Impact of renal function on treatment options and outcomes in advanced non-small cell lung cancer

Modernizing Clinical Trial Eligibility Criteria: Recommendations of the ASCO-Friends of Cancer Research Laboratory Reference Ranges and Testing Intervals Work Group

PURPOSE

In clinical research, eligibility criteria promote patient safety and optimize the evidence generated from clinical trials. However, overly stringent eligibility criteria, including laboratory requirements, may limit enrollment, resulting in delayed trial completion and potentially limiting applicability of trial results to a general practice population.

EXPERIMENTAL DESIGN

Starting in 2018, a working group consisting of experts in direct patient care, the FDA, industry, and patient advocacy developed recommendations to guide the optimal use of laboratory reference ranges and testing intervals in clinical trial eligibility criteria and study procedures. The working group evaluated current eligibility criteria across different clinical trial phases and performed a literature review to evaluate the impact of and justification for laboratory test eligibility requirements and testing intervals in clinical trials. Recommendations were developed on the basis of the goals of promoting safety and optimizing the evidence generated, while also expanding eligibility and applicability, and minimizing excess burden of trial participation.

RESULTS

In general, we found little variation over time and trial phase in laboratory test requirements, suggesting that these eligibility criteria are not refined according to ongoing clinical experience. We propose recommendations to optimize the use of laboratory tests when considering eligibility criteria.

CONCLUSIONS

Tailoring the use of laboratory test requirements and testing intervals may increase the number and diversity of patients in clinical trials and provide clinical data that more closely represent the general practice populations.See related commentary by Giantonio, p. 2369.

Nivolumab treatment in advanced non-small cell lung cancer: real-world long-term outcomes within overall and special populations (the UNIVOC study)

OBJECTIVE

To describe long-term outcomes of patients treated with nivolumab for advanced non-small cell lung cancer (aNSCLC) in everyday clinical practice in France, with a focus on patients aged ⩾80 years, patients with renal impairment and patients with brain metastases.

METHODS

The study included all patients with aNSCLC recorded in the French national hospital database, starting nivolumab in 2015-2016 and followed until December 2018. Patients were stratified by age, the presence of renal impairment and brain metastasis, as documented in the hospital discharge summaries. Information was retrieved on demographics, comorbidities and treatment history at baseline. Time to discontinuation of nivolumab treatment and overall survival were estimated using Kaplan-Meier survival analysis.

RESULTS

Overall, 10,452 patients were included, of whom 514 were octogenarians, 479 had renal impairment and 1800 had brain metastases at baseline. Median duration of nivolumab treatment was 2.8 months in the overall population and in both the octogenarian and renally impaired subgroups, and 2.3 months in patients with brain metastases. Median overall survival in these patient groups was 11.7 months (95% confidence interval: 11.3-12.2), 11.7 months (11.3-12.1), 11.7 months (11.3-12.2) and 9.9 months (9.0-10.9) respectively. Three-year overall survival rates were 19.1% (18.1-20.2) in the overall population, 16.5% (11.6-23.4) in octogenarians, 15.9% (11.8-21.4) in patients with renal impairment and 21.7% (19.4-24.2) in those with brain metastases.

CONCLUSION

This large nationwide retrospective real-life cohort provided narrow estimates of long-term overall survival, which reached 19% at 3 years, consistent with data from phase III trials of nivolumab. Survival rates were comparable in the three special populations of interest and the overall population.

Classical versus non-classical EGFR mutations: Erlotinib response and impact of renal insufficiency

INTRODUCTION

Erlotinib is an effective treatment option for EGFR-mutant non-small cell lung cancer. It is important to predict patients who will respond better to erlotinib. We designed this study to investigate the effect of renal insufficiency (RI) on erlotinib treatment outcomes.

METHODS

All patients receiving erlotinib were stratified into 3 groups. Group 1 consisted of non-RI subjects with classical epidermal growth factor receptor (EGFR) mutations, Group 2 consisted of those with RI (Estimated glomerular filtration rate <60 mL/min) and classical EGFR mutations, and Group 3 consisted of those with non-classical EGFR mutations.

