Use of frailty to predict survival in elderly patients with early stage non-small-cell lung cancer treated with stereotactic body radiation therapy

Prognostic value of electronic health records-based frailty measures for all-cause mortality in older patients with non-small cell lung cancer

INTRODUCTION

Frailty screening is important to guide treatment decisions for older patients with non-small cell lung cancer (NSCLC). However, the performance of frailty measures (FMs) remains unclear. This study aimed to evaluate the prognostic value of FMs based on electronic health records (EHR) data in clinical settings for all-cause mortality in older patients with NSCLC.

MATERIALS AND METHODS

We retrospectively analyzed 4253 patients aged ≥65 years, newly diagnosed with NSCLC (2007-2018) using EHR data from the National Cancer Center, Korea. Frailty was measured by either laboratory tests (frailty index based on routine laboratory tests [FI-Lab]), comorbidities and performance status (electronic Frailty index [eFI]), or both (combined frailty index [FI-combined]). Patients were categorized as frail or non-frail. Cox proportional hazards models and C-index were used to estimate the predictive ability of FMs for all-cause mortality in 1 year, 3 years, and 5 years post-diagnosis, adjusting for age, sex, and SEER stage.

RESULTS

EHR-based FMs could enhance the prognostic ability to predict the survival of older patients with NSCLC. In the total population, FI-Lab showed the largest predictive value, especially for 1-year mortality with an adjusted hazard ratio for frail vs. non-frail groups of 2.25 (95 % CI 2.02-2.51) and C-index of 0.74 compared to 0.72 in the base model (p-value<0.001). FI-Lab could improve the prognostic ability for 1-year mortality in patients with regional and distant SEER stages and those receiving systemic therapy, whereas FI-combined could improve the prediction of 3-year and 5-year mortality in patients with localized disease and receiving surgery.

DISCUSSION

Easy-to-use FMs derived from EHR data can enhance the prediction of all-cause mortality in older patients with NSCLC. Oncologists can utilize comprehensive FMs comprising comorbidities, functional status, and subclinical tests or FI-Lab, depending on the patient's medical condition, to facilitate shared cancer care planning.

Role of frailty in predicting prognosis of older patients with lung cancer: An updated systematic review and meta-analysis

INTRODUCTION

Frailty is a syndrome affecting primarily older adults that can impact disease course, treatment, and outcomes in patients with lung cancer (LC). We systematically reviewed current data on the correlation between frailty and overall survival (OS), recurrence-free survival (RFS), and the risk of complications in older patients with LC.

MATERIALS AND METHODS

PubMed, EMBASE, and Scopus databases were searched for observational cohort, cross-sectional, and case-control studies involving participants aged 18 years or older diagnosed with LC. Eligible studies were required to perform frailty assessments and have non-frail participants as a comparator group. Random-effects models were used for analysis, and the reported effect sizes were represented as hazards ratio (HR) or odds ratios (OR) with associated 95% confidence intervals (CI).

RESULTS

Seventeen studies were included, most with a retrospective cohort design (n = 16) and patients with non-small cell lung carcinoma (NSCLC). Older patients with LC and frailty had lower OS (HR 1.70, 95% CI: 1.39, 2.07) and RFS (HR 2.50, 95% CI: 1.02, 6.12), compared to non-frail subjects. Frail subjects also had increased risk of complications (OR 1.89, 95% CI: 1.42, 2.53).

DISCUSSION

The observed association between frailty and OS, RFS, and an increased susceptibility to complications emphasizes the potential significance of frailty status as a substantial prognostic indicator. Our results underscore the vital role of including frailty assessment as an integral element within the management plan for patients dealing with lung cancer.

Frailty and Cancer Prognosis

PURPOSE OF REVIEW

This review aims to summarize the current evidence regarding the prognostic role of frailty in older patients diagnosed with cancer and to explore the evidence regarding its prognostic implications in cancer survivors.

RECENT FINDINGS

Frailty has been consistently associated with mortality/overall survival, postoperative complications, short- and long-term postoperative mortality, length of stay, among other adverse health-related outcomes in several oncological contexts. The possible association between frailty and treatment toxicity has been less explored, however most studies suggest frailty is a predictor of treatment induced toxicity. In addition, in cancer survivors, frailty is a risk factor for cardiovascular disease, incident type 2 diabetes mellitus, mortality, altered cognitive performance and increased symptom severity. Due to its usefulness in establishing prognosis and informing treatment decision making, it is expected that frailty screening and assessment will continue to gain popularity as part of the pretreatment evaluation of older patients with cancer.

