Predictors of survival for younger patients less than 50 years of age with non-small cell lung cancer (NSCLC): a California Cancer Registry analysis

A Nomogram for Predicting Cancer-Specific Survival in Young Patients With Advanced Lung Cancer Based on Competing Risk Model

BACKGROUND

Young lung cancer is a rare subgroup accounting for 5% of lung cancer. The aim of this study was to compare the causes of death (COD) among lung cancer patients of different age groups and construct a nomogram to predict cancer-specific survival (CSS) in young patients with advanced stage.

METHODS

Lung cancer patients diagnosed between 2004 and 2015 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and stratified into the young (18-45 years) and old (> 45 years) groups to compare their COD. Young patients diagnosed with advanced stage (IVa and IVb) from 2010 to 2015 were reselected and divided into training and validation cohorts (7:3). Independent prognostic factors were identified through the Fine-Gray's test and further integrated to the competing risk model. The area under the receiver operating characteristic curve (AUC), consistency index (C-index), and calibration curve were applied for validation.

RESULTS

The proportion of cancer-specific death (CSD) in young patients was higher than that in old patients with early-stage lung cancer (p < 0.001), while there was no difference in the advanced stage (p = 0.999). Through univariate and multivariate analysis, 10 variables were identified as independent prognostic factors for CSS. The AUC of the 1-, 3-, and 5-year prediction of CSS was 0.688, 0.706, and 0.791 in the training cohort and 0.747, 0.752, and 0.719 in the validation cohort. The calibration curves demonstrated great accuracy. The C-index of the competing risk model was 0.692 (95% CI: 0.636-0.747) in the young patient cohort.

CONCLUSION

Young lung cancer is a distinct entity with a different spectrum of competing risk events. The construction of our nomogram can provide new insights into the management of young patients with lung cancer.

Tackling Non-Small Cell Lung Cancer in Young Adults: From Risk Factors and Genetic Susceptibility to Lung Cancer Profile and Outcomes

Lung cancer has traditionally been associated with advanced age; however, its increasing incidence among young adults raises concerning questions regarding its etiology and unique considerations for this population. In contrast to the older population, the onset of lung cancer at younger age may be attributed to a complex interplay of incompletely understood individual susceptibility and prevalent environmental risk factors beyond tobacco smoke exposure, such as radon gas and air pollution, which are widespread globally. Consequently, this leads to distinct clinical and molecular profiles, requiring a tailored approach. Furthermore, a diagnosis of cancer represents a threatening event during the prime years of a young person's life, prompting concern about career development, social aspects, fertility aspirations, and physical independence. This poses significant additional challenges for health care professionals in a field that remains underexplored. This comprehensive review recognizes lung cancer in young adults as a distinct entity, exploring its clinical and molecular characteristics, diverse predisposing factors, and priorities in terms of quality of life, with the aim of providing practical support to oncologists and enhancing our understanding of this under-researched population.

Machine-Learning-Aided Prediction of Brain Metastases Development in Non-Small-Cell Lung Cancers

PURPOSE

Non-small-cell lung cancer (NSCLC) shows a high incidence of brain metastases (BM). Early detection is crucial to improve clinical prospects. We trained and validated classifier models to identify patients with a high risk of developing BM, as they could potentially benefit from surveillance brain MRI.

METHODS

Consecutive patients with an initial diagnosis of NSCLC from January 2011 to April 2019 and an in-house chest-CT scan (staging) were retrospectively recruited at a German lung cancer center. Brain imaging was performed at initial diagnosis and in case of neurological symptoms (follow-up). Subjects lost to follow-up or still alive without BM at the data cut-off point (12/2020) were excluded. Covariates included clinical and/or 3D-radiomics-features of the primary tumor from staging chest-CT. Four machine learning models for prediction (80/20 training) were compared. Gini Importance and SHAP were used as measures of importance; sensitivity, specificity, area under the precision-recall curve, and Matthew's Correlation Coefficient as evaluation metrics.

RESULTS

Three hundred and ninety-five patients compromised the clinical cohort. Predictive models based on clinical features offered the best performance (tuned to maximize recall: sensitivity∼70%, specificity∼60%). Radiomics features failed to provide sufficient information, likely due to the heterogeneity of imaging data. Adenocarcinoma histology, lymph node invasion, and histological tumor grade were positively correlated with the prediction of BM, age, and squamous cell carcinoma histology were negatively correlated. A subgroup discovery analysis identified 2 candidate patient subpopulations appearing to present a higher risk of BM (female patients + adenocarcinoma histology, adenocarcinoma patients + no other distant metastases).

CONCLUSION

Analysis of the importance of input features suggests that the models are learning the relevant relationships between clinical features/development of BM. A higher number of samples is to be prioritized to improve performance. Employed prospectively at initial diagnosis, such models can help select high-risk subgroups for surveillance brain MRI.

Serum cytokine levels and other associated factors as possible immunotherapeutic targets and prognostic indicators for lung cancer

Lung cancer is one of the most prevalent cancer types and the leading cause of cancer-related deaths worldwide. Non-small cell lung cancer (NSCLC) accounts for 80-85% of all cancer incidences. Lung cancer therapy and prognosis largely depend on the disease's degree at the diagnosis time. Cytokines are soluble polypeptides that contribute to cell-to-cell communication, acting paracrine or autocrine on neighboring or distant cells. Cytokines are essential for developing neoplastic growth, but they are also known to operate as biological inducers following cancer therapy. Early indications are that inflammatory cytokines such as IL-6 and IL-8 play a predictive role in lung cancer. Nevertheless, the biological significance of cytokine levels in lung cancer has not yet been investigated. This review aimed to assess the existing literature on serum cytokine levels and additional factors as potential immunotherapeutic targets and lung cancer prognostic indicators. Changes in serum cytokine levels have been identified as immunological biomarkers for lung cancer and predict the effectiveness of targeted immunotherapy.

Prognostic value of pretherapeutic FDG PET/CT in non-small cell lung cancer with pulmonary lymphangitic carcinomatosis

Pulmonary lymphangitic carcinomatosis (PLC) is associated with a poor prognosis in patients with non-small cell lung cancer (NSCLC). We sought to determine prognostic value of pretherapeutic fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in NSCLC with radiologically diagnosed PLC. We retrospectively reviewed 50 NSCLC patients with radiologically diagnosed PLC. Among eight clinical variables and five imaging parameters, metabolic PLC burden, which represents the overall tumor burden of PLC, and cPLC, which represents the location and extent of PLC in a three-grade system, were used. In multivariate analyses for progression-free survival, metabolic PLC burden (P = 0.0181), cPLC (P = 0.0401), and clinical stage (P = 0.0284) were identified as independent prognostic factors. High metabolic PLC burden had a worse prognosis, and the prognosis of cPLC3 was significantly worse than that of cPLC1 or cPLC2. In univariate analyses for overall survival, only age (P = 0.0073) was identified a prognostic factor. In conclusion, FDG PET/CT parameters were identified as independent prognostic factors in NSCLC with radiologically diagnosed PLC. Furthermore, a combination of anatomical and metabolic information about PLC obtained using FDG PET/CT provides insight into the overall tumor burden of PLC and is useful in predicting prognosis.

Immunotherapy-based combination strategies for treatment of EGFR-TKI-resistant NSCLC

The rapid development of molecular targeted therapy brings hope to patients with advanced non-small-cell lung cancer (NSCLC). However, drug resistance inevitably occurs during treatment with EGFR-tyrosine kinase inhibitors (TKIs). Osimertinib, a third-generation EGFR-TKI, shows a favorable prognosis in T790M-positive NSCLC. Unfortunately, acquired resistance is still a challenge for both patients and clinicians. There is still no consensus on the optimal treatment. PD-1 and its ligand receptor 1 (PD-L1) inhibitors have yielded great progress, especially in patients with no actionable mutations. In this review, the authors take stock of the relationship between EGFR mutations and PD-L1 expression and summarize the important clinical studies on immunotherapy-inhibitor-based treatment in patients with EGFR-TKI-resistant NSCLC.

Real-world data prognostic model of overall survival in patients with advanced NSCLC receiving anti-PD-1/PD-L1 immune checkpoint inhibitors as second-line monotherapy

Background and aim

The objective of this retrospective, observational, noninterventional cohort study was to investigate prognostic factors of overall survival (OS) in patients with advanced non‐small cell lung cancer (aNSCLC) and to develop a novel prognostic model.

