-EV on the behavior of cancer cells, and the exact mechanism for this effect is still unknown. Our research has focused on MSCs and their key characteristics, such as their immunomodulatory capabilities for cancer therapy. Our research has also explored the potential of MSCs and their derivatives to treat small-cell and non-small-cell lung cancers (NSCLC and SCLC, respectively) by leveraging MSCs' immunomodulatory characteristics. At the end of this article, we covered the pros and cons of this therapy procedure, as well as what researchers want to do in the future to make it more suitable for clinical application in LC treatment.

A multicenter, randomized, double-blind, placebo-controlled phase 3 study of Socazolimab or placebo combined with carboplatin and etoposide in the first-line treatment of extensive-stage small cell lung cancer

This is a randomized, double-blind, placebo-controlled phase 3 clinical trial (ClinicalTrials.gov, NCT04878016) conducted in 54 hospitals in China. Adults who were histologically diagnosed and never treated for extensive-stage small cell lung cancer (ES-SCLC) were enrolled. Eligible Patients were randomly assigned (1:1) to receive four cycles (21 days as one cycle) of intravenous carboplatin (area under the curve of 5 mg/mL per min, day 1 of each cycle) and etoposide (100 mg/m² of body-surface area, on days 1-3 of each cycle) with either socazolimab (5 mg/kg, day 1 of each cycle) or matching placebo, following maintenance therapy with socazolimab or placebo. From July 15, 2021, to May 12, 2022, 498 eligible patients were randomly assigned to receive socazolimab (250 patients) or placebo (248 patients) combined with chemotherapy. As of October 13, 2023, patients treated with socazolimab presented significant overall survival (OS) benefit (13.90 months) compared with the placebo plus EC group (11.58 months) (hazard ratio for death, 0.799; 95% CI, 0.652-0.979; p = 0.0158). The median progression free survival (PFS) was 5.55 months in the socazolimab plus EC group, prolonging disease progression or death by nearly 1.2 months (5.55 months vs 4.37 months, hazard ratio for progression or death, 0.569; 95% CI, 0.457-0.708; p < 0.0001). 200 (80.3%) patients in the socazolimab plus EC group experienced ≥ grade 3 treatment-related adverse events and 187 (75.7%) patients occurred in the placebo plus EC group. Socazolimab combined with standard EC regimen chemotherapy for first-line treatment of ES-SCLC significantly prolonged overall survival and did not increase the safety risk of treatment.

Trends in lung cancer incidence in Spain (1990-2019): insights from Global Burden of Diseases data

BACKGROUND

This study examines lung cancer incidence in Spain (1990-2019) through age-period-cohort (A-P-C) analysis and Global Burden of Diseases (GBD) data, unravelling the complex interplay of age, period, and birth cohort in shaping these trends.

METHODS

Utilizing GBD and Spanish population data, the study calculates age-standardized incidence rates (ASIRs) and employs Joinpoint analysis to identify significant trends. A-P-C analysis dissects the individual effects of age, calendar period, and birth cohort on incidence patterns.

RESULTS

Between 1990 and 2019, almost 738,000 cases of lung cancer were diagnosed in Spain, with an average annual increase of 1.7%. The ASIR of lung cancer in Spain from 1990 to 2019 showed a sustained upward trend in women (Average Annual Per cent Change: 2.5%, P < 0.05), reaching 23.3 cases per 100,000 in 2019, whilst men experienced a significant decrease in incidence rates (AAPC: -0.6%, P < 0.05), falling to 108.9 in 2019. The male-to-female incidence ratio decreased from 12.2 in 1992 to 4.9 in 2019. Joinpoint analysis identified distinct periods for both sexes, with men showing stability, decline and then a significant decrease, whereas women showed an initial increase followed by a decrease. The longitudinal age curves showed a consistently higher incidence risk in men, peaking in the 80-84 age group. Male cohorts since the 1920s showed a decreasing relative risk, whereas women showed fluctuations in risk over time.

CONCLUSION

Lung cancer rates are falling in Spain, especially amongst men, due to lower smoking rates. The gender gap is closing, but prevention targeted at women is needed. Tighter tobacco control and research into other risk factors are essential. Understanding the long-term effects of smoking and early exposure is key to better prevention and treatment in Spain.