Frailty and prognosis in lung cancer: systematic review and meta-analysis

Lung cancer is one of the most common malignant tumours. Patients are frequently at risk of frailty as lung cancer progresses. The meta-analysis aims to explore the impact of frailty on the long-term prognosis and the incidence of short-term chemotherapy toxicity in patients with lung cancer. This study was designed adhered to the criteria of Cochrane Handbook for Systematic Reviews. Systematic searches were performed on PubMed, Embase, Web of Science and Cochrane Library databases for relevant studies until December 2022. The outcome measures were overall survival, progression-free survival, chemotherapy toxicity and all-cause mortality. We then performed sensitivity analyses, subgroup analyses and evidence quality. This meta-analysis was performed using Review Manager V.5.4 software. Of the included studies, six were retrospective and five were prospective. There was a statistically significant difference between the frail and non-frail groups in overall survival (HR 2.27, 95% CI 1.24 to 4.15, p=0.008), all-cause mortality (HR 1.63, 95% CI 1.00 to 2.65, p=0.05) and chemotherapy toxicity (OR 3.73, 95% CI 1.99 to 7.00, p<0.0001). We conducted a sensitivity analysis, and the result was stable. The study revealed frail group had shorter survival and experienced more severe adverse effects than the non-frail group. Frailty affects the long-term prognosis and the incidence of short-term chemotherapy toxicity of patients with lung cancer. Consequently, medical professionals should focus on frailty screening in patients with lung cancer and implement active intervention measures. PROSPERO registration number is CRD42023398606.

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Association of frailty with mortality in cancer survivors: results from NHANES 1999-2018

Cancer survivors are vulnerable to frailty. While few studies have focused on the association of frailty with mortality risk among cancer survivors, the current study aimed to reveal this association. In this cohort study, 4723 cancer survivors were enrolled from the National Health and Nutrition Examination Surveys (NHANES, 1999-2018). Frailty status was quantified using the 53-item frailty index. Death outcomes were linked to National Death Index mortality data (as of December 31, 2019). Cox proportional hazard models were used to estimate HRs (95% CIs). The median (IQR) frailty score was 0.190 (0.132, 0.277). During the median follow-up of 6.7 years, 1775 all-cause deaths (including 581 cancer deaths and 385 cardiac deaths) were documented. Compared to the lowest tertile of frailty scores, the adjusted HRs (95% CIs) for the highest tertile were 2.698 (2.224, 3.272) for all-cause mortality (P trend < 0.001), 2.145 (1.547, 2.973) for cancer mortality (P trend < 0.001), and 3.735 (2.231, 6.251) for cardiac mortality (P trend < 0.001). Moreover, a positive dose‒response association between the frailty score and mortality risk was determined. Each per-unit increase in the frailty score (natural logarithm transformed) was found to increase all-cause mortality by 159% (P < 0.001), cancer mortality by 103% (P < 0.001), and cardiac mortality by 256% (P < 0.001). A consistent result was shown when stratifying by age, sex, race, body mass index, and type of cancer. This study suggested that the frailty index was positively associated with all-cause mortality and cause-specific mortality (including cancer and cardiac deaths) among cancer survivors.

Frailty Among Breast Cancer Survivors: Evidence From Swedish Population Data

Incidence and survival of breast cancer, the most common cancer among women, have been increasing, leaving survivors at risk of aging-related health conditions. In this matched cohort study, we examined frailty risk with the Hospital Frailty Risk Score among breast cancer survivors (n = 34,900) and age-matched comparison subjects (n = 290,063). Women born in 1935-1975, registered in the Swedish Total Population Register (1991-2015), were eligible for inclusion. Survivors had a first breast cancer diagnosis in 1991-2005 and survived ≥5 years after initial diagnosis. Death date was determined by linkage to the National Cause of Death Registry (through 2015). Cancer survivorship was weakly associated with frailty (subdistribution hazard ratio (SHR) = 1.04, 95% confidence interval (CI): 1.00, 1.07). In age-stratified models, those diagnosed at younger ages (<50 years) had higher risk of frailty (SHR = 1.12, 95% CI: 1.00, 1.24) than those diagnosed at ages 50-65 (SHR = 1.03, 95% CI: 0.98, 1.07) or >65 (SHR = 1.09, 95% CI: 1.02, 1.17) years. Additionally, there was increased risk of frailty for diagnoses in 2000 or later (SHR = 1.15, 95% CI: 1.09, 1.21) compared with before 2000 (SHR = 0.97, 95% CI: 0.93, 1.17). This supports work from smaller samples showing that breast cancer survivors have increased frailty risk, particularly when diagnosed at younger ages.

How frail is frail in oncology studies? A scoping review

AIMS

The frailty index (FI) is one way in which frailty can be quantified. While it is measured as a continuous variable, various cut-off points have been used to categorise older adults as frail or non-frail, and these have largely been validated in the acute care or community settings for older adults without cancer. This review aimed to explore which FI categories have been applied to older adults with cancer and to determine why these categories were selected by study authors.

METHODS

This scoping review searched Medline, EMBASE, Cochrane, CINAHL, and Web of Science databases for studies which measured and categorised an FI in adults with cancer. Of the 1994 screened, 41 were eligible for inclusion. Data including oncological setting, FI categories, and the references or rationale for categorisation were extracted and analysed.

