1
|
Donington J, Hu X, Zhang S, Song Y, Arunachalam A, Chirovsky D, Gao C, Lerner A, Jiang A, Signorovitch J, Samkari A. Real-World Neoadjuvant Treatment Patterns and Outcomes in Resected Non-Small-Cell Lung Cancer. Clin Lung Cancer 2024; 25:440-448. [PMID: 38627155 DOI: 10.1016/j.cllc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Novel neoadjuvant chemoimmunotherapy treatments are being investigated for locally advanced non-small-cell lung cancer (NSCLC), but real-world outcomes for neoadjuvant treatments are poorly understood. This study examined neoadjuvant treatment patterns, real-world event-free survival (rwEFS) and overall survival (OS) in patients with resected, stage II-III NSCLC in the United States (US). METHODS This retrospective study identified patients in the SEER-Medicare database (2007-2019) with newly diagnosed stage II, IIIA, and IIIB (N2) NSCLC (AJCC 8th edition) treated with neoadjuvant chemo/chemoradiotherapy and resection (index date: neoadjuvant therapy initiation). Neoadjuvant treatment regimens were described. rwEFS (time from index to first recurrence or death, whichever occurred first) and OS (time from index to death) were summarized by Kaplan-Meier analysis for overall population, by disease stage at diagnosis, and by neoadjuvant treatment modality. RESULTS 221 patients (stage II, N=70; stage III, N=151) met eligibility criteria. The median follow-up from index was 32.7 months. All patients received neoadjuvant chemotherapy (51%) or chemoradiotherapy (49%) prior to surgery; 97% of patients received platinum-based regimens, among which carboplatin+paclitaxel was the most frequent (45%). In all patients, median rwEFS was 17.6 months and 5-year rwEFS was 20.9%; median OS was 48.5 months and 5-year OS was 44.9%. 71% of patients had disease recurrence during follow-up; among them, 28% developed locoregional recurrence as the first recurrence event. CONCLUSIONS Patients with resected, stage II-III NSCLC who received neoadjuvant chemo/chemoradiotherapy have high rates of disease recurrence and poor survival outcomes, highlighting need for more effective treatments to improve survival rates.
Collapse
Affiliation(s)
- Jessica Donington
- Department of Surgery, Section Thoracic Surgery, University of Chicago, Chicago, USA.
| | | | - Su Zhang
- Analysis Group, Inc., Boston, MA
| | - Yan Song
- Analysis Group, Inc., Boston, MA
| | | | | | - Chi Gao
- Analysis Group, Inc., Boston, MA
| | | | | | | | | |
Collapse
|
2
|
Dong H, Yang C. Efficacy of neoadjuvant chemotherapy combined with surgery in patients with nonsmall cell lung cancer: A meta-analysis. THE CLINICAL RESPIRATORY JOURNAL 2024; 18:e13756. [PMID: 38725310 PMCID: PMC11082538 DOI: 10.1111/crj.13756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 08/15/2023] [Accepted: 04/12/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION This meta-analysis sought to investigate the effect of neoadjuvant chemotherapy (NACT) combined with surgery in patients with nonsmall cell lung cancer (NSCLC). METHODS With time span from January 2010 to December 2022, PubMed, Web of Science and Embase, China National Knowledge Infrastructure, and WanFang databases were searched for randomized controlled trials on comparison between NACT combined with surgery and surgery alone in patients with NSCLC. Then a meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. RESULTS A total of 1511 studies were retrieved and 12 were finally included. Meta-analysis results showed that compared with surgery alone, a combination of NACT and surgery was associated with higher treatment response rate (odds ratio, OR = 2.459, 95% confidence interval, CI [1.785, 3.388], P < 0.001), 1-year survival rate (OR = 2.185, 95% CI [1.608, 2.970], P < 0.001), and 3-year survival rate (OR = 2.195, 95% CI [1.568, 3.073], P < 0.001) and lower levels of intraoperative blood loss (standardized mean difference, SMD = -0.932, 95% CI [-1.588, -0.275], P = 0.005) and length of hospital stay (SMD = -0.481, 95% CI [-0.933, -0.028], P = 0.037). CONCLUSION NACT combined with surgery is superior to surgery alone in the treatment of NSCLC and can promote postoperative recovery. Collectively, such combination is a safe and effective treatment for patients with NSCLC.