RESULTS

82 patients were included in the study. Median progression-free survival (PFS) in patients with classical mutation was approximately 6 months shorter in those with RI, although not statistically significant. Median overall survival (OS) in Group 1, 2 and 3 was 34.1 months, 35.2 months, and 15 months, respectively and although not statistically significant, median OS was 20 months shorter in Group 3. Univariate and multivariate cox-regression analysis revealed shorter PFS and OS in males and those with ECOG ≥2 while PFS and OS were longer in those with recurrent lung tumors and generating rash during erlotinib treatment. There was no difference between RI and non-RI patients in terms of adverse events except for fatigue and appetite loss.

CONCLUSIONS

This research showed OS in patients with and without RI was comparable. Although not statistically significant, PFS in patients with classical mutation was approximately 6 months shorter in those with RI patients.

Long-Term Outcomes of Pulmonary Resection for Lung Cancer Patients with Chronic Kidney Disease

BACKGROUND

The survival outcome in lung cancer patients with chronic kidney disease (CKD) has not been well evaluated. The aim of this study was to evaluate the survival outcomes following non-small cell lung cancer (NSCLC) surgery in patients with CKD as a preoperative comorbidity.

METHODS

Among 671 patients who underwent surgery for NSCLC between 2007 and 2014 at our hospital, 55 (8%) had CKD and we retrospectively analyzed the survival outcomes of these patients.

RESULTS

Most patients with CKD were elderly and male. Patients with CKD had a higher frequency of smoking habit, cardiovascular disease, and pulmonary diseases, and a notably lower pulmonary function, resulting in receiving limited pulmonary resection. There were no marked differences in the frequency of surgical complications between patients with and without CKD (p = 0.16). Squamous cell carcinoma was more frequently diagnosed in patients with CKD than in those without it. The 5-year disease-free survival rates in patients with and without CKD were 60.0% and 69.7% (p = 0.06), respectively, and the 5-year overall survival rates were 68.9% and 80.0%, respectively, showing significant differences (p = 0.01). The rate of receiving supportive care was higher in patients with CKD when recurrence observed.

CONCLUSION

CKD is associated with a poorer overall survival in patients who undergo lung cancer resection for recurrent disease. As patients with CKD tend to have a poor respiratory function, thoracic surgeons should carefully select the resection type to balance the therapeutic benefit and invasiveness.

Serum Cystatin C as a Potential Marker for Glomerular Filtration Rate in Patients with Cholangiocarcinoma

Background: Cholangiocarcinoma (CCA) is the second most common primary hepatobiliary cancer. These patients have meager prognosis and short-term survival. Precise assessment of glomerular filtration rate is a fundamental aspect of clinical care in cancer patients. Cystatin C has been proposed to be superior to creatinine, a well-known marker of renal function. This study aimed to evaluate cystatin C as a marker of GFR calculation in CCA patients. Materials and Methods: One hundred thirty serum samples from CCA patients and 32 from controls were included in this study. Serum cystatin C was measured using immunoturbidity assay. Estimated glomerular filtration rate was calculated by three equations established by chronic kidney disease epidemiology collaboration (based on creatinine and/or cystatin C). Results: Serum cystatin C in CCA patients was higher than that of controls (p=0.0002). Cystatin C was positively correlated with BUN in CCA group (p=0.019). eGFR based on cystatin C and based on both cystatin C and creatinine in CCA was low with significantly different from those of control (p<0.001). Although there was no difference in eGFR using three equations in control, creatinine based eGFR was high with significantly different from eGFR based on cystatin C and on both creatinine and cystatin C in CCA (P=0.000). Proportion in each eGFR stage by three equations showed a high sensitivity with significantly different in CCA (p<0.05). Conclusion: There was a high sensitivity of cys C with significant difference between creatinine and/or cystatin C based eGFR in CCA patients. It should be taken into consideration of mild changes in eGFR by cystatin C which is important in managing drug dosage for CCA patients.