RESULTS

The FI score used to categorise participants as frail ranged from 0.06 to 0.35, with 0.35 being the most frequently used, followed by 0.25 and 0.20. The rationale for FI categories was provided in most studies but was not always relevant. Three of the included studies using an FI > 0.35 to define frailty were frequently referenced as the rationale for subsequent studies, however, the original rationale for this categorisation was unclear. Few studies sought to determine or validate optimum FI categorises in this population.

CONCLUSION

There is significant variability in how studies have categorised the FI in older adults with cancer. An FI ≥ 0.35 to categorise frailty was used most frequently, however an FI in this range has often represented at least moderate to severe frailty in other highly-cited studies. These findings contrast with a scoping review of highly-cited studies categorising FI in older adults without cancer, where an FI ≥ 0.25 was most common. Maintaining the FI as a continuous variable is likely to be beneficial until further validation studies determine optimum FI categories in this population. Differences in how the FI has been categorised, and indeed how older adults have been labelled as 'frail', limits our ability to synthesise results and to understand the impact of frailty in cancer care.

Frailty Index is Associated with Treatment Decisions for Stage I Non-Small Cell Lung Cancer at a High-Burden Safety-Net Hospital

BACKGROUND

Lobectomy remains the cornerstone of care for stage I NSCLC while sublobar resection and stereotactic body radiation therapy (SBRT) are reserved for patients with smaller tumors and/or poor operative risk. Herein, we investigate the effect of patient frailty on treatment modality for stage I NSCLC at a safety-net hospital.

PATIENTS AND METHODS

A retrospective chart review was performed of stage I NSCLC patients between 2006 and 2015. Demographics, patient characteristics, and treatment rates were compared to a National Cancer Database cohort of stage 1 NSCLC patients. Patient frailty was assessed using the MSK-FI.

RESULTS

In our cohort of 304 patients, significantly fewer patient were treated via lobectomy compared to national rates (P < .001). Advanced age (P = .02), lower FEV1 (P < .001) and DLCO (P < .001), not socioeconomic factors, were associated with higher utilization of non-lobectomy (sublobar resection or SBRT). Patients with lower MSK-FI were more likely to receive any surgical treatment (P = .01) and lobectomy (P = .03). Lower MSK-FI was an independent predictor for use of lobectomy over other modalities (OR 0.75, P = .04). MSK-FI (OR 0.64, P = .02), and FEV1 (OR 1.03, P < .001) were independently associated with use of SBRT over any surgery.

CONCLUSION

Our safety-net hospital performed fewer lobectomies and lung resections compared to national rates. Patient frailty and clinical factors were associated with use of SBRT or sublobar resection suggesting that the increased illness burden of a safety-net population may drive the lower use of lobectomy. The MSK-FI may help physicians stratify patient risk to guide stage I NSCLC management.

The prevalence of comorbidity in the lung cancer screening population: A systematic review and meta-analysis

OBJECTIVE

Comorbidity is associated with adverse outcomes for all lung cancer patients, but its burden is less understood in the context of screening. This review synthesises the prevalence of comorbidities among lung cancer screening (LCS) candidates and summarises the clinical recommendations for screening comorbid individuals.

METHODS

We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL databases from January 1990 to February 2021. We included LCS studies that reported a prevalence of comorbidity, as a prevalence of a particular condition, or as a summary score. We also summarised LCS clinical guidelines that addressed comorbidity or frailty for LCS as a secondary objective for this review. Meta-analysis was used with inverse-variance weights obtained from a random-effects model to estimate the prevalence of selected comorbidities.

RESULTS

We included 69 studies in the review; seven reported comorbidity summary scores, two reported performance status, 48 reported individual comorbidities, and 12 were clinical guideline papers. The meta-analysis of individual comorbidities resulted in an estimated prevalence of 35.2% for hypertension, 23.5% for history of chronic obstructive pulmonary disease (COPD) (10.7% for severe COPD), 16.6% for ischaemic heart disease (IHD), 13.1% for peripheral vascular disease (PVD), 12.9% for asthma, 12.5% for diabetes, 4.5% for bronchiectasis, 2.2% for stroke, and 0.5% for pulmonary fibrosis.

CONCLUSIONS

Comorbidities were highly prevalent in LCS populations and likely to be more prevalent than in other cancer screening programmes. Further research on the burden of comorbid disease and its impact on screening uptake and outcomes is needed. Identifying individuals with frailty and comorbidities who might not benefit from screening should become a priority in LCS research.

Impact of Frailty on Outcomes of First-Line Pembrolizumab Monotherapy in a Real-World Population with Advanced Non-Small Cell Lung Cancer

ICIs have been able to improve overall survival in advanced-stage lung cancer. The benefit of this therapy is limited in patients with poor ECOG PS. However, this scale is imprecise and can be influenced by different factors, such as frailty. Cancer patients have a high risk of frailty independently of age. In this observational, single-center, retrospective study, we investigated the effect of frailty on the effectiveness of pembrolizumab in first-line use in a cohort of 101 patients with metastatic NSCLC. Frailty was determined using a frailty score system developed by Sakakida et al. Univariate and multivariate analysis was performed to determine the prognostic role of frailty on OS and PFS. Median OS was significantly higher in patients with low frailty compared with intermediate and high frailty (23.8 vs. 7.0 and 1.8 months, respectively; p < 0.001). Median PFS was also significantly higher in patients with low frailty compared with intermediate and high frailty (10.5 vs. 3.9 and 1.6 months; p < 0.001, respectively). Frailty was the only variable that showed significant differences in OS and PFS. Multivariate analysis confirms frailty as an independent predictor of OS and PFS. Frailty assessment could help to select which patients are candidates for ICIs in NSCLC.