Collapse
Affiliation(s)
- Hai‐jun Dong
- Department of Thoracic Surgery, Huzhou Central HospitalAffiliated Central Hospital of Huzhou UniversityHuzhouChina
| | - Cheng‐yan Yang
- Department of RespiratoryPeople's Hospital of Changxing CountyHuzhouChina
| |
Collapse
|
3
|
Katayama ES, Woldesenbet S, Munir MM, Endo Y, Rawicz-Pruszyński K, Khan MMM, Tsilimigras D, Dillhoff M, Cloyd J, Pawlik TM. Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients. J Am Coll Surg 2024; 238:625-633. [PMID: 38420963 DOI: 10.1097/xcs.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Behavioral health disorders (BHDs) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes. STUDY DESIGN Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018 and 2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Postoperative textbook outcomes (ie no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed. RESULTS Among 694,836 cancer patients, 46,719 (6.7%) patients had at least 1 BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs BHD: 20.3%; p < 0.001). Among surgical patients, individuals with BHD had higher odds of a complication (odds ratio [OR] 1.32 [1.26 to 1.39]), prolonged length of stay (OR 1.36 [1.29 to 1.43]), and 90-day readmission (OR 1.57 [1.50 to 1.65]) independent of social vulnerability or hospital-volume status resulting in lower odds to achieve a TO (OR 0.66 [0.63 to 0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: $16,159 vs BHD: $17,432; p < 0.001). Of note, patients with BHD had worse long-term postoperative survival (median, no BHD: 46.6 [45.9 to 46.7] vs BHD: 37.1 [35.6 to 38.7] months) even after controlling for other clinical factors (hazard ratio 1.26 [1.22 to 1.31], p < 0.001). CONCLUSIONS BHD was associated with lower likelihood to achieve a postoperative textbook outcome, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.
Collapse
Affiliation(s)
- Erryk S Katayama
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
- Division of Surgical Oncology, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH (Katayama)
| | - Selamawit Woldesenbet
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Muhammad Musaab Munir
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Yutaka Endo
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Karol Rawicz-Pruszyński
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
- Department of Surgical Oncology, Medical University of Lublin, Poland (Rawicz-Pruszyński)
| | - Muhammad Muntazir Mehdi Khan
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Diamantis Tsilimigras
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Mary Dillhoff
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Jordan Cloyd
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Timothy M Pawlik
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| |
Collapse
|
4
|
Rittberg R, Decker K, Lambert P, Bravo J, St John P, Turner D, Czaykowski P, Dawe DE. Impact of age, comorbidity, and polypharmacy on receipt of systemic therapy in advanced cancers: A retrospective population-based study. J Geriatr Oncol 2024; 15:101689. [PMID: 38219331 DOI: 10.1016/j.jgo.2023.101689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 11/18/2023] [Accepted: 12/12/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Cancer incidence, comorbidity, and polypharmacy increase with age, but the interplay between these factors on receipt of systemic therapy (ST) in advanced cancer has rarely been studied. MATERIALS AND METHODS A retrospective cohort study was conducted including patients aged ≥18 years diagnosed from 2004 to 2015 with multiple myeloma (MM) (all stages), lung cancer (stage IV), and stage III-IV non-Hodgkin's lymphoma (NHL), breast, colorectal (CRC), prostate, or ovarian cancer in Manitoba, Canada. Clinical and administrative health data were used to determine demographic and cancer characteristics, treatment history, comorbidity (Charlson Comorbidity Index [CCI] and Resource Utilization Band [RUB]), and polypharmacy (≥6 medications). Multivariable logistic regression was used to evaluate variable associations with receipt of ST and interaction with age. RESULTS In total, 17,228 patients were diagnosed with advanced cancer. Ages were distributed as follows: 7% <50 years, 16% 50-59 years, 26% 60-69, 26% 70-79, 24% ≥80 years. ST was administered to 50% of patients. Increased age, polypharmacy, and comorbidity each independently decreased the likelihood of receiving ST. Significant interaction effects were found between age at diagnosis with stage of cancer and cancer type. Differences in probability of ST by cancer stage converged as age increased. In multivariable analysis, adjusting for covariates, patients with MM had the highest odds and lung cancer the lowest odds to receive ST. The impact of comorbidity and polypharmacy did not differ meaningfully with increasing age. DISCUSSION Increased age, polypharmacy, and comorbidity were each independently associated with decreased receipt of ST in people with advanced cancers. The impact of comorbidity and polypharmacy did not differ meaningfully with increasing age, while age meaningfully interacted with stage and cancer type.