Better survival in impaired renal function patients with metastatic non-small cell lung cancer treated by cisplatin-pemetrexed

PURPOSE

Cisplatin-pemetrexed is the first-line chemotherapy for advanced, metastatic non-squamous non-small cell lung cancer (NSCLC), but the risk of kidney toxicity limits the therapeutic schedule. We performed a retrospective study of patient survival at 1 year and glomerular filtration rate (GFR) outcomes in cisplatin-pemetrexed-treated NSCLC patients.

METHODS

Patients (P) treated for NSCLC between 2008 and 2014 were divided into two groups according to GFR at diagnosis: G1 (GFR ≥ 90 mL/min/1.73 m²) and G2 (GFR between 60 and 89 mL/min/1.73 m²). GFR were compared in the two groups at 3 and 12 months. The following statistical methods were used: multivariate generalized estimating equation model for GFR outcome, Kaplan-Meier method for patient survival rate, and Cox model for analysing survival criteria.

RESULTS

A total of 112 patients were included in the study (G1 = 87 P, G2 = 25 P). At 12 months, mean GFR significantly decreased by 28.4 mL/min/1.73 m² (- 22.3%, p = 0.001) in G1 and. 13.8 mL/min/1.73 m² (- 17.2%, p = 0.001) in G2. Median patient survival was 9.6 months (1.1-52.4) in G1 and 19.7 months (3.7-56.9) in G2. A better overall survival was significantly correlated with GFR between 60 and 89 mL/min/1.73 m² at diagnosis (p = 0.04), and higher cumulated doses of pemetrexed (p = 0.003) and cisplatin (p = 0.001).

CONCLUSION

The better survival rate in G2 and its correlation with pemetrexed and cisplatin treatments suggest that, until other therapeutic choices become available, a cautious increase in dosage could be investigated as a way to improve poor prognoses.

A nomogram to predict outcomes of lung cancer patients after pneumonectomy based on 47 indicators

Aims

We aimed to establish a nomogram for lung cancer using patients' characteristics and potential hematological biomarkers.

Methods

Principle component analysis was used to reduce the dimensions of the data, and each component was transformed into categorical variables based on cutoff values obtained using the X‐tile software. Multivariate analysis was used to determine potential prognostic biomarkers. Five components were used in the predictive nomogram. Internal validation of the model was performed by bootstrapping of samples, while external validation was performed on a separate cohort from Shandong Cancer Hospital. The predictive accuracy of the model was measured by concordance index and risk group stratification. Decision curve analysis was performed to evaluate the net benefit of the models.

Results

One hundred patients in the Discovery group and 111 patients in the Validation group were retrospectively analyzed in this study. Forty‐seven indexes were sorted into eight subgroups. Five components based on cox regression analysis were enrolled into the predictive nomogram. The nomogram prediction of the probability of 3‐ and 5‐year overall survival was in great concordance with the actual observations. Of interest, the nomogram allowed better risk stratification of patients and better accuracy in predicting patients' survival compared with pathological tumor‐node‐metastasis staging system.

Conclusion

A nomogram was established for prognosis of lung cancer, which can be used for treatment selection and clinical care management.

Timing, Sites, and Correlates of Lung Cancer Recurrence

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of changes in renal function in PARAMOUNT: a phase III study of maintenance pemetrexed plus best supportive care versus placebo plus best supportive care after induction treatment with pemetrexed plus cisplatin for advanced nonsquamous non-small-cell lung cancer

OBJECTIVES

To assess the effect of long-term pemetrexed maintenance therapy on patients' renal function.

METHODS

In the PARAMOUNT phase III trial (NCT 00789373), pemetrexed was compared with placebo as maintenance treatment in advanced nonsquamous non-small-cell lung cancer patients who completed 4 cycles of pemetrexed plus cisplatin induction therapy. To evaluate changes in renal function during pemetrexed continuation maintenance treatment, we retrospectively analyzed changes in serum creatinine (sCr), treatment-emergent adverse events, dose delays and treatment discontinuations associated with impaired renal function.