Methods

A total of 4049 patients with aNSCLC diagnosed between January 2011 and February 2020 who received atezolizumab, nivolumab, or pembrolizumab as second‐line monotherapy were selected from a real‐world deidentified database to build the cohort. Patients could not have received first‐line treatment with clinical study drug(s) nor immune checkpoint inhibitors including anti‐programmed cell death 1 (PD‐1)/programmed death‐ligand 1 (PD‐L1), and anti‐cytotoxic T‐lymphocyte‐associated protein 4 therapies.

Results

Patients had a median age of 69 years; 45% were female, 75% White, 70% had stage IV at initial diagnosis, and 70% had nonsquamous histology. A Cox proportional hazards model with lasso regularization was used to build a prognostic model for OS using 18 baseline demographic and clinical factors based on the real‐world data cohort. The risk‐increasing prognostic factors were abnormally low albumin and chloride levels, Eastern Cooperative Oncology Group performance status score ≥ 2, and abnormally high levels of alkaline phosphatase and white blood cells. The risk‐decreasing prognostic factors were PD‐L1 positivity, longer time from advanced diagnosis to start of first‐line therapy, and higher systolic blood pressure. The performance of the model was validated using data from the OAK trial, and the c‐index for the OAK trial validation cohort was 0.65 and 0.67 for the real‐world data cohort.

Conclusions

Based on baseline demographic and clinical factors from a real‐world setting, this prognostic model was developed to discriminate the risk of death in patients with aNSCLC treated with checkpoint inhibitors as second‐line monotherapy, and it performed well in the real‐world data and clinical trial cohorts.

Pretreatment neutrophil-to-lymphocyte ratio and cigarette smoking as prognostic factors in patients with advanced NSCLC treated with osimertinib

Background

The remarkable efficacy of osimertinib in non‒small cell lung cancer (NSCLC) with acquired T790M mutation has been widely documented in clinical trials and real-world practice. However, some patients show primary resistance to this drug. Even patients who initially show a favorable response have inconsistent clinical outcomes later. Therefore, the aim of this study was to identify additional clinical predictive factors for osimertinib efficacy.

Methods

A prospective cohort of patients with acquired T790M positive stage IV lung adenocarcinoma treated with osimertinib salvage therapy in Hallym University Medical Center were analyzed.

Results

Sixty-one eligible patients were analyzed, including 38 (62%) women and 39 (64%) who never smoked. Their mean age was 63.3 years. The median follow-up after treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) was 36.0 months (interquartile range, 24.7–50.2 months). The majority (n=45, 74%) of patients were deceased. Based on univariate analysis, low baseline neutrophil-to-lymphocyte ratios (NLR), age ≥50 years, never-smoking history, stage IVA at osimertinib initiation, and prolonged response to previous TKIs (≥10 months) were associated with a significantly longer progression-free survival (PFS). Multivariate analysis showed that never-smoking status (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.30–0.98; p=0.041) and a baseline NLR less than or equal to 3.5 (HR, 0.23; 95% CI, 0.12–0.45; p<0.001) were independently associated with a prolonged PFS with osimertinib.

Conclusion

Smoking history and high NLR were independent negative predictors of osimertinib PFS in patients with advanced NSCLC developing EGFR T790M resistance after the initial EGFR-TKI treatment.

Ethnic Differences in Survival Among Lung Cancer Patients: A Systematic Review

Background

Despite a substantially worse risk factor profile, Hispanics in the United States experience lower incidence of many diseases and longer survival than non-Hispanic Whites (NHWs), an epidemiological phenomenon known as the Hispanic Health Paradox (HHP). This systematic review evaluated the published longitudinal literature to address whether this pattern extends to lung cancer survival.

Methods

Searches of Medline, PubMed, Embase, Web of Science, and the Cochrane Library were conducted for publications dated from January 1, 2000, to July 18, 2018. Records were restricted to articles written in English, employing a longitudinal design, and reporting a direct survival comparison (overall survival [OS], cancer-specific survival [CSS]) between NHW and Hispanic lung cancer patients.

Results

A final sample of 29 full-text articles were included, with 28 fully adjusted models of OS and 21 of CSS included. Overall, 26 (92.9%) OS models and 20 (95.2%) CSS models documented either no difference (OS = 16, CSS = 11) or a Hispanic survival advantage (OS = 10, CSS = 9). Both larger studies and those including foreign-born Hispanics were more likely to show a Hispanic survival advantage, and 2 studies of exclusively no-smokers showed a survival disadvantage. A number of reporting gaps were identified including Hispanic background and sociodemographic characteristics.

Conclusions

Hispanics exhibit similar or better survival in the context of lung cancer relative to NHWs despite a considerably worse risk factor profile. These findings support the HHP in the context of lung cancer. Further research is needed to understand the potential mechanisms of the HHP as it relates to lung cancer.

A fourteen-lncRNA risk score system for prognostic prediction of patients with non-small cell lung cancer

Growing evidence has underscored long non-coding RNAs (lncRNAs) serving as potential biomarkers for cancer prognosis. However, systematic tracking of a lncRNA signature for prognosis prediction in non-small cell lung cancer (NSCLC) has not been accomplished yet. Here, comprehensive analysis with differential gene expression analysis, univariate and multivariate Cox regression analysis based on The Cancer Genome Atlas (TCGA) database was performed to identify the lncRNA signature for prediction of the overall survival of NSCLC patients. A risk-score model based on a 14-lncRNA signature was identified, which could classify patients into high-risk and low-risk groups and show poor and improved outcomes, respectively. The receiver operating characteristic (ROC) curve revealed that the risk-score model has good performance with high AUC value. Multivariate Cox's regression model and stratified analysis indicated that the risk-score was independent of other clinicopathological prognostic factors. Furthermore, the risk-score model was competent for the prediction of metastasis-free survival in NSCLC patients. Moreover, the risk-score model was applicable for prediction of the overall survival in the other 30 caner types of TCGA. Our study highlighted the significant implications of lncRNAs as prognostic predictors in NSCLC. We hope the lncRNA signature could contribute to personalized therapy decisions in the future.

Characterization of pneumonia and other factors leading to poorer survival across all age groups in patients with non-small cell lung cancer (NSCLC)

Background

Lung cancer death rates and incidence in both men and women have decreased over the past two decades. However, certain subsets of non-small cell lung cancer (NSCLC) have arisen with poor outcomes. Identifying factors which contribute to poorer outcomes as well as those that inform early detection strategies remain unmet needs. We present data from a contemporaneous group of NSCLC patients that received care at a single University teaching hospital to understand clinical and pathological factors influencing outcomes in the past decade.

Methods

A cohort of 2,289 patients with NSCLC who established care at the Rogel Cancer Center, University of Michigan between January 2011 and April 2019 were identified. Patient characteristics and clinical outcomes were recorded using electronic health records. The Kaplan-Meier method and the Cox proportional model were used to assess relationship between clinic-pathological factors and survival.

Results

Of the 2,289 patients, 92% were >50 years of age while 8% were <50 years of age. The majority (70%) of older patients were former smokers. The majority (61%) of younger patients were diagnosed as having Stage IV NSCLC. Among younger patients, 87% had histologically confirmed non-squamous histology. Univariate analysis revealed that overall survival was significantly lower in patients diagnosed with pneumonia prior to the diagnosis of NSCLC than in those who were not diagnosed with pneumonia (1.9 vs. 21.8 months; P<0.001). Multivariate analysis revealed that older patients had poorer survival than younger patients (HR 1.57, 95% CI: 1.10–2.06, P=0.01) and that patients diagnosed with pneumonia prior to their lung cancer diagnosis had poorer survival across all age groups, particularly in those with advanced-stage disease.

Conclusions

Findings from this study merit prospective studies to understand cost-benefit ratio of follow- up cross sectional imaging of all patients diagnosed with unprovoked pneumonia, including in younger non/current smokers.

A nomogram prognostic model for large cell lung cancer: analysis from the Surveillance, Epidemiology and End Results Database

Background

Currently, there is no reliable method for predicting the prognosis of patients with large cell lung cancer (LCLC). The aim of this study was to develop and validate a nomogram model for accurately predicting the prognosis of patients with LCLC.