Prognostic significance of frailty status in patients with primary lung cancer

Lung cancer has one of the highest morbidity and mortality rates in the world. Frailty is common in many countries and is a major cause of premature functional decline and premature death in older adults, and may affect the treatment and prognosis of lung cancer patients. To investigate the predictive value of frailty at diagnosis on all-cause mortality in lung cancer patients, this study retrospectively collected and analysed clinical information on lung cancer patients from 2015-2018. A total of 1667 patients with primary lung cancer were finally included in this study. The median follow-up time of patients was 650 (493, 1001.5) days. A total of 297(17.8%) patients had FI-LAB(the frailty index based on laboratory test) status of frail at the moment of diagnosis and the all-cause mortality rate for all patients was 61.1% (1018/1667). In a univariate model, we found a higher total all-cause mortality risk in frail patients (frail vs. robust, HR(hazard ratio) = 1.616, 95% CI(confidence interval) = 1.349,1.936), after balancing other variables combined into model 1 to model 6. The results were analyzed visually using ROC(Receiver operating characteristic) curves with nomogram and the AUC values ranged from 0.866-0.874. The final inclusion of age, TNM stage, CCI(Charlson comorbidity index) score, surgery history and chemotherapy into a multifactorial model balanced the predictive power of frailty grading on all-cause mortality. The study showed that for lung cancer patients, the higher the level of frailty at diagnosis, the higher the risk of all-cause mortality. In the context of widespread electronic medical records in hospitals, it is convenient and feasible to use FI-LAB to assess the prognosis of lung cancer patients.

Frailty-the missing constraint in radiotherapy treatment planning for older adults

Current demographic changes translate into an increased frequency of cancer in older adults. Available data show that about 45-55% of the new cancer patients will need RT treatments, with an expected increase of 20-30% in the future. To provide the best cancer care it is mandatory to assess frailty, offer appropriate curative treatments to patients and personalise them for the frail. Based on published data, the median prevalence of frailty in older population is about 42%. Recently, the free radical theory of frailty has been proposed stating that oxidative damage is more prevalent in frail patients. In parallel, RT is one of the most frequent cancer treatments offered to older adults and is a source of external free radicals. RT dose constraints correlate with toxicity rates, so we open the question whether frailty should be considered when defining these constraints. Thus, for this paper, we will highlight the importance of frailty evaluation for RT treatment decisions and outcomes.

Frailty in Patients With Lung Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies regarding the prevalence of frailty in patients with lung cancer and mortality in frail patients with lung cancer are inconsistent and require clarification.

RESEARCH QUESTION

What is the prevalence and impact of frailty in patients with lung cancer?

STUDY DESIGN AND METHODS

This systematic review and meta-analysis used a combination of free-text terms and medical subject headings terms, according to the database requirements in MEDLINE/PubMed, Scopus, and Cochrane Library from inception until November 15, 2020.

RESULTS

A total of 2,571 articles were identified, and 16 articles involving 4,183 patients were included for study. The prevalence of frailty in lung cancer was 45% (95% CI, 28-61; I² = 99.5%; P < .0001). In patients with lung cancer, frailty was associated with an increased hazard ratio for mortality (hazard ratio, 3.01; 95% CI, 1.77-5.10; P < .001).

INTERPRETATION

The prevalence of frailty in lung cancer is 45%, which has a significant negative impact on survival of patients with lung cancer. These results highlight the importance of measuring frailty, which provides important prognostic information, and may provide opportunities for interventions to improve outcomes in patients with lung cancer.

Prognostic value of the veterans affairs frailty index in older patients with non-small cell lung cancer

BACKGROUND

Older patients with non-small cell lung cancer (NSCLC) are a heterogeneous population with varying degrees of frailty. An electronic frailty index such as the Veterans Affairs Frailty Index (VA-FI) can potentially help identify vulnerable patients at high risk of poor outcomes.

METHODS

NSCLC patients ≥65 years old and diagnosed in 2002-2017 were identified using the VA Central Cancer Registry. The VA-FI was calculated using administrative codes from VA electronic health records data linked with Medicare and Medicaid data. We assessed associations between the VA-FI and times to mortality, hospitalization, and emergency room (ER) visit following diagnosis by Kaplan-Meier analysis and multivariable stratified Cox models. We also evaluated the change in discrimination and calibration of reference prognostic models after adding VA-FI.