Collapse
Affiliation(s)
- Rebekah Rittberg
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Department of Medical Oncology, BC Cancer, Vancouver, Canada
| | - Kathleen Decker
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Pascal Lambert
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Jen Bravo
- Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Philip St John
- Section of Geriatric Medicine, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - Donna Turner
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Epidemiology and Cancer Registry, CancerCare Manitoba, Winnipeg, Canada
| | - Piotr Czaykowski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Canada
| | - David E Dawe
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada; CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, Canada; Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Canada.
| |
Collapse
|
5
|
Lu S, Zhang W, Wu L, Wang W, Zhang P. Perioperative Toripalimab Plus Chemotherapy for Patients With Resectable Non-Small Cell Lung Cancer: The Neotorch Randomized Clinical Trial. JAMA 2024; 331:201-211. [PMID: 38227033 PMCID: PMC10792477 DOI: 10.1001/jama.2023.24735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/09/2023] [Indexed: 01/17/2024]
Abstract
Importance Adjuvant and neoadjuvant immunotherapy have improved clinical outcomes for patients with early-stage non-small cell lung cancer (NSCLC). However, the optimal combination of checkpoint inhibition with chemotherapy remains unknown. Objective To determine whether toripalimab in combination with platinum-based chemotherapy will improve event-free survival and major pathological response in patients with stage II or III resectable NSCLC compared with chemotherapy alone. Design, Setting, and Participants This randomized clinical trial enrolled patients with stage II or III resectable NSCLC (without EGFR or ALK alterations for nonsquamous NSCLC) from March 12, 2020, to June 19, 2023, at 50 participating hospitals in China. The data cutoff date for this interim analysis was November 30, 2022. Interventions Patients were randomized in a 1:1 ratio to receive 240 mg of toripalimab or placebo once every 3 weeks combined with platinum-based chemotherapy for 3 cycles before surgery and 1 cycle after surgery, followed by toripalimab only (240 mg) or placebo once every 3 weeks for up to 13 cycles. Main Outcomes and Measures The primary outcomes were event-free survival (assessed by the investigators) and the major pathological response rate (assessed by blinded, independent pathological review). The secondary outcomes included the pathological complete response rate (assessed by blinded, independent pathological review) and adverse events. Results Of the 501 patients randomized, 404 had stage III NSCLC (202 in the toripalimab + chemotherapy group and 202 in the placebo + chemotherapy group) and 97 had stage II NSCLC and were excluded from this interim analysis. The median age was 62 years (IQR, 56-65 years), 92% of patients were male, and the median follow-up was 18.3 months (IQR, 12.7-22.5 months). For the primary outcome of event-free survival, the median length was not estimable (95% CI, 24.4 months-not estimable) in the toripalimab group compared with 15.1 months (95% CI, 10.6-21.9 months) in the placebo group (hazard ratio, 0.40 [95% CI, 0.28-0.57], P < .001). The major pathological response rate (another primary outcome) was 48.5% (95% CI, 41.4%-55.6%) in the toripalimab group compared with 8.4% (95% CI, 5.0%-13.1%) in the placebo group (between-group difference, 40.2% [95% CI, 32.2%-48.1%], P < .001). The pathological complete response rate (secondary outcome) was 24.8% (95% CI, 19.0%-31.3%) in the toripalimab group compared with 1.0% (95% CI, 0.1%-3.5%) in the placebo group (between-group difference, 23.7% [95% CI, 17.6%-29.8%]). The incidence of immune-related adverse events occurred more frequently in the toripalimab group. No unexpected treatment-related toxic effects were identified. The incidence of grade 3 or higher adverse events, fatal adverse events, and adverse events leading to discontinuation of treatment were comparable between the groups. Conclusions and Relevance The addition of toripalimab to perioperative chemotherapy led to a significant improvement in event-free survival for patients with resectable stage III NSCLC and this treatment strategy had a manageable safety profile. Trial Registration ClinicalTrials.gov Identifier: NCT04158440.