RESULTS

Creatinine clearance ≥45 mL/min was required before the start of any cycle. Patients on pemetrexed maintenance had a significantly higher percentage maximum increase in sCr over baseline versus placebo for the range of ≥10% to ≥90% increase (p < .05). The risk of experiencing renal events leading to dose delays and discontinuations was higher with higher increases in sCr but reversible in most patients. sCr increases of ≥30% and ≥40% were associated with gender (female), age (<70 years) and longer exposure to pemetrexed compared with placebo. Sixteen (4%) pemetrexed patients and 1 (1%) placebo patient discontinued treatment due to drug-related renal events; 13/16 (81%) of those pemetrexed patients had sCr increases ≥30% and 7/13 (54%) had pre-existing conditions and/or were receiving nephrotoxic drugs.

CONCLUSIONS

The appearance of renal events leading to dose delays and/or treatment discontinuations was associated with sCr increase of at least 30%. However, it was difficult to identify patients at a higher risk of treatment discontinuation due to a drug-related renal event based only on changes in pre-maintenance laboratory values.

Association of chronic kidney disease with mortality risk in patients with lung cancer: a nationwide Taiwan population-based cohort study

OBJECTIVE

Our population-based research aimed to clarify the association between chronic kidney disease (CKD) and mortality risk in patients with lung cancer.

DESIGN

Retrospective cohort study SETTING: National health insurance research database in Taiwan PARTICIPANTS: All (n=1 37 077) Taiwanese residents who were diagnosed with lung cancer between 1997 and 2012 were identified. Eligible patients with baseline CKD (n=2269) were matched with controls (1:4, n=9076) without renal disease according to age, sex and the index day of lung cancer diagnosis.

METHODS

The cumulative incidence of death was calculated by the Kaplan-Meier method, and the risk determinants were explored by the Cox proportional hazards model.

RESULTS

Mortality occurred in 1866 (82.24%) and 7135 (78.61%) patients with and without CKD, respectively (P=0.0001). The cumulative incidences of mortality in patients with and without chronic renal disease were 72.8% vs 61.6% at 1 year, 82.0% vs 76.6% at 2 years and 88.9% vs 87.2% at 5 years, respectively. After adjusting for multiple confounding factors including age and comorbidities, Cox regression analysis revealed that CKD was associated with an increased risk of mortality (adjusted HR 1.38; 95% CI 1.29 to 1.47). Stratified analysis further showed that the association was consistent across patient subgroups.

CONCLUSION

Comorbidity associated with CKD is a risk factor for mortality in patients with lung cancer.

Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration equations for estimating glomerular filtration rates in cancer patients receiving cisplatin-based chemotherapy

Background

Although the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation has been recommended for accurate estimates of glomerular filtration rate (eGFR), there is little information regarding differences in GFR estimates obtained using the Cockcroft-Gault (CG) or Modification of Diet in Renal Disease (MDRD) equations in East Asian cancer patients. We investigated discrepancies in GFR and toxicities in patients treated with cisplatin-based chemotherapy using three equations equations.

Methods

A total of 229 patients were retrospectively recruited. We calculated eGFR using the three equations and separated patients into three categories based on GFR < 10 (group A), 10-50 (group B), and > 50 (group C) mL/min/1.73m². We analyzed chemotherapy toxicities.

Results

The mean eGFR calculated using the CG was the lowest of the values derived using the three equations. Estimates using the MDRD and CKD-EPI equations resulted in reclassifying 32 (71.1%) and 33 (73.3%) of 45 patients, originally placed in group B using the CG into group C. However, only 1 (7.7%) of 13 patients placed in group B using the MDRD were reclassified into group C using the CKD-EPI. Twenty-eight of 45 patients classified into group B using the CG equation were treated with reduced doses of cisplatin. However, these patients did not show significant differences in toxicities compared with other patients taking full doses of cisplatin.