Methods

LCLC patients, diagnosed from 2007 to 2009, were identified from the Surveillance, Epidemiology and End Results (SEER) database and used as the training dataset. Significant clinicopathologic variables (P<0.05) in a multivariate Cox regression were selected to build the nomogram. The performance of the nomogram model was evaluated by the concordance index (C-index), the area under the curve (AUC), and internal calibration. LCLC patients diagnosed from 2010 to 2016 in the SEER database were selected as a testing dataset for external validation. The nomogram model was also compared with the currently used American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system (8^th edition) by using C-index and a decision curve analysis.

Results

Eight variables-age, sex, race, marital status, T stage, N stage, M stage, and treatment strategy-were statistically significant in the multivariate Cox model and were selected to develop the nomogram model. This model exhibited excellent predictive performance. The C-index and AUC value were 0.761 [95% confidence interval (CI), 0.754 to 0.768] and 0.886 for the training dataset and 0.773 (95% CI, 0.765 to 0.781) and 0.876 for the testing dataset, respectively. This model also predicted three-year and five-year lung cancer-specific survival (LCSS) in both datasets with good fidelity. This nomogram model performs significantly better than the 8th edition AJCC TNM staging system, with a higher C-index (P<0.001) and better net benefits in predicting LCSS in LCLC patients.

Conclusions

We developed and validated a prognostic nomogram model for predicting 3- and 5-year LCSS in LCLC patients with good discrimination and calibration abilities. The nomogram may be useful in assisting clinicians to make individualized decisions for appropriate treatment in LCLC.

Genomic profiling in non-small-cell lung cancer in young patients. A systematic review

Lung cancer in young patients is an uncommon and understudied entity that harbors distinctive epidemiological, clinic-demographic, and genomic features. We carried out a systematic review of genomic profiling in young patients with lung cancer from 2010 to 2020 in the main electronic databases and selected 23 manuscripts. Lung cancer in young patients occurs more frequently in women with adenocarcinoma histology and at more advanced stages. Some studies report higher oncogenic genomic alteration in this population, with higher anaplastic lymphoma kinase rearrangements, a distinct profile of epidermal growth factor receptor mutations, and other novel genomic alterations. Although still uncommon, the implementation of next-generation sequencing (NGS) has shed some light on germline genomic alterations associated with lung cancer in young patients. Although outcomes when compared with the older population are conflicting, the overall prognosis is still poor in this subset of patients and efforts to find targetable genomic alterations should be made to improve survival.

Clinical and Imaging Features of Non-Small-Cell Lung Cancer in Young Patients

BACKGROUND

Non-small-cell lung cancer (NSCLC) in young adult patients is rare, with scarce data available in patients aged < 40 years and even less in those aged < 35 years. Our goal was to determine the presenting symptoms, clinicopathologic characteristics, and imaging features of young patients with NSCLC at time of diagnosis and compare them to those of older adults.

PATIENTS AND METHODS

We retrospectively analyzed the medical records and imaging of young patients (≤ 40 years old) with NSCLC treated at our institution between 1998 and 2018. Patients < 35 years old were compared to those between 35 and 40 years old. Characteristics of patients ≤ 40 years old were compared to older patients (> 40 years) from publicly available data sets.

RESULTS

We identified 166 young patients with NSCLC (median age, 36.6 years; range, 18-40 years). Most presented with nonspecific respiratory symptoms and were diagnosed with pneumonia (84/136, 62%). Compared to patients < 35 years old, patients 35-40 years old were more likely to have malignancy detected incidentally (15% vs. 5%, P = .04). Patients < 35 years old were more likely to have central tumors (55% vs. 33%, P = .02) and to have bone (38% vs. 19%, P = .007) and lung (39% vs. 24%, P = .03) metastases. Compared to older patients (> 40 years), young patients were more likely to be never smokers (65.0% vs. 14.7%, P < .001) and to have advanced disease (88% vs. 66%, P < .001).

CONCLUSION

Young patients with NSCLC often present with nonspecific symptoms and have advanced disease at diagnosis, often mimicking other pathologies. Awareness of the clinical presentation and imaging features of NSCLC in young patients may help minimize delays in diagnoses.

Non-Small Cell Lung Cancer in Young Patients: An Analysis of Clinical, Pathologic and TNM Stage Characteristics Compared to the Elderly

Purpose

To compare clinicopathologic factors including tumor-node-metastasis (TNM) stage between young and elderly patients with non-small cell lung cancer (NSCLC).

Methods

This retrospective study compared the following characteristics between 52 young patients with NSCLC (<50 years of age) and 67 elderly patients with NSCLC (>60 years): duration of symptoms before medical consultation, smoking index, family history of cancer, Ki-67 index, and pTNM stage. A binary logistic regression analysis was used to identify factors predictive of greater stage NSCLC (stage III/IV compared to stage I/II) within each age group.

Results

The incidence of adenocarcinoma was higher in the young than in the elderly (P=0.006). Smoking index (P=0.002) and Ki-67 index (P<0.001) were lower in the young than in the elderly. In young patients with NSCLC, delayed treatment (greater duration from symptoms to medical consultation, P=0.050) and active tumor proliferation (higher Ki-67 index, P=0.003) were predictive of more advanced cancer stage (III/IV), with only symptom duration being predictive of stage III/IV NSCLC among elderly patients. Among young patients, cough (P=0.021) and chest congestion (P=0.040) were the most significant warning symptoms of advanced-stage NSCLC.

Conclusion

High tumor proliferation and delayed treatment are predictive of advanced NSCLC on presentation among young individuals. Early diagnosis by imaging, such as with the use of low dose computed tomography (LDCT), for young individuals with coughing and chest congestion over 1 month might be effectiveto improve prognosis and outcomes.

Younger patients operated for lung cancer have a better prognosis

Background

The incidence of lung cancer in the population of patients younger than 50 years of age is relatively low. The aim of this study was to compare the clinical outcomes of patients with early lung cancer onset (ELCO, onset before the age of 50) and late lung cancer onset (LLCO, onset after the age of 50).

Methods

We have retrospectively analyzed the prospectively collected data of 1,518 patients with lung cancer treated in a Thoracic Surgery Department in the years 2007–2015. Including carcinoid tumors for the analysis may blur ELCO and LLCO population comparison; therefore we have made three analyses. We have compared overall survival (OS) in unmatched (86 patients with ELCO and 1,432 patients with LLCO) and matched the populations (with the use of propensity-score matched analysis).

Results

In comparison of unmatched patients, five-year survival in patients with ELCO was 71.9% compared to 58.7% in LLCO patients (P=0.008). In comparison of matched populations (comparing sex, pTNM, type of operation, pathological diagnosis and Charlson Comorbidity Index) five-year survival in patients with ELCO was 77.6% comparing to 61.5% in LLCO patients P<0.001). After exclusion of rare histological types of lung cancer and advanced stages no significant difference in survival rates was discovered comparing ELCO patients with LLCO patients, although there was still a trend towards better survival in ELCO patients (P=0.086).

Conclusions

Patients with ELCO have higher five-year survival after surgical treatment compared to patients with LLCO.

Non-small cell lung cancer in the very young: Higher EGFR/ALK mutation proportion than the elder

BACKGROUND

This study aimed to analyze pathologic characteristics, treatment, prognosis, and tumor epidermal growth factor receptor/anaplastic large-cell lymphoma kinase (EGFR/ALK) mutation proportion of non-small cell lung cancer (NSCLC) patients aged <40 years at diagnosis.

METHODS

We retrospectively reviewed data of NSCLC patients diagnosed at Taipei Veterans General Hospital between June 2007 and December 2014, aged <90 years at the time of the diagnosis.

RESULTS

We found 5051 cases of NSCLC, including 168 patients who were <40 years (younger group) and 4883 patients aged 40 to 89 years (older group). We found that the younger group had a significantly higher proportion of the EGFR mutation (22.6% vs 16.2%, p = 0.026) and the ALK mutation (4.2% vs 0.5%, p < 0.001) than the older group. Although the younger group included more stage IV patients (60.1% vs 49.6%, p = 0.002), it had a better overall survival (OS) rate (1 year: 73.7% vs 66.2%, p = 0.043; 5 years: 44.4% vs 33.7%, p = 0.004) (median survival time: 55 vs 26 months, p = 0.002). About the histologic subtype of NSCLC, the younger group presented less frequent cases of squamous cell carcinoma (4.2% vs 16.1%, p < 0.001), whereas the adenocarcinoma subtype was similarly frequent in the two groups (76.8% vs 76.5%, p = 0.924).