Collapse
Affiliation(s)
- Shun Lu
- Department of Medical Oncology, Shanghai Chest Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Lin Wu
- Department of Thoracic Medical Oncology, Hunan Cancer Hospital, Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Wenxiang Wang
- Second Department of Thoracic Surgery, Hunan Cancer Hospital, Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Peng Zhang
- Shanghai Pulmonary Hospital, Tong Ji University, Shanghai, China
| | | |
Collapse
|
6
|
Zhang S, Zheng M, Tian H, Liu W, Feng Z, Xing S, Han F. Are immune checkpoint inhibitors ineffective in treating patients with head and neck squamous cell carcinoma aged 75 years or Older? A Meta-Analysis. Oral Oncol 2024; 148:106632. [PMID: 38039875 DOI: 10.1016/j.oraloncology.2023.106632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 11/06/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVES The efficacy of immune checkpoint inhibitors (ICIs) is unclear in patients aged ≥ 75 years with head and neck squamous cell carcinoma (HNSCC). We conducted a systematic review and meta-analysis of randomized trials that compared ICIs with standard-of-care (SOC) therapy for recurrent/metastatic HNSCC. MATERIALS AND METHODS PubMed, EMBASE, Web of Science, and ClinicalTrials.gov were searched for eligible trials. We evaluated the overall survival (OS) benefit of ICIs versus SOC according to patient age (<75 versus ≥ 75 years). The OS benefit was evaluated and compared between the age subgroups using hazard ratios (HRs). Data were pooled using a random-effects model. RESULTS Five phase 3 trials involving 3437 patients were included. In patients aged ≥ 75 years (n = 207), ICIs did not improve OS compared to SOC (HR = 1.30, 95 % confidence interval [CI]: 0.93-1.81, P = 0.127). However, an improvement in OS was observed in patients aged < 75 years (n = 3230, HR = 0.90, 95 % CI: 0.83-0.99, P = 0.025). There is a significant difference in OS benefit between patients aged < 75 and ≥ 75 years (ratio of HR = 0.69, 95 % CI: 0.49-0.98, P = 0.036). Subgroup, meta-regression, and sensitivity analyses supported the reliability of the results. CONCLUSIONS Given the small sample size, our findings showing no improvement in OS suggest a lack of evidence to support the use of ICIs in patients with recurrent/metastatic HNSCC aged ≥ 75 years. Therefore, prospective studies are needed to clarify their efficacy among this age group.
Collapse
Affiliation(s)
- Siqi Zhang
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| | - Mengge Zheng
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| | - Huimin Tian
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| | - Wenjia Liu
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| | - Zhenbang Feng
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| | - Shasha Xing
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| | - Fujun Han
- Cancer Center, The First Hospital of Jilin University, 71 Xinmin Ave, Changchun, China.