Conclusion

The CG equations underestimated GFR compared to the MDRD and CKD-EPI equations. Therefore, when GFR is estimated using CG equations, East Asian cancer patients may receive insufficient doses of chemotherapeutic agents, including cisplatin.

Thoracic Oncology Clinical Trial Eligibility Criteria and Requirements Continue to Increase in Number and Complexity

INTRODUCTION

Eligibility criteria and screening procedures are designed to optimize the scientific yield and maximize the safety of clinical trials. However, they may also heighten trial complexity, hinder enrollment, decrease generalizability, and increase costs. We analyzed the types and number of eligibility criteria and screening procedures among thoracic oncology clinical trials sponsored or endorsed by the Eastern Cooperative Oncology Group.

METHODS

We identified trials and obtained protocols from the Eastern Cooperative Oncology Group website. Eligibility criteria were grouped and categorized as comorbidity (classified by organ system), administrative requirements, prior treatment, and measurable disease requirements. Associations between trial characteristics and eligibility criteria were analyzed by using the Kruskal-Wallis and Wilcoxon tests.

RESULTS

A total of 74 lung cancer trials activated in 1986-2016 were identified. The total number of eligibility criteria was associated with trial principal therapy (a median of nine for surgical, 18 for radiation, and 20 for medical therapy [p = 0.02]), trial primary end point (a median of 20 for overall survival, 28 for progression-free survival, and 17 for other [p = 0.001]), number of therapies (p = 0.05), and year of activation (a median of 16 for 1986-1995, 19 for 1996-2005, and 27 for 2006-2016 [P < 0.001]). The increase in trial eligibility requirements over time was limited to medical therapy trials. Over time, there was also an increase in blood test screening procedures (p = 0.05) but not in imaging, cardiac assessment, or pulmonary function screening procedures.

CONCLUSIONS

The number of eligibility criteria and screening procedures in medical therapy lung cancer clinical trials continues to rise. Continued efforts to simplify protocol eligibility and procedures are warranted to promote trial adherence, enrollment, completion, and generalizability.

Renal Impairment Hampers Bisphosphonate Treatment in a Quarter of Lung Cancer Patients with Bone Metastasis

Renal function impairment in lung cancer patients with bone metastases was investigated, as this can limit the application of bisphosphonates representing the gold standard in the management of such cases. Clinicopathological data of 570 lung cancer patients were retrospectively analysed for changes in renal function parameters. Comorbidities included hypertension (50%), COPD (33%) and diabetes mellitus (15%). Statistical analysis was performed with Fisher's exact tests and a Cox proportional hazards model. In patients suffering from hypertension, both median serum creatinine and blood urea nitrogen (BUN) were higher (81.9 versus 75.8 μmol/L, p < 0.001 and 6.0 versus 5.7 mmol/L, p = 0.005, respectively). Such a difference could not be observed in patients with diabetes. In patients with COPD, only serum creatinine was higher (81.1 versus 77.3 μmol/L, p = 0.004). In the whole cohort, we found that while at the time of lung cancer diagnosis the ratio of patients in the pathological range (PRR) was 8.67% for serum creatinine (median: 75 μmol/L) and 14.16% for BUN (median: 5.4 mmol/L), at the time of bone metastasis the PRR for serum creatinine increased to 16.11% (median: 77.0 μmol/L) and for BUN to 24.07% (median: 6.0 mmol/L), which is a significant increase for both parameters (p < 0.001). For the whole cohort, the last laboratory results showed a 26.37% PRR for serum creatinine and 45.66% PRR for BUN (significant increase for both, p < 0.001). Multivariate analysis revealed that patients with hypertension had a higher chance for switching to the pathological range sooner (p = 0.033, HR: 1.372, CI: 1.025-1.835). Also, the appearance of the bone metastasis correlated with an acceleration of the onset of such a switch (p < 0.001, HR: 2.655, CI: 1.581-4.456). Our results suggest that renal function is impaired in a significant proportion of patients with lung cancer and highlight the importance of non-nephrotoxic drug in the management of bone metastases.