CONCLUSION

The OS rate in younger NSCLC patients was higher than that in the older NSCLC patients, despite the higher rate of stage IV NSCLC patients in the younger group. This survival benefit is most likely due to the higher proportion of the EGFR and ALK mutations and the corresponding tyrosine kinase inhibitor treatment.

Socioeconomic disparity trends in diagnostic imaging, treatments, and survival for non-small cell lung cancer 2007-2016

Socioeconomic status (SES) has led to treatment and survival disparities; however, limited data exist for non‐small cell lung cancer (NSCLC). This study investigates the impact of SES on NSCLC diagnostic imaging, treatment, and overall survival (OS), and describes temporal disparity trends. The Ontario Cancer Registry was used to identify NSCLC patients diagnosed between 2007 and 2016. Through linkage to administrative datasets, patients’ demographics, imaging, treatment, and survival were obtained. Based on median household neighborhood income, the Ontario population was divided into five income quintiles (Q1‐Q5; Q1 = lowest income). Multivariable regressions assessed SES association with OS, imaging, treatment receipt, and treatment delay, and their interaction with year of diagnosis to understand temporal trends. Endpoints were adjusted for demographics, stage and comorbidities, along with treatments and imaging for OS. A total of 50 542 patients were identified. Higher SES patients (Q5 vs. Q1) showed improved 5‐year OS (hazard ratio, 0.89; 95% confidence interval [CI], 0.87‐0.92; P < .0001) and underwent greater magnetic resonance imaging head (stages IA‐IV; odds ratio [OR], 1.24; 95% CI, 1.16‐1.32; P < .0001), lung resection (IA‐IIIA; OR, 1.58; 95% CI, 1.43‐1.74; P < .0001), platinum‐based vinorelbine adjuvant chemotherapy (IB‐IIIA; OR, 1.63; 95% CI, 1.39‐1.92; P < .0001), palliative radiation (IV; OR, 1.14; 95% CI, 1.05‐1.25; P = .023), and intravenous chemotherapy (IV; OR, 1.45; 95% CI, 1.32‐1.60; P < .0001). Lower SES patients underwent greater thoracic radiation (IA‐IIIB; OR, 0.86; 95% CI, 0.79‐0.94; P = .0003). Across 2007‐2016, socioeconomic disparities remain largely unchanged (interaction P > .05) despite widening income inequality.

Development of a Survival Prognostic Model for Non-small Cell Lung Cancer

Lung cancer is a leading cause of cancer-related death, and >80% of lung cancer diagnoses are non-small-cell lung cancer (NSCLC). However, when using current staging and prognostic indices, the prognosis can vary significantly. In the present study, we calculated a prognostic index for predicting overall survival (OS) in NSCLC patients. The data of 545 NSCLC patients were retrospectively reviewed. Univariate and multivariate Cox proportional hazards regression analyses were performed to evaluate the prognostic value of clinicopathological factors. Age (hazard ratio [HR] = 1.25, 95% confidence interval [CI] = 1.02–1.54), TNM stage (III, HR = 1.64, 95% CI = 1.08–2.48; IV, HR = 2.33, 95% CI = 1.48–3.69), lung lobectomy (HR = 1.96, 95% CI = 1.45–2.66), chemotherapy (HR = 1.42, 95% CI = 1.15–1.74), and pretreatment hemoglobin level (HR = 1.61, 95% CI = 1.28–2.02) were independent prognosticators. A prognostic index for NSCLC (PInscl, 0–6 points) was calculated based on age (≥65 years, 1 point), tumor-node-metastasis (TNM) stage (III, 1 point; IV, 2 points), lung lobectomy (no, 1 point), chemotherapy (no, 1 point), and pretreatment hemoglobin level (low, 1 point). In comparison with the “PInscl = 0” subgroup (survival time = 2.71 ± 1.86 years), the “PInscl = 2” subgroup (survival time = 1.86 ± 1.24 years), “PInscl = 3” subgroup (survival time = 1.45 ± 1.07 years), “PInscl = 4” subgroup (survival time = 1.17 ± 1.06 years), “PInscl = 5” subgroup (survival time = 0.81 ± 0.78 years), and “PInscl = 6” subgroup (survival time = 0.65 ± 0.56 years) exhibited significantly shorter survival times. Kaplan-Meier survival analysis showed that patients with higher PInscl scores had poorer OS than those with lower scores (log-rank test: χ² = 155.82, P < 0.0001). The area under the curve of PInscl for predicting the 1-year OS was 0.73 (95 % CI = 0.69–0.77, P < 0.001), and the PInscl had a better diagnostic performance than the Karnofsky performance status or TNM stage (P < 0.01). In conclusion, the PInscl, which is calculated from age, TNM stage, lung lobectomy, chemotherapy, and pretreatment hemoglobin level, significantly predicted OS in NSCLC patients.

Socioeconomic differences and lung cancer survival in Germany: Investigation based on population-based clinical cancer registration

OBJECTIVES

Studies from several countries reported socioeconomic inequalities in lung cancer survival. Hypothesized reasons are differences in cancer care or tumor characteristics. We investigated associations of small-area deprivation and lung cancer survival in Germany and the possible impact of differences in patient, tumor or treatment factors.

MATERIALS AND METHODS

Patients registered with a primary tumor of the lung between 2000-2015 in three German population-based clinical cancer registries were included. Area-based socioeconomic deprivation on municipality level was measured with the categorized German Index of Multiple Deprivation. Association of deprivation with overall survival was investigated with Cox regression models.

RESULTS

Overall, 22,905 patients were included. Five-year overall survival from the least to the most deprived quintile were 17.2%, 15.9%, 16.7%, 15.7%, and 14.4%. After adjustment for patient and tumor factors, the most deprived group had a lower survival compared to the least deprived group (Hazard Ratio (HR) 1.06, 95% confidence interval (CI) 1.01-1.11). Subgroup analyses revealed lower survival in the most deprived compared to the least deprived quintile in patients with stage I-III [HR: 1.14, 95% CI: 1.06-1.22]. The association persisted when restricting to patients receiving surgery but was attenuated for subgroups receiving either chemotherapy or radiotherapy.

CONCLUSION

Our results indicate differences in lung cancer survival according to area deprivation in Germany, which were more pronounced in patients with I-III stage cancer. Future research should address in more detail the underlying reasons for the observed inequalities and possible approaches to overcome them.

Molecular and clinical analysis of Chinese patients with anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancer

Anaplastic lymphoma kinase (ALK) fusions have been recognized as a therapeutic target in non‐small cell lung cancer (NSCLC). However, molecular signatures and clinical characteristics of the Chinese population with ALK‐rearranged NSCLC are not well elucidated. In the present study, we carried out targeted next‐generation sequencing on tissue and plasma ctDNA samples in 1688 patients with NSCLC. Overall, ALK fusions were detected in 70 patients (4.1%), and the frequencies of ALK fusions detected in tissue and plasma samples were 5.1% and 3.3%, respectively. Additionally, the prevalence of breakpoint locations for EML4‐ALK fusions in ctDNA was significantly correlated with that in tumor tissues (R² = .91, P = .045). According to age, the incidence rates of ALK fusions among young (age <45 years), middle‐aged (between 45 and 70 years) and elderly (>70 years) patients were significantly different (P < .001). In 70 ALK‐rearranged cases, coexistence of epidermal growth factor receptor (EGFR) alterations and ALK fusions was detected in 12 cases (17.1%) and EGFR mutations tended to coexist with non‐EML4‐ALK rearrangements. Notably, novel ALK fusion partners, including TRIM66,SWAP70,WNK3,ERC1,TCF12 and FBN1 were identified in the present study. Among EML4‐ALK fusion variants, patients with variant V1 were younger than patients with variant V3 (P = .023), and TP53 mutations were more frequently concurrent with variant V3 compared with variant V1 (P = .009). In conclusion, these findings provide new insights into the molecular‐clinical profiles of patients with ALK‐rearranged NSCLC that may improve the treatment strategy of this population.

TNM stages inversely correlate with the age at diagnosis in ALK-positive lung cancer

BACKGROUND

To clearly reveal the correlations between age at diagnosis, tumor-nodes-metastasis (TNM) stages and frequency of ALK-positive lung cancer.

