Impact of comorbidities on clinical outcomes in non-small cell lung cancer patients who are elderly and/or have poor performance status

Health-related quality of life and clinical complexity of a real-life cohort of patients with advanced HR+/HER2- breast cancer treated with CDK4/6 inhibitors and endocrine therapy

Background

Advanced breast cancer (ABC) is characterized by multidimensional clinical complexity that is usually not considered in randomized clinical trials. In the present real-life study, we investigated the link between clinical complexity and quality of life of patients with HR⁺/HER2^- ABC treated with CDK4/6 inhibitors.

Methods

We evaluated multimorbidity burden assessed with the Cumulative Illness Rating Scale (CIRS), polypharmacy and patient-reported outcomes (PROs). PROs were assessed at baseline (T0), after 3 months of therapy (T1), and at disease progression (T2) using EORTC QLC-C30 and QLQ-BR23 questionnaires. Baseline PROs and changes between T0 and T1 were evaluated amongst patients with different multimorbidity burden (CIRS <5 and ≥5) and polypharmacy (<2 or ≥2 drugs).

Results

From January 2018 to January 2022, we enrolled 54 patients (median age 66 years, IQR 59-74). The median CIRS score was 5 (IQR 2-7), whilst the median number of drugs taken by patients was 2 (IQR 0-4). No changes in QLQ-C30 final scoring between T0 and T1 were observed in the overall cohort (p=0.8944). At T2, QLQ-C30 global score deteriorated with respect to baseline (p=0.0089). At baseline, patients with CIRS ≥5 had worse constipation than patients without comorbidities (p<0.05) and a lower trend in the median QLQ-C30 global score. Patients on ≥2 drugs had lower QLQ-C30 final scores and worse insomnia and constipation (p<0.05). No change in QLQ-C30 final score from T0 to T1 was observed (p>0.05).

Conclusion

Multimorbidity and polypharmacy increase the clinical complexity of patients with ABC and may affect baseline PROs. The safety profile of CDK4/6 inhibitors seems to be maintained in this population. Further studies are needed to assess clinical complexity in patients with ABC.This article is part of the Tackling clinical complexity in breast cancer Special Issue: https://www.drugsincontext.com/special_issues/tackling-clinical-complexity-in-breast-cancer/.

Comorbidities cluster with impaired functional capacities and depressive mood and predict adverse outcome in older patients with hematological malignancies

This study evaluates prevalence of comorbidities and their association with impairments in older patients with hematological malignancies at initial diagnosis (n = 209). At least one comorbidity was present in 62.2%, 68.5% and 93.8% as defined by CCI (Charlson Comorbidity Index), Cumulative Illness Rating Scale-Geriatric (CIRS-G) and HCT-Comorbidity Index, respectively. Severe comorbidities (CIRS-G Grade 3/4) were present in 57.9%. The mean number of affected organ systems was 3.6 (CIRS-G categories), with diabetes (18.2%), congestive heart failure and prior solid tumors (each 17.7%) detected most frequently. Comorbidities were significantly correlated with reduced functional and objective physical capacities, impaired performance and depressive mood. Both CCI and CIRS-G were found to be prognostic factors for OS (p < 0.05). CCI scoring of comorbidities, diagnosis MDS/AML and a body mass index <23kg/m² were independent adverse predictors for OS. This first prospective analysis reveals a prognostic significance of comorbidities. Clustering of comorbidities with impairments suggests common mechanisms.

Clinical factors associated with treatment toxicity of pemetrexed plus platinum in elderly patients with non-small cell lung cancer

BACKGROUND

This study was to explore the clinical factors associated with treatment toxicities of pemetrexed plus platinum in elderly patients with non-small cell lung cancer (NSCLC).

METHODS

Chemo-naive patients aged ≥ 70 with advanced NSCLC treated with pemetrexed plus platinum were included. Medical records were reviewed and clinical data, including age, gender, smoking status, comorbidities, EGFR mutation status, chemotherapy regimens, previous use of epidermal growth factor receptor-tyrosine kinase inhibitors, treatment-related hematologic, renal, and hepatic toxicities, and treatment responses, were analyzed. Comorbidity conditions were evaluated by using the Simplified Comorbidity Score (SCS) and Charlson Comorbidity Index Score (CCIS).