Is chronic kidney disease an adverse factor in lung cancer clinical outcome? A propensity score matching study

BACKGROUND

Comorbidity has a great impact on lung cancer survival. Renal function status may affect treatment decisions and drug toxicity. The survival outcome in lung cancer patients with coexisting chronic kidney disease (CKD) has not been fully evaluated. We hypothesized that CKD is an independent risk factor for mortality in patients with lung cancer.

METHODS

A retrospective, propensity-matched study of 434 patients diagnosed between June 2004 and May 2012 was conducted. CKD was defined as estimated glomerular filtration rate <60 mL/minute. Lung cancer and coexisting CKD patients were matched 1:1 to patients with lung cancer without CKD.

RESULTS

Age, gender, smoking status, histology, and lung cancer stage were not statistically significantly different between the CKD and non-CKD groups. Kaplan-Meier survival analysis demonstrated a median survival of 7.26 months (95% confidence interval [CI] 6.06-8.46) in the CKD group compared with 7.82 months (95% CI 6.33-9.30) in the non-CKD group (P = 0.41). Lung cancer stage-specific survival is not affected by CKD. Although lung cancer patients with CKD presented with an increased risk of death of 6%, this result was not statistically significant (hazard ratio 1.06, 95% CI 0.93-1.22; P = 0.41).

CONCLUSION

According to our limited experience, CKD is not an independent risk factor for survival in lung cancer patients. Clinicians should not be discouraged to treat lung cancer patients with CKD.

Risk Factors Associated with Cisplatin-Induced Nephrotoxicity in Patients with Advanced Lung Cancer

Cisplatin (CDDP) combination chemotherapy is widely administered to patients with advanced lung cancer. The dose depends on multiple factors, including whether the tumor is non-small-cell lung cancer (NSCLC) or small-cell lung cancer (SCLC). Although efficacy is limited by cisplatin-induced nephrotoxicity (CIN), little is known about the risk factors for this complication. The aim of this study was to identify the risk factors for CIN in patients with advanced lung cancer, both NSCLC and SCLC. We retrospectively reviewed clinical data for 148 patients who underwent initial chemotherapy including CDDP ≥50 mg/m² per patient per day for the first course at Kyushu Medical Center between October 2010 and September 2013. All data were collected from the electronic medical record system. Nephrotoxicity was defined as an increase in serum creatinine concentration of at least grade 2 during the first course of CDDP chemotherapy, as described by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. CIN was observed in nine patients. Univariate analysis revealed that cardiac disease and lower baseline serum albumin (Alb) values conferred a higher risk of nephrotoxicity (p<0.05). The cut-off value of Alb was 3.8 g/dL, calculated by receiver operating characteristics (ROC) curves. Multivariable logistic regression analysis revealed that cardiac disease (odds ratio=11.7; p=0.002) and hypoalbuminemia (odds ratio=6.99 p=0.025 significantly correlated with nephrotoxicity. In conclusion, cardiac disease and low baseline Alb values are possible risk factors for CIN.

Clinical outcome in lung cancer with a second malignancy: The time sequence matters

The aim of the study was to determine the clinical outcome of lung cancer patients with a secondary malignancy according to the time sequence between the lung cancer and the secondary malignancy.Retrospective review of all lung cancer patients with any secondary cancer treated from June 2004 to July 2012. The survival of patients with a secondary malignancy was compared to those patients without a secondary malignancy. According to the time sequence between the lung cancer and the secondary malignancy, patients were divided into 4 groups. Group I: lung cancer without any other malignancy, Group II: lung cancer with a secondary malignancy at follow-up, Group III: lung cancer with a pre-existing malignancy, Group IV: synchronous malignancies (diagnosis interval between lung cancer and a secondary malignancy of less than 3 months).Patients with any secondary cancer in their history or at follow up included 157 patients (9.5%). Collectively; the median survival was significantly better for patients with a secondary malignancy, 19.09 months, compared to those without a secondary malignancy, 9.53 months, P < 0.001, HR 0.66 (95% CI 0.55 - 0.79). However, the survival differed significantly according to the time sequence between the lung cancer and the secondary malignancy. The median survival was 47.9 months for group II patients, 12.19 months for group III, 17.51 months for group IV, and 9.53 months for group I; P = 0.001. In Cox proportional hazard analysis, the risk of dying decreased by 68% in group II patients compared to group I patients, HR 0.32 (95% CI 0.21-0.5), P < 0.001. Although the risk of dying for group III and IV decreased by 19% and 16% respectively compared to group I patients, it did not reach statistical significance.Nowadays, secondary malignancy in lung cancer patients is a frequent finding. Better survival was observed for patient with secondary malignancy following lung cancer.