METHODS

We reviewed patients who presented with ALK rearrangements (n=411) or KRAS-mutations (n=122) between September 2010 and January 2018. The clinical characteristics and overall survival were analyzed for the two genotype cohorts and stratified by different age categories (<40, 40-49, 50-59, ≥60 years).

RESULTS

In the ALK-positive cohort, the younger group showed more frequent disease in the T3/4 stage (P=0.014), lymph node metastasis (P=0.011) and distant metastasis (P=0.015) than the older groups. Meanwhile, the mean age at diagnosis for the ALK-positive patients showed a significant inverse correlation with the clinical stages (stage I/II vs. III vs. IV, 54.7 vs. 52.0 vs. 49.7 years; P<0.001), as well as with the T, N, and M categories. However, KRAS-mutant patients did not exhibit similar relationships to those observed in ALK-positive patients. Importantly, for ALK-positive patients, the frequency of stage IIIb-IV disease was almost twice that of stage I-IIIa disease (6.1% vs. 3.4%, P<0.001); there was a similar incidence of the different disease stages in KRAS-mutant lung cancer (P=0.924). Lastly, in ALK-positive patients, the ≥60 years group was associated with a trend toward better survival than the other younger groups.

CONCLUSIONS

The TNM stages exhibited a significant inverse correlation with age at diagnosis for ALK-positive lung cancer patients. More unique therapeutic strategies should be required in these young patients.

Improved long-term survival following pulmonary resections for non-small cell lung cancer: results of a nationwide study from Iceland

Background

We studied the outcome of pulmonary resection with curative intent for non-small cell lung cancer (NSCLC) in a nationwide study covering a 24-year period, focusing on survival.

Methods

All patients who underwent pulmonary resection for NSCLC in Iceland in the period 1991-2014 were reviewed for demographics, TNM stage and survival. Median length of follow-up was 45 months. Three 8-year periods were compared, overall survival was estimated, and prognostic factors for survival were identified.

Results

Altogether, 652 surgical resections were performed on 644 individuals (52% females): 492 lobectomies (75%), 77 pneumonectomies (12%), and 83 sublobar resections (13%). Mean age increased from 65 to 68 yrs during the study period (P=0.002). The number of cases operated at stage IA increased substantially between the first and last periods (29% vs. 37%; P<0.001). Survival improved from 75% to 88% at 1 year and from 38% to 53% at 5 years (P<0.001). Independent prognostic factors for mortality were advanced TNM stage (HR =2.68 for stage IIIA vs. I), age (HR =1.04), ischaemic heart disease (HR =1.26), any minor complication (HR =1.26), and sublobar resection (HR =1.33), but surgical margins free from tumour growth (HR =0.59) and treatment during the latter two eight-year periods were predictors of lower mortality. The best survival was seen between 2007 and 2014 (HR =0.61, 95% CI: 0.48-0.78; P<0.001).

Conclusions

Survival of patients who have undergone pulmonary resection for NSCLC has improved significantly in Iceland. This may be explained by the increased number of patients diagnosed at lower stages and improved preoperative staging, with fewer understaged patients.

Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis

Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival.

Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures.

Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08–1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis.

Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.

Driver mutations of young lung adenocarcinoma patients with malignant pleural effusion

Young lung cancer patients have several distinct characteristics. However, there are limited epidemiological data of genetic abnormalities in this population. We conducted a prospective cohort study to delineate the various oncogenic driver mutations of lung adenocarcinoma in young Asian patients. We consecutively collected malignant pleural effusions (MPEs) from lung adenocarcinoma patients. RNA was extracted from MPEs for mutation analysis by reverse transcription-polymerase chain reaction and direct sequencing. Selected gene mutations for testing included EGFR, HER2, BRAF, KRAS, PIK3CA, JAK2, MEK1, NRAS, and AKT2 mutations, as well as EML4-ALK, ROS1, and RET fusions. We collected MPEs from 142 patients aged ≤50 years and 730 patients aged >50 years. Patients aged ≤50 years (91%) had a higher incidence of driver gene mutations than those aged >50 years (84%; P = .036), especially EML4-ALK (P < .001) and ROS1 (P < .001). Among patients aged ≤50 years, EGFR mutation was the major oncogenic driver mutation. The mutation rates of other genes were 18% EML4-ALK, 6% ROS1, 5% HER2, 1% RET, 1% BRAF, and 1% KRAS. We did not detect PIK3CA, JAK2, MEK1, NRAS, or AKT2 mutations. No difference in gender or smoking history was noted among those with different driver mutations. Patients who had a good performance status or received appropriate targeted therapy had longer overall survival. In conclusion, lung adenocarcinoma in Asian patients aged ≤50 years had a higher gene mutation rate than in those aged >50 years, especially EML4-ALK and ROS1 fusion. Mutation analysis may be helpful in determining targeted therapy for the majority of these patients.

Expression profiling and microRNA regulation of the LKB1 pathway in young and aged lung adenocarcinoma patients

Lung cancer in young patients appears to have distinct clinicopathological features. The present study focused on the role of the serine/threonine kinase liver kinase B1 (LKB1), a known tumor suppressor gene, and its miRNA regulation in lung adenocarcinoma, particularly in young versus elderly patients. A total of 88 patients with lung adenocarcinoma were retrospectively analysed. A simultaneous quantification was performed of the expression of LKB1 mRNA and 15 microRNAs (miRNA/miRs; miRs −93, −96, −34a, −34c, −214, −33a, −30b, −145, −182, −30c, −183, −29b, −29c, −153 and −138) involved in the LKB1 pathway, as well as of 5 identified target mRNAs [cyclin D1 (CCND1), catenin β-1 (CTNNB1), lysyl oxidase (LOX), yes-associated protein 1 (YAP1) and survivin], using NanoString technology. KRAS mutations were investigated by pyrosequencing analysis. Patients ≤50 years were defined as a younger group, while patients >50 years old as an older group (n=44/group). No difference between the two groups was identified in terms of survival times analysed using the Kaplan-Meier method or KRAS mutations. Subsequently, the LKB1 signalling pathway was focused on, as a target for therapy in lung adenocarcinoma, and assessed with regards to clinicopathological features; we found that LOX levels in adenocarcinoma patients were significantly associated with histological subtype (P=0.03), stage (P<0.0001) and prognosis (P=0.02 for disease-free interval and P=0.005 for overall survival), but not with age. Furthermore, the miRNA target prediction model indicated that miR-93 and miR-30b appeared to have functional binding sites and downregulate the gene expression of LKB1 and LOX, respectively. In conclusion, young patients appeared have similar survival rates to elderly patients. The assessment of LKB1, its downstream genes and its regulation by miRNAs may have an impact on future research on lung adenocarcinoma in young and elderly patients. Further investigations will be necessary to elucidate the potential of this pathway as a novel target for therapy.

Esophageal cancer in patients under 50: a SEER analysis

Background

Concomitant with rising rates of esophageal adenocarcinoma, there has been a significant increase of diagnoses among relatively younger individuals. However, most studies that focus on esophageal cancer (EC) in younger patients have had small sample sizes of patients treated at a single institute. The aim of this study was to analyze the clinical characteristics, outcomes and independent prognostic factors for EC in patients under 50-year-old using a large, multi-center dataset.

Methods

The national Surveillance, Epidemiology, and End Results (SEER) database was analyzed for EC reported from 2004 to 2013. Patients were divided into two groups, those under 50-year-old and those 50 years or older, and comparisons were made regarding demographics, histology, stage distribution, treatment, overall survival (OS), and esophageal cancer-specific survival (ECSS). Multivariate Cox proportional hazard regression analyses were also used to identify independent prognostic factors.

Results

Among the 16,544 eligible patients, 1,385 (8.37%) were under 50 and 15,159 (91.63%) were over 50. Compared with the older group, patients under 50 were characterized by a higher frequency of males, lower esophagus involvement, adenocarcinoma histology, stage III/IV disease, and receiving esophagectomy or radiation therapy. The stage-wise OS and ECSS were significantly better in the younger group (P<0.001). The multivariate analysis indicated that African-American heritage, grade III or IV, later stage, and not undergoing surgical or radiation therapy were independent negative prognostic factors of ECSS for patients under 50.

Conclusions

EC patients under 50-year-old had distinctive clinicopathological characteristics compared with patients over 50-year-old. Despite more often presenting with stage III and IV disease, survival rates were better in the younger cohort. Prognostic factors for ECSS in patients under 50 differed from those in all age patients.