RESULTS

We identified a cohort of 42,204 older NSCLC VA patients, in which 55.5% were classified as frail (VA-FI >0.2). After adjustment, there was a strong association between VA-FI and the risk of mortality (HR = 1.23 for an increase of four deficits or, equivalently, an increase of 0.129 on VA-FI, p < 0.001), hospitalization (HR = 1.16 for four deficits, p < 0.001), and ER visit (HR = 1.18 for four deficits, p < 0.001). Adding VA-FI to baseline prognostic models led to statistically significant improvements in time-dependent area under curves and did not have a strong impact on calibration.

CONCLUSION

Older NSCLC patients with higher VA-FI have significantly elevated risks of mortality, hospitalizations, and ER visits following diagnosis. An electronic frailty index can serve as an accessible tool to identify patients with vulnerabilities to inform clinical care and research.

Prognostic Values of Inflammatory Indexes and Clinical Factors in Patients with Epidermal Growth Factor Receptor Mutations in Lung Adenocarcinoma and Treated with Tyrosine Kinase Inhibitors

This study aimed to access the predictive value of inflammatory indices and clinical factors in toxicity and survival in patients with epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma receiving first-line tyrosine kinase inhibitor (TKI)-treatment. A total of 259 patients with stage IIIB−IV lung adenocarcinoma and actionable EGFR mutation who received first-line TKI treatment between 2008 and 2020 were retrospectively enrolled and analyzed. The prognostic factors of TKI-related toxicity, overall survival (OS), and progression-free survival (PFS) were identified by using logistic regression analysis and Cox proportional hazards models. Pre-TKI high platelet-to-lymphocyte ratio (PLR) was associated with post-TKI anemia. Hypoalbuminemia was associated with acneiform rash. Elderly age (≥70 years) and lower body mass index (<18.5 kg/m2) were also associated with hypoalbuminemia. Elderly age, stage IV, EGFR-mutated with L858R and uncommon mutations, and neutrophil-to-lymphocyte ratio were found to be independent prognostic factors for PFS, while elderly age, uncommon EGFR-related mutations, and lymphocyte-to-monocyte ratio were found to be independent prognostic factors for OS. A useful prognostic scoring tool for improving the survival risk stratification of patients was established by incorporating the above essential factors. Baseline hypoalbuminemia and PLR could be crucial clinical assessment factors when initiating TKI therapy. In addition, the optimization of individualized treatment strategies for these patients may be assisted by using the risk-scoring model.

Longitudinal patient-reported outcomes and survival among early-stage non-small cell lung cancer patients receiving stereotactic body radiotherapy

BACKGROUND AND PURPOSE

The study objective was to determine whether longitudinal changes in patient-reported outcomes (PROs) were associated with survival among early-stage, non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiation therapy (SBRT).

MATERIALS AND METHODS

Data were obtained from January 2015 through March 2020. We ran a joint probability model to assess the relationship between time-to-death, and longitudinal PRO measurements. PROs were measured through the Edmonton Symptom Assessment Scale (ESAS). We controlled for other covariates likely to affect symptom burden and survival including stage, tumor diameter, comorbidities, gender, race/ethnicity, relationship status, age, and smoking status.

RESULTS

The sample included 510 early-stage NSCLC patients undergoing SBRT. The median age was 73.8 (range: 46.3-94.6). The survival component of the joint model demonstrates that longitudinal changes in ESAS scores are significantly associated with worse survival (HR: 1.04; 95% CI: 1.02-1.05). This finding suggests a one-unit increase in ESAS score increased probability of death by 4%. Other factors significantly associated with worse survival included older age (HR: 1.04; 95% CI: 1.03-1.05), larger tumor diameter (HR: 1.21; 95% CI: 1.01-1.46), male gender (HR: 1.87; 95% CI: 1.36-2.57), and current smoking status (HR: 2.39; 95% CI: 1.25-4.56).

CONCLUSION

PROs are increasingly being collected as a part of routine care delivery to improve symptom management. Healthcare systems can integrate these data with other real-world data to predict patient outcomes, such as survival. Capturing longitudinal PROs-in addition to PROs at diagnosis-may add prognostic value for estimating survival among early-stage NSCLC patients undergoing SBRT.

Association of Operability with Post-Treatment Mortality in Early-Stage Non-Small Cell Lung Cancer

BACKGROUND

Operability is both a crucial determinant in treatment selection and a potential confounder in analyses comparing surgery with non-surgical approaches such as stereotactic body radiotherapy (SBRT). We aimed to assess the association between operability status and intervention with post-treatment mortality in early-stage non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

We defined four groups of patients with cT1-T2N0M0 NSCLC diagnosed 2010 to 2014 from the National Cancer Database: SBRT patients deemed operable vs. inoperable and surgery patients receiving open vs. minimally-invasive approaches. Mortality rates at 30, 60, and 90 days post-treatment were calculated and compared.