Chemotherapy for Advanced Non-small Cell Lung Cancer

Non-small cell lung cancer has seen an unprecedented augmentation of therapeutic options over the last couple of years. Improved understanding of molecular drivers and the role of the immune system in cancer therapy have brought new drugs to the armamentarium. Despite these advances, cytotoxic chemotherapy remains a substantial part of therapy for most patients in locally advanced and metastatic stage. Initially thought to be a chemotherapy-resistant entity, meta-analyses in the mid-1990s demonstrated modest efficacy of platinum-based therapy. Further combination trials demonstrated enhanced efficacy for several regimen in first and second lines, including the introduction of antimetabolites, taxanes, and anti-angiogenic agents. Maintenance chemotherapy has been another novel, successful approach for management of metastatic disease. Herein, we summarize the current concepts of chemotherapy, its applicability to the different histologies, and novel concepts of therapy.

[Impact of lung cancer treatments on renal function]

INTRODUCTION

Renal failure in patients with lung cancer may be multifactorial: related to the patients and their comorbidities, direct tumor compression or the toxicity of cancer treatments and other associated medications. This literature review is intended to describe the state of knowledge regarding the nephrotoxicity of treatments used in thoracic oncology.

FINDINGS

The majority of chemotherapy treatments are potentially nephrotoxic. Cisplatin and pemetrexed exhibit mainly renal tubular toxicity, while vascular renal impairment is found with gemcitabine and bevacizumab. Cisplatin results in acute renal failure in 30% of patients. Renal protective strategies (compliance with recommendations, limitation of nephrotoxic treatments, hydration, magnesium supplementation) must be employed systematically. Targeted therapies do not require any adjustment of the dosage in case of moderate or severe renal insufficiency but adapting the doses of biphosphonates to renal function is necessary.

CONCLUSION

This review highlights the need for monitoring of renal function in patients with lung cancer during treatment with chemotherapy or biphosphonates.

Weekly nab-paclitaxel in combination with carboplatin as first-line therapy in patients with advanced non-small-cell lung cancer: analysis of safety and efficacy in patients with renal impairment

INTRODUCTION

Renal impairment in cancer patients can affect treatment tolerability and outcomes. This analysis evaluated the safety and efficacy of nab-paclitaxel (nab-P) versus solvent-based paclitaxel (sb-P), both in combination with carboplatin (C), in patients with advanced non-small-cell lung cancer (NSCLC) and renal impairment.

METHODS

Untreated patients with stage IIIB/IV disease with NSCLC and a performance status of 0/1 were randomly assigned (1:1) to receive 100 mg/m(2)nab-P weekly plus C (under the curve = 6, every 3 weeks) or 200 mg/m(2) sb-P plus C (under the curve = 6) every 3 weeks. The primary end point was overall response rate.