Frequent genomic alterations and better prognosis among young patients with non-small-cell lung cancer aged 40 years or younger

BACKGROUND

The subgroup of young patients with non-small-cell lung cancer (NSCLC) is poorly understood. We retrospectively studied the clinical characteristics, gene mutations, and outcomes of patients with NSCLC (aged ≤ 40 years).

RESULTS

Of the 7494 patients with lung cancer diagnosed from February 2001 to October 2016, 252 aged ≤ 40 years showed NSCLC. We divided their cases into non-squamous cell carcinoma and squamous cell carcinoma groups according to their histology results. Of the 252 young NSCLC patients, 173 (69%) patients had stage IIIB or IV, and 196 (78%) had never smoked. The four most common metastases were intrapulmonary lesions, pleura, bone, and brain. Among patients with adenocarcinoma, 29 (40%, n = 73) harbored epidermal growth factor receptor (EGFR) mutations, 25 (34%, n = 74) harbored anaplastic lymphoma kinase (ALK) translations, and 1 (14%, n = 7) harbored ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) translations. The median progression-free survival (PFS) and overall survival (OS) were 3.3 and 27.6 months for patients receiving chemotherapy (n = 65), and 12.1 and 33.6 months for patients receiving EGFR tyrosine kinase inhibitors (TKIs) (n = 13), respectively. Patients receiving crizotinib had a median PFS time of 21.9 months (n = 8).

CONCLUSIONS

Young patients are associated with an increased likelihood of gene mutations and can receive a better prognosis when patients harboring gene mutations are treated with EGFR-TKIs or ALK inhibitors.

Development and validation of a prognostic index for survival in non-small cell lung cancer: Results from a Tunisian cohort study

INTRODUCTION

Despite the continuous efforts made with the TNM system, the issue of heterogeneity of prognosis within the stages of non-small cell lung cancer (NSCLC) could not be resolved. Our aim was to identify prognostic factors and develop an index to predict NSCLC survival with greater accuracy.

METHODS

We conducted a survival study over 5 years on patients with NSCLC. Kaplan-Meier analysis followed by Cox regression modelling were used. Prognostic indices were derived, using either an additive or a multiplicative pattern, and were compared by their receiver operating characteristics (ROC) curves. We then proceeded to a risk stratification and validation of the index on the derivation cohort.

RESULTS

Two hundred and sixty-two NSCLC patients were included. Two models were constructed, using the following nine variables as prognostic factors: age, performance status, haemoglobin level, leucocyte count, calcium, lactate dehydrogenase, alkaline phosphatase levels, histological type and TNM stage. Four prognostic indices were derived, and the best one was picked and validated on a population of five risk groups. The higher the risk group, the shorter the survival.

CONCLUSIONS

This novel and simple prognostic tool could predict survival more accurately in patients with NSCLC.

Young age increases risk for lymph node positivity but decreases risk for non-small cell lung cancer death

Non-small cell lung cancer (NSCLC) prognosis and risk of lymph node positivity (LN+) are reference points for reasonable treatments. The aim of the current study was to investigate the effect of age on LN+ and NSCLC death. Data from the Surveillance, Epidemiology, and End Results (SEER) registry were used to identify 82,253 patients with NSCLC diagnosed between 1988 and 2008. All the patients underwent standard lung cancer surgery with lymph node examination. Demographic and clinicopathological parameters were extracted and compared among each age group. Impact of age on LN+ and NSCLC death was evaluated by the Cochran-Armitage trend test and logistic univariate and multivariate analyses for all T stages. Overall, 22,711 (27.60%) patients of the entirety had lymph node metastasis and 28,968 (35.22%) patients died of NSCLC within 5 years. With the increase in age, LN+ rates decreased regardless of T stages (P<0.001), whereas NSCLC-specific mortality increased in stages T1-T3 (P<0.001). Controlling other covariates in multivariable logistic regression, age remained an independent risk factor for LN+ in all T stages (P<0.05) and in stages T1-T3 (P<0.05). Our SEER analysis demonstrated a higher rate of LN+ and lower mortality in younger patients with NSCLC, after accounting for other covariates.

An international epidemiological analysis of young patients with non-small cell lung cancer (AduJov-CLICaP)

BACKGROUND

A proportion of patients with NSCLC is diagnosed at 40 years or younger. These patients tend to be never-smokers, usually present with stage IV adenocarcinoma, and have somatic genomic alterations. Few studies have documented and analyzed epidemiological characteristics of this population.

MATERIALS AND METHODS

We performed an international epidemiological analysis of 389 young patients with NSCLC. Data was collected from centers participating in the Latin American Consortium for Lung Cancer Research (AduJov-CLICaP). Patients were identified and data was retrospectively collected from different Latin American countries and Canada (Argentina=6, Canada=19, Colombia=29, Costa Rica=9, Mexico=219, Nicaragua=2, Panama=19, Perú=76 and Venezuela=10). The period of study was from 2012 to 2017. Inclusion criteria were: age 40 years or less and a histologically confirmed NSCLC. Clinical data was obtained, and EGFR mutation status and EML4-ALK translocation were collected.

RESULTS

NSCLC patients aged 40 years or less accounted for approximately 4% of the total NSCLC population. Female patients accounted for 54.5%, while median age was of 37 years. Adenocarcinoma accounted for 86.1% (n=335/389), 72.5% (n=282/389; unknown=5) of patients were non-smokers, and 90.3% (n=351/389) had stage IV disease. Site of metastasis was obtained from 260/351 (unknown=91) stage IV patients (lung metastasis=40.0%, CNS metastasis=35.7%, and bone metastasis=31.5%). OS for the total population was 17.3 months (95%CI=13.9-20.7). OS for EGFRm(+)=31.4months (95%CI=11.6-51.3), EGFRm(-)=14.5months (95%CI=11.0-17.9) (p=0.005). OS for alk(+)=9.8months (95%CI=3.1-16.5) and alk(-)=5.6months (95%CI=3.9-7.3) (p=0.315).

CONCLUSIONS

Patients aged 40 years or less account for a small but important proportion of NSCLC cases. Younger patients may have different characteristics compared to the older population. EGFRm and EML4-alk translocation frequency is higher than that of the general population.

Clinical predictors of survival in young patients with small cell lung cancer: Results from the California Cancer Registry

BACKGROUND

Small cell lung cancer (SCLC) is an often lethal disease that commonly occurs in older individuals with a history of heavy tobacco use. Limited epidemiologic and outcomes data are available on young SCLC patients aged less than 50 years of age. We assessed clinical variables related to cause specific survival (CSS) of young patients with SCLC.

METHODS

SCLC patients in the California Cancer Registry diagnosed between 1998 and 2012 were included. Primary outcome measure was CSS. Hazard ratios (HR) for CSS were calculated using Cox Proportional Hazards (pH) models for all ages & for patients <50 years, adjusted for baseline variables: age, gender, stage, race, year of diagnosis, initial treatment, socioeconomic status (SES), and location (urban vs. rural).

RESULTS

We identified 22,863 SCLC patients, of which 975 were less than 50 years of age (4.2%). Most patients <50years of age were male (51%), white race (71%), and had stage IV disease (60%). A lower proportion of patients aged 50 years or younger was diagnosed in later years: from 40% in 1998-2002 to 24% in 2008-2012. For all SCLC patients, age less than 50 years was an independent predictor of improved CSS (HR=0.82, p<0.0001). Multivariate Cox pH models showed that in younger patients, female sex (HR=0.81, p=0.0045), Asian race (HR=0.57, p=0.0075), and rural residence (HR=0.75, p=0.042) were associated with better CSS, among other variables.

CONCLUSIONS

In patients with SCLC, age less than 50 years was an independent predictor of improved CSS. Baseline clinical variables associated with better CSS were identified. These results have potential clinical applications.

Lung adenocarcinoma patients of young age have lower EGFR mutation rate and poorer efficacy of EGFR tyrosine kinase inhibitors

Patients aged ≤50 years are rarely diagnosed with nonsmall cell lung cancer. We conducted a retrospective cohort study to understand the mutation status of EGFR and the efficacy of epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) treatment in young Asian patients with lung adenocarcinoma.

We collected tumour specimens and malignant pleural effusions from lung adenocarcinoma patients from June 2005 to April 2014, recorded their clinical demographic data, and analysed EGFR mutations by reverse transcriptase PCR.