RESULTS

A total of 144 patients were included. In the univariate analysis, patients with SCS >9 (p = 0.006) and cigarette smoking (p = 0.028) were associated with a significantly higher rate of grade 3/4 neutropenia than their counterpart. Carboplatin use was associated with a higher rate of grade 3/4 thrombocytopenia than cisplatin use (p = 0.028). In the multivariate analysis, SCS >9 was associated with a significantly higher risk of anemia of any grade (odds ratio [OR]: 2.72, 95% confidence interval [CI]: 1.09-6.77). Carboplatin use was associated a higher risk of any grade (OR: 4.61, 95% CI: 1.07-19.90) and grade 3/4 thrombocytopenia (OR: 7.37, 95% CI: 1.36-39.92). No clinical factors were found to be associated with hepatic and renal toxicities.

CONCLUSION

High SCS and carboplatin use were associated with hematological toxicities with pemetrexed plus platinum use in elderly patients with NSCLC.

Treatment Patterns Among De Novo Metastatic Cancer Patients Who Died Within 1 Month of Diagnosis

BACKGROUND

Little is known about patterns of and factors associated with treatment for de novo metastatic cancer patients who die soon after diagnosis. In this study, we examine treatment patterns for patients newly diagnosed with metastatic lung, colorectal, breast, or pancreatic cancer who died within 1 month of diagnosis.

METHODS

We identified 100 848 adult patients in the National Cancer Database with de novo metastatic lung, colorectal, breast, and pancreatic cancer, diagnosed between 2004 and 2014 and who died within 1 month. We performed descriptive and multivariable logistic regression analyses to examine receipt of surgery, chemotherapy, radiation, and hormonal therapy by cancer type, adjusting for sociodemographic and clinical variables.

RESULTS

Treatment substantially varied by cancer type, over time, age, insurance, and facility type. Surgery ranged from 0.4% in pancreatic to 28.3% in colorectal cancer (CRC) patients, chemotherapy from 5.8% among CRC to 11% in lung and breast cancer patients, and radiotherapy from 1.3% in pancreatic to 18.7% in lung cancer patients. Use of some treatments (eg, surgery for CRC and breast cancer) progressively declined between 2004 and 2014. Compared with lung cancer patients treated at National Cancer Institute-designated cancer centers, those treated at community cancer centers had 48% lower odds of radiation.

CONCLUSIONS

Treatment of patients diagnosed with imminently fatal de novo metastatic cancer varied markedly by cancer type and patient/facility characteristics. These variations warrant more research to better identify patients with imminently fatal de novo metastatic cancer who may not benefit from aggressive and expensive therapies.

Sociodemographic and Clinical Determinants of Quality of Life of Patients with Non-small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is a serious health problem. Identifying factors affecting quality of life (QoL) may help modify risk factors and improve survival. The study included 180 patients treated for NSCLC in the Lower Silesian Center of Lung Diseases between January and December 2015. QoL was assessed with QLQ-C30 and QLQ-LC13 scales. General physical functioning was measured with the ECOG Performance Status scale. The clinical and sociodemographic data were retrieved from medical records. The influence of clinical and sociodemographic factors on QoL was examined. NSCLC reduced the global QoL (47.1 ± 23.4) and emotional functioning (57.8 ± 28.8); cognitive functioning was affected in least (76.0 ± 21.0). The patients reported fatigue (42.2 ± 26.2), sleep problems (42.0 ± 30.8), cough (49.8 ± 24.0), and taking analgesics (50.3 ± 37.1) as the most limiting factors. The worsening of a health condition expressed by the length of malignant disease; the presence of comorbidities, metastases, the cluster of symptoms, worse spirometric indices, and living alone had a negative influence on QoL. In conclusion, patients with NSCLC experience reduced QoL and emotional functioning. Proper treatment of comorbidities and symptom management may improve QoL in these patients.

General recommendations paper on the management of older patients with cancer: the SEOM geriatric oncology task force's position statement

Population aging is associated with greater numbers of older people with cancer. Thanks to treatment advances, not only are more seniors diagnosed with cancer, but there are also more and more older cancer survivors. This upward trend will continue. Given the heterogeneity of aging, managing older patients with cancer poses a significant challenge for Medical Oncology. In Spain, a Geriatric Oncology Task Force has been set up within the framework of the Spanish Society for Medical Oncology (SEOM). With the aim of generating evidence and raising awareness, as well as helping medical oncologists in their training with respect to seniors with cancer, we have put together a series of basic management recommendations for this population. Many of the patients who are assessed in routine clinical practice in Oncology are older. CGA is the basic tool by means of which to evaluate older people with cancer and to understand their needs. Training and the correct use of recommendations regarding treatment for comorbidities and geriatric syndromes, support care, and drug–drug interactions and toxicities, including those of antineoplastic agents, as detailed in this article, will ensure that this population is properly managed.