RESULTS

Of 1038 treated patients in the phase III trial, 38% had mild renal impairment (creatinine clearance > 50 to ≤ 80 mL/min; n = 198 for nab-P/C and n = 206 for sb-P/C) and 5% had moderate renal impairment (creatinine clearance ≤ 50 mL/min: n = 26 for nab-P/C and n = 27 for sb-P/C). For nab-P/C versus sb-P/C, the treatment difference in efficacy in patients with either level of renal impairment was comparable to the overall population but did not reach statistical significance, with an overall response rate of 35% versus 27% (response rate ratio, 1.324; P = .060) in patients with mild renal impairment, and 31% versus 19% (response rate ratio, 1.662; P = .300) in patients with moderate renal impairment. Overall survival and progression-free survival were nonsignificantly longer for nab-P/C versus sb-P/C in these subsets. Patients with renal impairment experienced less grade 3 or higher neutropenia and sensory neuropathy, but more thrombocytopenia and anemia with nab-P/C versus sb-P/C.

CONCLUSION

nab-P/C proved beneficial and tolerable in patients with advanced NSCLC and mild and moderate renal impairment.

Body mass index and its association with clinical outcomes for advanced non-small-cell lung cancer patients enrolled on Eastern Cooperative Oncology Group clinical trials

INTRODUCTION

Obesity increases the risk of death from many adverse health outcomes and has also been linked with cancer outcomes. The impact of obesity on outcomes of advanced non-small-cell lung cancer patients is unclear.

METHODS

The authors evaluated the association of body mass index (BMI) and outcomes in 2585 eligible patients enrolled in three consecutive first-line trials conducted by the Eastern Cooperative Oncology Group. BMI was categorized as underweight (BMI < 18.5 kg/m), normal weight (BMI: 18.5 to < 25 kg/m), overweight (BMI: 25 to < 30 kg/m), and obese (BMI ≥ 30 kg/m). In addition to analyzing overall and progression-free survival, reasons for treatment discontinuation were also assessed by BMI group.

RESULTS

Of the patients enrolled, 4.6% were underweight, 44.1% were normal weight, 34.3% of patients were classified as overweight, and 16.9% were obese. Nonproportional hazards existed for obese patients relative to the other three groups of patients, with a change in overall survival hazard occurring at approximately 16 months. In multivariable Cox models, obese patients had superior outcomes earlier on study compared with normal/overweight patients 0.86 (HR=0.86, p=0.04; 95% CI: 0.75-0.99), but later experienced increased hazard (HR=1.54, p< 0.001; 95% CI: 1.22-1.94), indicating a time effect while undergoing treatment.

CONCLUSION

Data from these three trials suggest differential outcomes associated with BMI, and additional studies of the mechanisms underlying this observation, as well as dietary and lifestyle interventions, are warranted to help optimize therapy.

Maintenance Therapy for Advanced Lung Cancer: Who, What, and When?

A 60-year-old woman with hypertension, dyslipidemia, and 35–pack-year smoking history is referred for treatment of advanced non–small-cell lung cancer (NSCLC). She initially presented after a transient ischemic attack, when a chest radiograph demonstrated a right lung mass. Computed tomography (CT) of the chest revealed a 5-cm right upper lobe mass, without mediastinal adenopathy, and a 6-cm cystic mass in the spleen. Additional imaging showed no brain metastasis. Endobronchial ulstrasound-guided core biopsies of the lung mass and ipsilateral mediastinal nodes confirmed a poorly differentiated non–small-cell carcinoma. Immunohistochemical stains were positive for napsin A and thyroid transcription factor 1, suggestive of adenocarcinoma ( Fig 1 ). Molecular analysis identified a KRAS G12C mutation. A positron emission tomography (PET) –CT scan demonstrated [18F]fluorodeoxyglucose uptake in the right upper lobe mass and splenic lesion ( Fig 2 A). CT-guided fine-needle aspiration of the splenic lesion was performed and revealed metastatic carcinoma, consistent with the lung primary. Treatment with carboplatin plus pemetrexed was initiated, without bevacizumab because of the recent transient ischemic attack; carboplatin was selected over cisplatin because of similar concerns. The patient received two cycles of chemotherapy without complications, and repeat imaging showed decrease in size of the lung mass and splenic lesion ( Figs 2 B and 2 C). After four cycles of chemotherapy, a chest CT showed ongoing response ( Fig 2 D). Her Eastern Cooperative Oncology Group performance status remained 0.