EGFR mutation data were collected from 1039 lung adenocarcinoma patients, including 161 patients aged ≤50 years and 878 patients aged >50 years. Fewer patients aged ≤50 years had EGFR mutations than older patients (p=0.043), but they showed a higher rate of uncommon EGFR mutations (p=0.035). A total of 524 patients with EGFR mutations received EGFR-TKI treatment, including 81 patients aged ≤50 years. Younger patients had a lower response rate than older patients (p=0.038) and had the shortest progression-free survival compared with other predefined age categories (p=0.033). Multivariate analysis of overall survival revealed age ≤50 years as a poor prognostic factor.

In conclusion, fewer Asian patients aged ≤50 years had EGFR mutations, but the EGFR mutation types were more uncommon. Age ≤50 years is associated with poorer efficacy of EGFR-TKI treatment.

Association between age and EGFR mutationshttp://ow.ly/jV4n30bRBUX

Clinical significance of age at diagnosis among young non-small cell lung cancer patients under 40 years old: a population-based study

BACKGROUND

Young non-small cell lung cancer (NSCLC) patients under the age of 40 can further be categorized into different age subgroups. Whether they have homogeneous clinical features and survival outcomes remains unexplored.

METHODS

Information of 4623 NSCLC patients up to 40 years old from 1988 to 2012 was retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Clinicopathologic characteristics and survival outcomes were compared between patients diagnosed at 18-30 years old (younger group) and those at 31-40 years old (older group).

RESULTS

The proportion of patients in the younger group among all lung cancer patients was stable between 1988 and 2012. However, the proportion of patients in the older group decreased from 1.2% to 0.5%. The younger patients had a higher proportion of adenocarcinoma (P = 0.016), a lower proportion of large cell carcinoma (P = 0.008), a higher proportion of stage I disease (P = 0.002) and a lower proportion of stage III disease (P < 0.001). The younger patients had significantly better lung cancer-specific survival (LCSS) in the whole cohort (P < 0.001) and in the subgroup of patients with stage I (P = 0.038) or stage IV (P < 0.001) disease. Multivariate survival analysis showed that patients under 30 years old was an independent predictor of both better LCSS (P = 0.010) and overall survival (OS) (P = 0.018).

CONCLUSIONS

Adult NSCLC patients under 30 years old had distinctive clinicopathologic characteristics and survival outcomes compared to patients diagnosed at 31-40 years old.

Lung Cancer in the Very Young: Treatment and Survival in the National Cancer Data Base

INTRODUCTION

Young patients with lung cancer represent a distinct subset of patients with this disease. The National Cancer Data Base includes patients of all ages and contains detailed staging, treatment, and survival information. The objective of this study was to examine treatment patterns and outcomes in young patients with non-small cell lung cancer (NSCLC).

METHODS

The National Cancer Data Base was queried for NSCLC cases from 2003 to 2009. Younger patients were defined as those aged 20 to 46 years. Older patients were defined as those aged 47 to 89 years. Patient demographics, tumor characteristics, treatment, and survival were analyzed. The primary outcomes were 5-year overall and relative survival.

RESULTS

The study included 173,856 patients; 5657 were 20 to 46 years of age. Younger patients were treated differently and received more aggressive therapy at each stage. At stage I, 64% of younger patients received surgery only versus 55% of the older patients (p < 0.0001). Younger patients had improved survival at all stages. This effect was more pronounced at earlier stages (the hazard ratios for the older group were 1.84, 1.62, 1.18, and 1.14 for stages I through IV, respectively [all p < 0.0001]). The absolute differences in 5-year overall survival between the younger and older groups were 25% for stages I and II but only 9% and 2% for stages III and IV, respectively.

CONCLUSIONS

Overall and relative survival in younger patients with NSCLC is better than in older patients, with greater benefit seen in earlier stages. Despite having fewer comorbidities and undergoing more aggressive treatment, younger patients with advanced-stage NSCLC have only marginally better overall and relative survival than older patients.

Cancer-Specific Production of N-Acetylaspartate via NAT8L Overexpression in Non-Small Cell Lung Cancer and Its Potential as a Circulating Biomarker

In order to identify new cancer-associated metabolites that may be useful for early detection of lung cancer, we performed a global metabolite profiling of a non-small cell lung cancer (NSCLC) line and immortalized normal lung epithelial cells from the same patient. Among several metabolites with significant cancer/normal differences, we identified a unique metabolic compound, N-acetylaspartate (NAA), in cancer cells-undetectable in normal lung epithelium. NAA's cancer-specific detection was validated in additional cancer and control lung cells as well as selected NSCLC patient tumors and control tissues. NAA's cancer specificity was further supported in our analysis of NAA synthetase (gene symbol: NAT8L) gene expression levels in The Cancer Genome Atlas: elevated NAT8L expression in approximately 40% of adenocarcinoma and squamous cell carcinoma cases (N = 577), with minimal expression in all nonmalignant lung tissues (N = 74). We then showed that NAT8L is functionally involved in NAA production of NSCLC cells through siRNA-mediated suppression of NAT8L, which caused selective reduction of intracellular and secreted NAA. Our cell culture experiments also indicated that NAA biosynthesis in NSCLC cells depends on glutamine availability. For preliminary evaluation of NAA's clinical potential as a circulating biomarker, we developed a sensitive NAA blood assay and found that NAA blood levels were elevated in 46% of NSCLC patients (N = 13) in comparison with age-matched healthy controls (N = 21) among individuals aged 55 years or younger. Taken together, these results indicate that NAA is produced specifically in NSCLC tumors through NAT8L overexpression, and its extracellular secretion can be detected in blood. Cancer Prev Res; 9(1); 43-52. ©2015 AACR.

Factors Associated With Early Mortality in Patients Treated With Concurrent Chemoradiation Therapy for Locally Advanced Non-Small Cell Lung Cancer

PURPOSE

Concurrent chemoradiation therapy (con-CRT) is recommended for fit patients with locally advanced non-small cell lung cancer (LA-NSCLC) but is associated with toxicity, and observed survival continues to be limited. Identifying factors associated with early mortality could improve patient selection and identify strategies to improve prognosis.

METHODS AND MATERIALS

Analysis of a multi-institutional LA-NSCLC database consisting of 1245 patients treated with con-CRT in 13 institutions was performed to identify factors predictive of 180-day survival. Recursive partitioning analysis (RPA) was performed to identify prognostic groups for 180-day survival. Multivariate logistic regression analysis was used to create a clinical nomogram predicting 180-day survival based on important predictors from RPA.

RESULTS

Median follow-up was 43.5 months (95% confidence interval [CI]: 40.3-48.8) and 127 patients (10%) died within 180 days of treatment. Median, 180-day, and 1- to 5-year (by yearly increments) actuarial survival rates were 20.9 months, 90%, 71%, 45%, 32%, 27%, and 22% respectively. Multivariate analysis adjusted by region identified gross tumor volume (GTV) (odds ratio [OR] ≥100 cm(3): 2.61; 95% CI: 1.10-6.20; P=.029) and pulmonary function (forced expiratory volume in 1 second [FEV1], defined as the ratio of FEV1 to forced vital capacity [FVC]) (OR <80%: 2.53; 95% CI: 1.09-5.88; P=.030) as significant predictors of 180-day survival. RPA resulted in a 2-class risk stratification system: low-risk (GTV <100 cm(3) or GTV ≥100 cm(3) and FEV1 ≥80%) and high-risk (GTV ≥100 cm(3) and FEV1 <80%). The 180-day survival rates were 93% for low risk and 79% for high risk, with an OR of 4.43 (95% CI: 2.07-9.51; P<.001), adjusted by region. A clinical nomogram predictive of 180-day survival, incorporating FEV1, GTV, N stage, and maximum esophagus dose yielded favorable calibration (R(2) = 0.947).

CONCLUSIONS

This analysis identified several risk factors associated with early mortality and suggests that future research in the optimization of pretreatment pulmonary function and/or functional lung avoidance treatment may alter the therapeutic ratio in this patient population.

Non-small cell lung cancer in young adults: presentation and survival in the English National Lung Cancer Audit

BACKGROUND

Non-small cell lung cancer (NSCLC) in young adults is a rare but devastating illness with significant socioeconomic implications, and studies of this patient subgroup are limited.

AIM

This study employed the National Lung Cancer Audit to compare the clinical features and survival of young adults with NSCLC with the older age groups.

DESIGN

A retrospective cohort review using a validated national audit dataset.