The influence of insurance type on stage at presentation, treatment, and survival between Asian American and non-Hispanic White lung cancer patients

The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (OR_adj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (OR_adj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (OR_adj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart.

Prognostic role of a comprehensive geriatric assessment on the management of elderly patients with advanced non-small cell lung cancer (NSCLC): a pooled analysis of two prospective phase II trials by the GFPC Group

Background

The prognostic role of a comprehensive geriatric assessment (CGA) on the management of elderly patients with advanced-stage non-small cell lung cancer (NSCLC) remains to be established. The objective of this analysis was to determine the prognostic role of each CGA domain on overall survival (OS) among elderly patients with advanced-stage NSCLC.

Methods

We pooled individual data from two prospective, randomized phases II trials in patients over 65 years old with advanced-stage NSCLC, who were considered fit (0405 trial) or no-fit (0505 trial) based on a CGA. Both trials compared first-line chemotherapy followed by second-line erlotinib with the reverse strategy in terms of progression-free survival (PFS) and OS. Factors prognostic of OS were sought by using the Kaplan-Meier method and the log rank test for univariate analysis, and a Cox model for multivariate analysis.

Results

Analysis performed on 194 patients (mean age: 77 years, male gender: 70%, never- or ex-smokers: 56%) showed, in univariate analysis that performance status (PS), smoking status, Charlson, simplified Charlson, nutritional scores, and a mobility score were prognostics of OS. In multivariate analysis, PS [HR: 1.4 (1.02-1.9), P=0.04] and the Charlson score [HR: 1.46 (1.07-1.99), P=0.02] were independently prognostic of OS, while the nutritional score [HR: 0.69 (0.46-1.04), P=0.07] and the mobility score [HR: 0.25 (0.06-1.01), P=0.06] were close to significance.

Conclusions

PS and comorbidities appear to be the main predictors of OS in elderly advanced NSCLC patients selected on the basis of CGA.

Interventions to improve the quality of life and survivorship of older adults with cancer: The funding landscape at NIH, ACS and PCORI

Identifying knowledge gaps and research opportunities in cancer and aging research was the focus of a three-part conference series led by the Cancer and Aging Research Group from 2010 to 2015. The third meeting, featured representatives from the NIA, NCI, ACS and PCORI each of whom discussed research priorities and funding opportunities in cancer and aging at their respective agencies. This manuscript reports on the proceedings of that conference with a specific focus on funding priorities for interventions to improve the quality of life and survivorship of older adults with cancer. Helpful tips from each funder regarding writing a scientifically strong research proposal are presented.

Pharmacotherapy for treatment of lung cancer in the elderly

INTRODUCTION

The chance for elderly patients with NSCLC to receive chemotherapy decreases significantly with age. In addition, older patients are often underrepresented in clinical trials. Consequently, due to the paucity of data, evidence-based decisions with regard to chemotherapy treatment strategies in the elderly are lacking.

AREAS COVERED

We performed a literature search to identify mainly randomized trials focusing on treatment of NSCLC in older patients with chemotherapy and targeted therapy, toxicity and quality of life. In conclusion, the efficacy of regular chemotherapy and targeted therapy seems quite similar in older patients compared to their younger counterparts, with increased toxicity, but acceptable. However, these data are mostly derived from subgroup analyses and highly selected fit patients, which may not represent the general older population.

EXPERT OPINION

Further research is necessary to investigate the role of a comprehensive geriatric assessment in older patients, before the start of a chemotherapeutic treatment. Proteomic tests can have potential in the future, if these tests turn out to be able to separate patients with advanced NSCLC into groups with better or worse outcomes. It can be of special interest for the elderly population, to prevent unnecessary side effects of a possible inferior treatment.