Neoadjuvant immunotherapy strategies for resectable non-small cell lung cancer (NSCLC): Current evidence among special populations and future perspectives

About one third of patients with Non-Small Cell Lung Cancer (NSCLC) presents at diagnosis with localized or locally advanced disease amenable to curative surgical resection. Surgical operability refers to stage I to IIIA and selected stage IIIB NSCLC. One of the main challenges in the management of early-stage resectable NSCLC is the optimization of available therapeutic strategies to prevent local and distant disease relapse, thus improving survival outcomes. There is evidence supporting the clinical use of both adjuvant and neoadjuvant immunotherapy-based strategies for resected/resectable, stage IB-IIIA NSCLC. Available data from randomized phase III trials have led to the incorporation of several immune checkpoint blockers (ICBs) into the international guidelines for early-stage NSCLC. Preclinical rationale of targeting specific subsets of T-cells by acting early on immune checkpoint receptors (e.g., PD-(L)1 and CTLA-4) is strong. Recent evidence is in favor of the neoadjuvant approach alone or as a part of perioperative strategy, demonstrating survival benefit. Combining neoadjuvant chemotherapy and immunotherapy before surgery results in both pathologic complete response (pCR) and major pathologic response (MPR) improvement, and survival outcomes, with no major safety issues. In this review, we summarize the rationale behind neoadjuvant/perioperative immunotherapy strategies and, due to the clinical relevance of immunotherapy in resectable NSCLC, we provide current evidence of this cutting-edge approach among special populations including older adults, women, and oncogene addicted NSCLC. To conclude, we present future perspectives in the use of immunotherapy for operable NSCLC with a special focus on novel investigational combinations underway.

Therapeutic Potential of lncRNAs in Regulating Disulfidptosis for Cancer Treatment

Non-coding RNAs (lncRNAs) play critical roles in various cellular processes, including a novel form of regulated cell death known as disulfidptosis, characterized by accumulating protein disulfide bonds and severe endoplasmic reticulum stress. This review highlights the therapeutic potential of lncRNAs in regulating disulfidptosis for cancer treatment, emphasizing their influence on key pathway components such as GPX4, SLC7A11, and PDIA family members. Recent studies have demonstrated that targeting specific lncRNAs can sensitize cancer cells to disulfidptosis, offering a promising approach to cancer therapy. The regulation of disulfidptosis by lncRNAs involves various signaling pathways, including oxidative stress, ER stress, and calcium signaling. This review also discusses the molecular mechanisms underlying lncRNA regulation of disulfidptosis, the challenges of developing lncRNA-based therapies, and the future potential of this rapidly advancing field in cancer research.

Overexpression of microRNA-611 inhibits TGF-β-induced epithelial-mesenchymal transition and migration in lung cancer cells through MAPKAP1

Metastasis is a major cause of death in patients with lung cancer (LC). microRNA-611 (miR-611), a miRNA, has been little studied in cancer. Here, we aimed to further elucidate the roles of miR-611 in epithelial-mesenchymal transition (EMT) and migration induced by transforming growth factor-β (TGF-β) in LC cells and the possible underlying mechanisms. miR-611 and MAPKAP1 expression was first identified in LC tissues from metastatic and nonmetastatic patients, and their expression was associated with overall survival. Gain- and loss-of-function experiments were performed to verify the impacts of miR-611 and MAPKAP1 on pAKT expression, EMT, and migration in LC cells treated with TGF-β. The interaction between miR-611 and MAPKAP1 was also determined with a luciferase reporter assay. In our study, miR-611 was expressed at low levels, and MAPKAP1 was highly expressed in LC tissues, which was associated with metastasis and short overall survival. Functionally, miR-611 inhibition or MAPKAP1 overexpression accelerated EMT and migration and upregulated pAKT in TGF-β-treated A549 and H1299 cells; miR-611 overexpression or MAPKAP1 silencing exerted the opposite effects as miR-611 inhibition or MAPKAP1 overexpression. Mechanistically, miR-611 could target and downregulate MAPKAP1. MAPKAP1 expression was also negatively correlated with miR-611 expression in LC tissues. In addition, miR-611 overexpression reduced the EMT and migration of TGF-β-treated A549 and H1299 cells by targeting MAPKAP1. In conclusion, miR-611 overexpression attenuated EMT and migration by targeting MAPKAP1 in TGF-β-induced LC cells, indicating that miR-611 is a biological target for LC treatment.