RESULTS

We abstracted 80,108 patients, 0.8% undergoing SBRT and operable, 13.2% undergoing SBRT and inoperable, 52.4% undergoing open surgery, and 33.7% undergoing minimally-invasive surgery. Mortality rates were highest among open surgery patients and lowest among operable SBRT patients (2.0% vs. 0.2% at 30 days and 3.7% vs. 0.7% at 90 days), with intermediate results in the other two groups. These findings persisted on multivariate Cox regression: compared to patients undergoing minimally-invasive surgery, mortality risk was highest among open surgery patients (30 days HR 1.32, 95%CI 1.16-1.51; 90 days HR 1.36, 95%CI 1.24-1.50; both P < .001) and lowest among operable SBRT patients (30 days HR 0.09, 95%CI 0.01-0.64; 90 days HR 0.15, 95%CI 0.05-0.46; both P ≤ .016). These associations were maintained in a propensity score-matched subset.

CONCLUSION

Operable patients undergoing SBRT experience minimal post-treatment mortality compared to their inoperable counterparts. These findings illustrate the potential for confounding by operability to bias results in cohort studies that compare surgical vs. non-surgical approaches in early-stage NSCLC.

Do Cancer and Cancer Treatments Accelerate Aging?

PURPOSE OF REVIEW

This review focuses on describing the mechanisms and clinical manifestations that underlie accelerated aging associated with cancer and its treatment.

RECENT FINDINGS

The direct and indirect effects of cancer and its treatment are associated with late occurrence of comorbidities that happen earlier or more frequently in cancer survivors compared to cancer-free individuals, otherwise known as accelerated aging. Use of senolytics and dietary and exercise interventions including prehabilitation, caloric restriction, and rehabilitation are currently under investigation to reverse or decelerate the aging process and will be covered in this review. Further research on how to decelerate or reverse aging changes associated with cancer and its treatment will be of paramount importance as the number of cancer survivors continues to grow.

The Electronic Frailty Index is Associated with Increased Infection and All-Cause Mortality Among Older Patients with Primary Lung Cancer: A Cohort Study

Introduction

To assess whether the electronic frailty index (eFI) is independently associated with all-cause mortality and chemotherapy adverse reactions among older Chinese patients with lung cancer.

Methods

This is a retrospective, single-institution, chart review, and not a prospective cohort study. All patients ≥60 years with primary lung cancer in the West China Hospital from 2010 to 2017 were included in this cohort. The eFI was established using 35 frailty-related variables in the electronic medical record (EMR) system and was cut by a value of 0.2 to classify the patients into frail (eFI ≥0.2) and robust/non-frail groups (eFI<0.2). The long-term outcome was all-cause mortality identified by government databases and telephone interviews. Short-term outcomes were any infection, bone suppression, chemotherapy discontinuation, impaired liver function, any gastrointestinal reactions and length of hospitalization. An inverse probability weighting method was used to eliminate the potential confounders. An adjusted Kaplan–Meier estimator and a weighted Cox model were used to calculate the survival and hazard ratio. A weighted logistic model was used to calculate the odds of short-term outcomes.

Results

A total of 997 patients were included in this study with a median follow-up of 34 months. Compared with non-frail patients, frail patients had an increased risk of mortality and shortened overall survival (hazard ratio [HR] of mortality, 1.29; 95% confidence interval [CI], 1.05 to 1.60; adjusted restricted mean survival time [aRMST] difference, −5.68 months; 95% CI, −10.15 to −1.21 months). For short-term outcomes, frail patients had increased odds of infection compared to non-frail patients (odds ratio, 1.83; 95% CI, 1.09 to 3.06). No other outcome showed a significant result.

Conclusion

This study of older Chinese patients with primary lung cancer suggests that eFI-based frail patients had worse prognoses with increased risk of all-cause mortality and shortened survival times.

Impacts of Frailty on Prognosis in Lung Cancer Patients: A Systematic Review and Meta-Analysis

Background: Frailty is a common geriatric syndrome and is described as a limited ability to compensate and recover from stressors. Lung cancer is largely diagnosed in old age, when frailty is common and might have predictive value on prognosis. Therefore, we performed a systematic review to evaluate the prognostic role of frailty in lung cancer.

Methods: The online PubMed, Web of Science, CNKI and Wanfang literature databases were searched to identify all related articles that reported the predictive value of frailty for mortality and therapeutic toxicity. Review Manager 5.3 was used to analyze results by standard meta-analysis methodology.

Results: Seven studies were included in this review, and only six studies with 2,359 patients were enrolled in meta-analysis. Patients in two studies received chemotherapy, two studies radiotherapy, two studies surgery, one study not reported. Compared to non-frail patients, frail patients had a higher risk of overall mortality [Hazard Ratio (HR) = 1.57, 95% confidence interval (CI), 1.32–1.87], and therapeutic toxicity [Odds Ratio (OR) = 2.60, 95% CI, 0.82–8.24]. Prefrail patients also showed higher overall mortality and therapeutic toxicity than non-frail patients (HR = 1.20, 95% CI, 1.05–1.38; OR = 1.72, 95% CI, 1.18–2.51, respectively).

Conclusions: Frailty is a powerful predictor of overall mortality and therapeutic toxicity in lung cancer patients.