A comprehensive review of nongenetic prognostic and predictive factors influencing the heterogeneity of outcomes in advanced non-small-cell lung cancer

While there have been advances in treatment options for those with advanced non-small-cell lung cancer, unmet medical needs remain, partly due to the heterogeneity of treatment effect observed among patients. The goals of this literature review were to provide updated information to complement past reviews and to identify a comprehensive set of nongenetic prognostic and predictive baseline factors that may account for heterogeneity of outcomes in advanced non-small-cell lung cancer. A review of the literature between 2000 and 2010 was performed using PubMed, Embase, and Cochrane Library. All relevant studies that met the inclusion criteria were selected and data elements were abstracted. A classification system was developed to evaluate the level of evidence for each study. A total of 54 studies were selected for inclusion. Patient-related factors (eg, performance status, sex, and age) were the most extensively researched nongenetic prognostic factors, followed by disease stage and histology. Moderately researched prognostic factors were weight-related variables and number or site of metastases, and the least studied were comorbidities, previous therapy, smoking status, hemoglobin level, and health-related quality of life/symptom severity. The prognostic factors with the most consistently demonstrated associations with outcomes were performance status, number or site of metastases, previous therapy, smoking status, and health-related quality of life. Of the small number of studies that assessed predictive factors, those that were found to be significantly predictive of outcomes were performance status, age, disease stage, previous therapy, race, smoking status, sex, and histology. These results provide a comprehensive overview of nongenetic prognostic and predictive factors assessed in advanced non-small-cell lung cancer over the last decade. This information can be used to inform the design of future clinical trials by suggesting additional subgroups based on nongenetic factors that may be analyzed to further investigate potential prognostic and predictive factors.

Adverse events in patients with liver cancer

This study aimed to further the understanding of the incidence of adverse events (AEs) in a population-based representative liver cancer population where there is currently a lack of knowledge. We carried out a retrospective cohort study using data from an administrative claims database between 1 January 2004 and 31 December 2010. Patients were included in the study if they had at least one primary liver cancer diagnosis [International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM): 155.0] and a metastatic diagnosis [ICD-9-CM: 196.x, 197.x (except 197.7), 198.x or 199.0]. We estimated the incidence rate (IR) and 95% confidence interval (CI) for each AE under study. Of the patients identified, 1292 fulfilled the inclusion and exclusion criteria. The most common AEs were nausea and vomiting (IR=878.5/1000 person-years; 95% CI=799.5-963.1). Other common AEs were hypertension (IR=648.7/1000 person-years; 95% CI=569.2-736.1) and hemorrhage (IR=580.0/1000 person-years; 95% CI=518.6-646.6). The least common AEs were rare dermatologic diseases such as Stevens-Johnson syndrome and toxic epidermal necrolysis where no cases were observed. The rates detailed in this analysis are helpful in understanding the benefit risk of treating patients with liver cancer in the real world. Although no formal comparisons were performed, the increased risk of certain events observed in sorafenib-treated patients from this analysis mirrors the risks reported on the label for sorafenib. Therefore, this analysis provided a reasonable assessment of the AEs that patients with liver cancer experience in the real world.

Influence of comorbidity on racial differences in receipt of surgery among US veterans with early-stage non-small-cell lung cancer

PURPOSE

It is unclear why racial differences exist in the frequency of surgery for lung cancer treatment. Comorbidity is an important consideration in selection of patients for lung cancer treatment, including surgery. To assess whether comorbidity contributes to the observed racial differences, we evaluated racial differences in the prevalence of comorbidity and their impact on receipt of surgery.

PATIENTS AND METHODS

A total of 1,314 patients (1,135 white, 179 black) in the Veterans Health Administration diagnosed with early-stage non-small-cell lung cancer in 2007 were included. The effect of comorbidity on surgery was determined by using generalized linear models with a logit link accounting for patient clustering within Veterans Administration Medical Centers.

RESULTS

Compared with whites, blacks had greater prevalence of hypertension, liver disease, renal disease, illicit drug abuse, and poor performance status, but lower prevalence of respiratory disease. The impact of most individual comorbidities on receipt of surgery was similar between blacks and whites, and comorbidity did not influence the race-surgery association in a multivariable analysis. The proportion of blacks not receiving surgery as well as refusing surgery was greater than that among whites.

CONCLUSION

Blacks had a greater prevalence of several comorbid conditions and poor performance status; however, the overall comorbidity score did not differ by race. In general, the effect of comorbidity on receipt of surgery was similar in blacks and whites. Racial differences in comorbidity do not fully explain why blacks undergo lung cancer surgery less often than whites.