METHODS

Data were analysed for the period between 1 January 2004 and 31 December 2011. Young adults were defined as between 18 and 39 years, and all others were divided into decade age groups, up to the 80 years and above group. We performed logistic and Cox regression analyses to assess clinical outcomes.

RESULTS

Of a total of 1 46 422 patients, 651 (0.5%) were young adults, of whom a higher proportion had adenocarcinoma (48%) than in any other age group. Stage distribution of NSCLC was similar across the age groups and 71% of young patients had stage IIIb/IV. Performance status (PS) was 0-1 for 85%. Young adults were more likely to have surgery and chemotherapy compared with the older age groups and had better overall and post-operative survival. The proportion with adenocarcinoma, better PS and that receiving surgery or chemotherapy diminished progressively with advancing decade age groups.

CONCLUSION

In our cohort of young adults with NSCLC, the majority had good PS despite the same late-stage disease as older patients. They were more likely to have treatment and survive longer than older patients.

Clinical Features and Gene Mutations of Lung Cancer Patients 30 Years of Age or Younger

Purpose

Few studies examining the clinical features and gene mutations in lung cancer patients 30 years of age or younger have been published. A trend towards increasing morbidity has been noted in young patients; thus, an urgent need exists to explore this subgroup of patients.

Methods

Patients aged ≤30 years with pathologically diagnosed lung cancer were retrospectively evaluated. We reviewed the clinical features, gene mutations and prognosis of each patient.

Results

Forty-one patients were included in this study. The mean age was 26.4±3.5 years. Cough, tightness/dyspnea and chest pain were common symptoms, and 58.5% of patients presented with advanced stages of lung cancer. Adenocarcinoma was the predominant histologic type noted in these young patients. Masses and nodules were the dominant imaging features observed upon lung computed tomography (CT). Thoracic lymphadenopathy occurred very frequently in these patients. Five of 6 patients with echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) gene fusions presented solid masses with no ground-glass opacity (GGO) and thoracic multifocal lymphadenopathy. Six of 22 (27.2%) cases contained EML4-ALK gene fusions. In addition, 5 of 22 (22.7%) patients harbored epidermal growth factor receptor (EGFR) mutations, and 2 of 17 patients exhibited KRAS and ROS1 gene mutations. The median survival times were 44.2 months for patients with early stage disease and 8 months for patients with advanced NSCLC disease. The one-year and 5-year survival rates were 56.6% and 38.6%, respectively.

Conclusions

Increased gene mutation frequencies are noted in these very young lung cancer patients. This finding indicates that the detection of gene mutations in these patients is important and will help to determine the appropriate targeted therapy.

Different mutation profiles and clinical characteristics among Hispanic patients with non-small cell lung cancer could explain the "Hispanic paradox"

OBJECTIVE

Sixteen percent of US population is Hispanic, mostly Mexican. Recently, two independent American reports demonstrated a higher overall survival (OS) in Hispanic populations compared with non-Hispanic-white populations (NHW) with non-small-cell lung cancer (NSCLC), even when most Hispanic patients are diagnosed at advanced disease stages and have lower income status. We analyzed the clinical, pathological, and molecular characteristics as well as outcomes in a cohort of NSCLC Hispanic patients from the National Cancer Institute of Mexico that could explain this "Hispanic Paradox".

MATERIAL AND METHODS

A cohort of 1260 consecutive NSCLC patients treated at the National Cancer Institute of Mexico from 2007 to 2014 was analyzed. Their clinical-pathological characteristics, the presence of EGFR and KRAS mutations and the prognosis were evaluated.

RESULTS

Patients presented with disease stages II, IIIa, IIIb and IV at rates of 0.6, 4.8, 18.4 and 76.3%, respectively. NSCLC was associated with smoking in only 56.5% of the patients (76.7% of male vs. 33.0% of female patients). Wood smoke exposure (WSE) was associated with 37.2% of the cases (27.3% in men vs. 48.8% in women). The frequency of EGFR mutations was 27.0% (18.5% in males vs. 36.9% in females, p<0.001) and the frequency for KRAS mutations was 10.5% (10.3% men vs. 10.1% in women p=0.939). The median OS for all patients was 23.0 [95% CI 19.4-26.2], whereas for patients at stage IV, it was 18.5 months [95% CI 15.2-21.8]. The independent factors associated with the OS were the ECOG, disease stage, EGFR and KRAS mutation status.

CONCLUSION

The high frequency of EGFR mutations and low frequency of KRAS mutations in Hispanic populations and different prevalence in lung cancer-related-developing risk factors compared with Caucasian populations, such as the lower frequency of smoking exposure and higher WSE, particularly in women, might explain the prognosis differences between foreign-born-Hispanics, US-born-Hispanics and NHWs.

Epidermal Growth Factor Receptor (EGFR)-Tyrosine Kinase Inhibitor Treatment and Salvage Chemotherapy in EGFR-Mutated Elderly Pulmonary Adenocarcinoma Patients

BACKGROUND

Lung cancer is frequently a disease of elderly patients. However, these patients are often treated less actively owing to a higher comorbidity rate and poor performance status. The efficacy of different treatments in elderly patients with epidermal growth factor receptor (EGFR)-mutated lung cancer is still unknown.

MATERIALS AND METHODS

We retrospectively reviewed the records of our pulmonary adenocarcinoma patients treated between 2010 and 2013. Data on patient age, type of tumor EGFR mutation, response to first-line EGFR-tyrosine kinase inhibitor (TKI) treatment, type of salvage chemotherapy, and efficacy of EGFR-TKI and salvage chemotherapy were collected.

RESULTS

In all, 473 of 1,230 stage IV adenocarcinoma patients had an EGFR mutation, and 330 of them received first-line TKI treatment. Of the 330 patients, 160 were ≥70 years old (elderly group) and 170 were <70 years old (younger group). The response rate and progression-free survival (PFS) with first-line TKI treatment were not significantly different. The elderly group had shorter median survival. A total of 107 patients received salvage chemotherapy after first-line EGFR-TKI treatment: 45 in the elderly group and 62 in the younger group. Their response rate and PFS were not significantly different; however, the younger group had longer median survival. Additional subgroup analysis showed that younger patients who received platinum-based chemotherapy or combination chemotherapy had better median survival than did the elderly patients. The PFS was longer among younger patients receiving a platinum-based regimen than that among the elderly patients.

CONCLUSION

Elderly patients with disease progression after first-line EGFR-TKI treatment can receive chemotherapy and have a response rate similar to that of younger patients.

IMPLICATIONS FOR PRACTICE

The aim of the present study was to investigate the efficacy of first-line epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) treatment in elderly patients and the outcomes of subsequent salvage chemotherapy after disease progression. The most important finding was that elderly patients with disease progression after first-line EGFR-TKI treatment can receive salvage chemotherapy and have a response rate similar to that of younger patients who received salvage chemotherapy.

Nonclinical Factors Associated with 30-Day Mortality after Lung Cancer Resection: An Analysis of 215,000 Patients Using the National Cancer Data Base

BACKGROUND

Clinical variables associated with 30-day mortality after lung cancer surgery are well known. However, the effects of nonclinical factors, including insurance coverage, household income, education, type of treatment center, and area of residence, on short-term survival are less appreciated. We studied the National Cancer Data Base, a joint endeavor of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, to identify disparities in 30-day mortality after lung cancer resection based on these nonclinical factors.

STUDY DESIGN

We performed a retrospective cohort analysis of patients undergoing lung cancer resection from 2003 to 2011 using the National Cancer Data Base. Data were analyzed using a multivariable logistic regression model to identify risk factors for 30-day mortality.

RESULTS

During our study period, 215,645 patients underwent lung cancer resection. We found that clinical variables, such as age, sex, comorbidity, cancer stage, preoperative radiation, extent of resection, positive surgical margins, and tumor size were associated with 30-day mortality after resection. Nonclinical factors, including living in lower-income neighborhoods with a lesser proportion of high school graduates, and receiving cancer care at a nonacademic medical center were also independently associated with increased 30-day postoperative mortality.

CONCLUSIONS

This study represents the largest analysis of 30-day mortality for lung cancer resection to date from a generalizable national cohort. Our results demonstrate that, in addition to known clinical risk factors, several nonclinical factors are associated with increased 30-day mortality after lung cancer resection. These disparities require additional investigation to improve lung cancer patient outcomes.