Combination of the G-8 Screening Tool and Hand-Grip Strength to Predict Long-Term Overall Survival in Non-Small Cell Lung Cancer Patients Undergoing Stereotactic Body Radiotherapy

The Geriatric 8 (G-8) is a known predictor of overall survival (OS) in older cancer patients, but is mainly based on nutritional aspects. This study aimed to assess if the G-8 combined with a hand-grip strength test (HGST) in patients with NSCLC treated with stereotactic body radiotherapy can predict long-term OS better than the G-8 alone. A total of 46 SBRT-treated patients with NSCLC of stage T1-T2N0M0 were included. Patients were divided into three groups: fit (normal G-8 and HGST), vulnerable (abnormal G-8 or HGST), or frail (abnormal G-8 and HGST). Statistically significant differences were found in 4-year OS between the fit, vulnerable, and frail groups (70% vs. 46% vs. 25%, p = 0.04), as well as between the normal and abnormal G-8 groups (69% vs. 39%, p = 0.02). In a multivariable analysis of OS, being vulnerable with a hazard ratio (HR) of 2.03 or frail with an HR of 3.80 indicated poorer OS, but this did not reach statistical significance. This study suggests that there might be a benefit of adding a physical test to the G-8 for more precisely predicting overall survival in SBRT-treated patients with localized NSCLC. However, this should be confirmed in a larger study population.

Frailty and aging in cancer survivors

There are over 15 million survivors of cancer in the United States whose rates of frailty, an aging phenotype, range from just under 10% to over 80%. Frailty impacts not only disease survival but also long-term function and quality of life in children, adolescents, and in all adults diagnosed and/or treated for cancer. This review explains frailty as a construct and model of physiologic well-being. It also describes how frailty at diagnosis impacts cancer outcomes in adult populations and enumerates the prevalence of frailty in different populations of cancer survivors. Biological mechanisms responsible for aging and potentially for frailty among individuals with or who have been treated for cancer are discussed. Finally, promising pharmaceutical and lifestyle interventions designed to impact aging rather than a specific disease, tested in other populations, but likely applicable in cancer patients and survivors, are discussed.

Impact of Health-Related Quality of Life and Prediagnosis Risk of Major Depressive Disorder on Treatment Choice for Stage I Lung Cancer

PURPOSE

We hypothesized that prediagnosis depressive symptoms and patient-reported health-related quality of life (HRQOL) would be associated with treatment choice for stage I non-small-cell lung cancer (NSCLC).

METHODS

Using the SEER and Medicare Health Outcomes Survey (SEER-MHOS)-linked data set, we identified patients age 65 years and older with stage I NSCLC diagnosed between 2004 and 2013 who completed the HOS 24 or fewer months before diagnosis. HRQOL was measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the Medical Outcomes Study Short Form-36 and the Veterans RAND 12-Item Health Survey instruments. Major depressive disorder (MDD) risk was derived from responses to HOS questions that screen for depressive symptoms. Associations with treatment choice were assessed with multivariable multinomial logistic regression while controlling for prespecified patient characteristics.

RESULTS

We analyzed 515 evaluable patients, of whom 140 (27%) met criteria for risk of MDD. On univariable analysis, a higher proportion of patients who received radiotherapy (RT) versus surgery were at risk for MDD (34% v 22%, respectively; P = .011). On multivariable analysis, higher PCS and MCS scores were associated with a decreased likelihood of receiving RT compared with surgery (adjusted odds ratio per 10-point PCS increase, 0.60 [95% CI, 0.45 to 0.79; P < .001]; adjusted odds ratio per 10-point MCS increase, 0.61 [95% CI 0.46 to 0.80; P < .001]).

CONCLUSION

Among older patients with stage I NSCLC, there was a significant association between those who self-reported lower HRQOL and receipt of RT. There was also a nonsignificant association in MDD risk and increased likelihood of RT receipt. Additional studies are warranted to examine the impact of pretreatment HRQOL and MDD risk on clinical decision making.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

Lung Cancer Surveillance After Definitive Curative-Intent Therapy: ASCO Guideline

PURPOSE

To provide evidence-based recommendations to practicing clinicians on radiographic imaging and biomarker surveillance strategies after definitive curative-intent therapy in patients with stage I-III non-small-cell lung cancer (NSCLC) and SCLC.

METHODS

ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, radiology, primary care, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2000 through 2019. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 14 relevant studies to inform the evidence base for this guideline.

RECOMMENDATIONS

Patients should undergo surveillance imaging for recurrence every 6 months for 2 years and then annually for detection of new primary lung cancers. Chest computed tomography imaging is the optimal imaging modality for surveillance. Fluorodeoxyglucose positron emission tomography/computed tomography imaging should not be used as a surveillance tool. Surveillance imaging may not be offered to patients who are clinically unsuitable for or unwilling to accept further treatment. Age should not preclude surveillance imaging. Circulating biomarkers should not be used as a surveillance strategy for detection of recurrence. Brain magnetic resonance imaging should not be used for routine surveillance in stage I-III NSCLC but may be used every 3 months for the first year and every 6 months for the second year in patients with stage I-III small-cell lung cancer who have undergone curative-intent treatment.