Accelerated hypofractionated radiation therapy compared to conventionally fractionated radiation therapy for the treatment of inoperable non-small cell lung cancer

Background

While conventionally fractionated radiation therapy alone is an acceptable option for poor prognostic patients with unresectable stage III NSCLC, we hypothesized that accelerated hypofractionated radiotherapy will have similar efficacy without increasing toxicity.

Methods

This is a retrospective analysis of 300 patients diagnosed with stage III NSCLC treated between 1993 and 2009. Patients included in the study were medically or surgically inoperable, were free of metastatic disease at initial workup and did not receive concurrent chemotherapy. Patients were categorized into three groups. Group 1 received 45 Gy in 15 fractions over 3 weeks (Accelerated Radiotherapy (ACRT)) while group 2 received 60-63 Gy (Standard Radiation Therapy 1 (STRT1)) and group 3 received > 63 Gy (Standard Radiation Therapy (STRT2)).

Results

There were 119 (39.7%) patients in the ACRT group, 90 (30.0%) in STRT1 and 91 (30.3%) in STRT2. More patients in the ACRT group had KPS ≤ 60 (p < 0.001), more commonly presented with weight loss > 5% (p = 0.002), and had stage 3B disease (p < 0.001). After adjusting for clinical variables, there were no differences in the radiation groups in terms of the patterns of local or distant tumor control or overall survival. Some benefit in relapse free survival was seen in the STRT1 group as compared to ACRT (HR = 0.65, p = 0.011). Acute toxicity profiles in the ACRT were significantly lower for grade ≥ 2 radiation dermatitis (p = 0.002), nausea/vomiting (p = 0.022), and weight loss during treatment (p = 0.020).

Conclusions

Despite the limitations of a retrospective analysis, our experience of accelerated hypofractionated radiation therapy with 45 Gy in 15 fractions appears to be an acceptable treatment option for poor performance status patients with stage III inoperable tumors. Such a treatment regimen (or higher doses in 15 fractions) should be prospectively evaluated using modern radiation technologies with the addition of sequential high dose chemotherapy in stage III NSCLC.

Epidemiology and management of common pulmonary diseases in older persons

Pulmonary disease prevalence increases with age and contributes to morbidity and mortality in older patients. Dyspnea in older patients is often ascribed to multiple etiologies such as medical comorbidities and deconditioning. Common pulmonary disorders are frequently overlooked as contributors to dyspnea in older patients. In addition to negative impacts on morbidity and mortality, quality of life is reduced in older patients with uncontrolled, undertreated pulmonary symptoms. The purpose of this review is to discuss the epidemiology of common pulmonary diseases, namely pneumonia, chronic obstructive pulmonary disease, asthma, lung cancer, and idiopathic pulmonary fibrosis in older patients. We will review common clinical presentations for these diseases and highlight differences between younger and older patients. We will also briefly discuss risk factors, treatment, and mortality associated with these diseases. Finally, we will address the relationship between comorbidities, pulmonary symptoms, and quality of life in older patients with pulmonary diseases.

Evaluation of the Reliability of Electronic Medical Record Data in Identifying Comorbid Conditions among Patients with Advanced Non-Small Cell Lung Cancer

Background. Traditional methods for identifying comorbidity data in EMRs have relied primarily on costly and time-consuming manual chart review. The purpose of this study was to validate a strategy of electronically searching EMR data to identify comorbidities among cancer patients. Methods. Advanced stage NSCLC patients (N = 2,513) who received chemotherapy from 7/1/2006 to 6/30/2008 were identified using iKnowMed, US Oncology's proprietary oncology-specific EMR system. EMR data were searched for documentation of comorbidities common to advanced stage cancer patients. The search was conducted by a series of programmatic queries on standardized information including concomitant illnesses, patient history, review of systems, and diagnoses other than cancer. The validity of the comorbidity information that we derived from the EMR search was compared to the chart review gold standard in a random sample of 450 patients for whom the EMR search yielded no indication of comorbidities. Negative predictive values were calculated. Results. The overall prevalence of comorbidities of 22%. Overall negative predictive value was 0.92 in the 450 patients randomly sampled patients (36 of 450 were found to have evidence of comorbidities on chart review). Conclusion. Results of this study suggest that efficient queries/text searches of EMR data may provide reliable data on comorbid conditions among cancer patients.