Exploring Demographic Representation and Reporting in Lung Cancer Clinical Trials with Canadian Sites from 2013 to 2023

This review evaluates the reporting of demographic characteristics and the diversity of participants of phase III lung cancer clinical trials with Canadian research sites. A literature search was conducted using the ClinicalTrials.gov registry to identify clinical trials conducted between 1 January 2013, and 31 December 2023. The demographic reporting practices and the representation of sex/gender, racial, and ethnic groups were assessed. The location of Canadian research sites was also examined for trends in reporting and representation. Associated publications were reviewed for demographic data collection methods. Of the 25 clinical trials, 24 reported race and 18 also reported ethnicity. All clinical trials reported sex/gender, and the city and province of the participating Canadian sites. Most participants were White (66.1%), identified as not Hispanic or Latino (81.4%), and were male (57.8%). The provinces with the most clinical trial sites were Ontario (43.6%) and Quebec (34.2%). Lung cancer clinical trials lack adequate demographic reporting and representation of females, diverse patient groups, and geographical locations in Canada with high lung cancer incidence rates. Specifically, the Indigenous Peoples of Canada and Nunavut require better representation in lung cancer clinical trials conducted in Canada. These findings highlight the need to improve diversity and demographic representation in clinical research.

Applications of CT-based radiomics for the prediction of immune checkpoint markers and immunotherapeutic outcomes in non-small cell lung cancer

In recent years, there has been significant research interest in the field of immunotherapy for non-small cell lung cancer (NSCLC) within the academic community. Given the observed variations in individual responses, despite similarities in histopathologic type, immunohistochemical index, TNM stage, or mutation status, the identification of a reliable biomarker for early prediction of therapeutic responses is of utmost importance. Conventional medical imaging techniques primarily focus on macroscopic tumor monitoring, which may no longer adequately fulfill the requirements of clinical diagnosis and treatment. CT (computerized tomography) or PEF/CT-based radiomics has the potential to investigate the molecular-level biological attributes of tumors, such as PD-1/PD-L1 expression and tumor mutation burden, which offers a novel approach to assess the effectiveness of immunotherapy and forecast patient prognosis. The utilization of cutting-edge radiological imaging techniques, including radiomics, PET/CT, machine learning, and artificial intelligence, demonstrates significant potential in predicting diagnosis, treatment response, immunosuppressive characteristics, and immune-related adverse events. The current review highlights that CT scan-based radiomics is a reliable and feasible way to predict the benefits of immunotherapy in patients with advanced NSCLC.

Towards equitable AI in oncology

Artificial intelligence (AI) stands at the threshold of revolutionizing clinical oncology, with considerable potential to improve early cancer detection and risk assessment, and to enable more accurate personalized treatment recommendations. However, a notable imbalance exists in the distribution of the benefits of AI, which disproportionately favour those living in specific geographical locations and in specific populations. In this Perspective, we discuss the need to foster the development of equitable AI tools that are both accurate in and accessible to a diverse range of patient populations, including those in low-income to middle-income countries. We also discuss some of the challenges and potential solutions in attaining equitable AI, including addressing the historically limited representation of diverse populations in existing clinical datasets and the use of inadequate clinical validation methods. Additionally, we focus on extant sources of inequity including the type of model approach (such as deep learning, and feature engineering-based methods), the implications of dataset curation strategies, the need for rigorous validation across a variety of populations and settings, and the risk of introducing contextual bias that comes with developing tools predominantly in high-income countries.

Precision Immuno-Oncology in NSCLC through Gender Equity Lenses

Precision immuno-oncology involves the development of personalized cancer treatments that are influenced by the unique nature of an individual's DNA, immune cells, and their tumor's molecular characterization. Biological sex influences immunity; females typically mount stronger innate and adaptive immune responses than males. Though more research is warranted, we continue to observe an enhanced benefit for females with lung cancer when treated with combination chemoimmunotherapy in contrast to the preferred approach of utilizing immunotherapy alone in men. Despite the observed sex differences in response to treatments, women remain underrepresented in oncology clinical trials, largely as a result of gender-biased misconceptions. Such exclusion has resulted in the development of less efficacious treatment guidelines and clinical recommendations and has created a knowledge gap in regard to immunotherapy-related survivorship issues such as fertility. To develop a more precise approach to care and overcome the exclusion of women from clinical trials, flexible trial schedules, multilingual communication strategies, financial, and transportation assistance for participants should be adopted. The impact of intersectionality and other determinants of health that affect the diagnosis, treatment, and outcomes in women must also be considered in order to develop a comprehensive understanding of the unique impact of immunotherapy in all women with lung cancer.