Prediction of chemotherapy adverse reactions and mortality in older patients with primary lung cancer through frailty index based on routine laboratory data

Objectives

To assess the role of a pre-chemotherapy frailty index based on routine laboratory data in predicting mortality and chemotherapy adverse reactions among older patients with primary lung cancer.

Design

Retrospective cohort study.

Setting

West China Hospital, Chengdu, China.

Participants

We included patients aged ≥60 years with primary lung cancer receiving the first course of chemotherapy.

Measurements

Data were collected from medical records, local government death databases or telephone interviews. Outcomes included chemotherapy adverse reactions and all-cause mortality. We constructed a frailty index based on 44 laboratory variables (FI-LAB) before chemotherapy, and chose the following cutoff points: robust (0.0-0.2), pre-frail (0.2-0.35) and frail (≥0.35).

Results

We included 1,020 patients (71.4% male; median age: 65 years old). Both pre-frailty and frailty was associated with any chemotherapy adverse reactions and infections during chemotherapy (OR=3.48, 95%CI: 1.77-6.87; OR=3.58, 95%CI: 1.55-8.26, respectively). Frail patients had a shorter median overall survival rate compared to robust patients (18.05 months vs 38.89 months, log-rank p<0.001). After adjusting for some potential confounding variables, the risk of all-cause mortality was dramatically increased in frail patients (HR:2.13, 95% CI:1.51-3.00) with an average follow-up of 3.9 years. Each 0.01 or per standard deviation (SD) increase in the FI-LAB value significantly increased the HR of death by 2.0% (HR:1.02, 95% CI: 1.01-1.03) and 23.0% (HR: 1.23, 95% CI: 1.13-1.34), respectively.

Conclusions

Frailty assessed by routine laboratory data indicates increased risks of chemotherapy adverse reactions and death in older patients with primary lung cancer receiving the first course of chemotherapy.

Multidisciplinary treatment of lung cancer in older patients: A review

Lung cancer is the leading cause of cancer death worldwide. Older patients represent approximately half of the patient population and optimal management of these patients is challenging. In early-stagenon-small cell lung cancer (NSCLC), lobectomy should be considered in fit older patients. For unfit patients, stereotactic body radiotherapy (SBRT) represents a good alternative. While data on the benefit and risk of concurrent chemo-radiotherapy (cCRT) in older patients with locally advanced NSCLC is conflicting, age alone should not preclude cCRT. Multidisciplinary collaboration is essential for appropriate patient selection. In limited disease small cell lung cancer (SCLC), older patients appear to benefit similarly from standard treatment compared to their younger counterparts, however, with a higher risk of toxicity. Appropriately selected older patients with lung cancer seem to derive as much benefit from active oncological treatment as their younger counterparts. Geriatric screening tests and comprehensive geriatric assessments (CGA) can be helpful when choosing between treatment strategies. Older patients are at risk for under-treatment; this should be avoided by proper selection and multidisciplinary management. This review outlines the management of lung cancer in older patients.

Comparing Outcomes of Patients With Early-Stage Non-Small-Cell Lung Cancer Treated With Stereotactic Body Radiotherapy Based on Frailty Status

INTRODUCTION

Frailty of surgical patients has been associated with worse outcomes. There is limited literature discussing frailty in patients with lung cancer treated with stereotactic body radiotherapy (SBRT). This study assesses the relationship between frailty and overall survival (OS), tumor control, and toxicity in patients with early-stage non-small-cell lung cancer (NSCLC) treated with SBRT.

PATIENTS AND METHODS

A retrospective review of patients with early-stage NSCLC treated with SBRT at a single institution between February 2009 and September 2014 was performed. A modified frailty index (mFI) of 8 variables was created, and patients were categorized as nonfrail (mFI ≤ 2) and frail (mFI > 2). OS, recurrence-free survival (RFS), local control (LC), regional control, and distant control (DC) were compared between frail and nonfrail patients by Kaplan-Meier analysis and log-rank tests. Univariate and multivariable analyses were conducted.

RESULTS

One hundred forty cases of early-stage NSCLC were included, with 49 frail (35.0%) and 91 nonfrail (65.0%) subjects. OS was significantly lower in frail than nonfrail patients (P = .01) with 3-year OS of 59.3% versus 82.0%. LC and DC were significantly lower in frail than nonfrail patients (LC: P = .02, 3-year LC of 85.3% vs. 97.0%; DC: P = .03, 3-year DC of 80.6% vs. 93.4%), as was RFS (P = .01, 3-year RFS of 53.4% vs. 74.5%). Frailty remained a significant predictor for shorter OS on multivariable analysis (hazard ratio = 1.98; 95% confidence interval, 1.02-3.85; P = .04).

CONCLUSION

Frailty is associated with reduced OS in early-stage NSCLC patients treated with SBRT. Characterizing frailty using an mFI before treatment could help guide treatment decision making and patient counseling.