| |
Collapse
|
7
|
Plessala I, Cawston H, Cortes J, Ajjouri R, Le Lay K, Souquet PJ, Chouaid C. Cost-effectiveness analysis of atezolizumab as adjuvant treatment of patients with stage II-IIIA non-small cell lung cancer, PD-L1+≥50% of tumor cells in France: A modeling study. Lung Cancer 2023; 184:107316. [PMID: 37562344 DOI: 10.1016/j.lungcan.2023.107316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION The objective of this study was to assess the cost-effectiveness of atezolizumab versus best supportive care (BSC) as adjuvant treatment following resection and platinum-based chemotherapy for patients with stage II-IIIA non-small cell lung cancer (NSCLC) whose tumours have a programmed death-ligand 1 (PD-L1) expression ≥ 50% of tumour cells and excluding those with ALK/EGFR mutations, from a French collective perspective. MATERIAL AND METHODS A five state Markov model over a 20-year time horizon was considered, including disease-free survival (DFS1) from IMpower010 trial, three progression states (locoregional recurrence, first and second-line metastatic recurrence) and death. Utilities, quality-adjusted life year (QALY) decrements associated to adverse events, costs, resource use, and transition probabilities were considered in the model. These inputs were sourced from IMpower010 trial, literature, and clinical experts' opinion. Model uncertainty was assessed through deterministic, probabilistic sensitivity analyses and scenario analyses. RESULTS Atezolizumab was associated with a QALY gain of 1.662, mainly driven by additional time spent in the DFS state, and a life-year gain of 2.112 years. The incremental cost-effectiveness ratio (ICER) for atezolizumab versus BSC was €21,348/QALY gained. The sensitivity analyses highlighted that uncertainty within the model had limited impact on results. Changing the DFS survival curves to other plausible distributions produced ICERs below €20,000/QALY. Introducing an increasing proportion of cured patients (91.5%) from year two to year five reduced the ICER to €13,083/QALY, while including a loss of efficacy at year two in the atezolizumab treatment arm increased the ICER to €33,755/QALY. DISCUSSION Atezolizumab as adjuvant treatment in stage II-IIIA NSCLC resected patients with PDL1 ≥ 50% and without ALK/EGFR mutations has a lower ICER than other oncology drugs in France and a similar ICER to other adjuvant treatment in oncology.
Collapse
Affiliation(s)
| | - Hélène Cawston
- Amaris, Health Economics and Market Access, Paris, France
| | - Justine Cortes
- Amaris, Health Economics and Market Access, Paris, France
| | | | | | | | - Christos Chouaid
- Service de Pneumologie, CHI Créteil, 5 Inserm U955, UPEC, IMRB, Créteil, France
| |
Collapse
|
8
|
Yip CY, Greystoke A, Abogunrin S, Belleli R, Di Maio D, Rouse P, Jovanoski N. Cost-effectiveness analysis of adjuvant atezolizumab in stage II-IIIA non-small cell lung cancer expressing ≥50% PD-L1: A United Kingdom health care perspective. Lung Cancer 2023; 179:107171. [PMID: 36947997 DOI: 10.1016/j.lungcan.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/28/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES Atezolizumab monotherapy has marketing authorisation by the Medicines and Healthcare products Regulatory Agency as adjuvant treatment following complete resection for adults with stage II-IIIA non-small cell lung cancer (NSCLC) whose tumours have PD-L1 expression on ≥ 50% of tumour cells and whose disease has not progressed following adjuvant platinum-based chemotherapy. This study evaluated the cost-effectiveness of atezolizumab vs best supportive care (BSC) in the licensed patient population from a UK perspective. MATERIALS AND METHODS Patient characteristics and clinical inputs were derived from the global, randomised, open-label, phaseIII IMpower010 trial. A Markov model with the following health states was developed: disease-free survival (DFS), locoregional recurrence, first-line metastatic recurrence, second-line metastatic recurrence, and death (all partitioned based on receipt of treatment, excluding death). The base case model used a lifetime time horizon (40 years) and 3.5% discounting annually after the first year. DFS from IMpower010 was analysed with parametric survival models to extrapolate outcomes for time points beyond trial follow-up. The models were adjusted to avoid overestimating results for patients with recurrences in the longer term. Grade ≥ 3 treatment-related adverse events with incidences ≥ 2% were included. Health state utility values were derived from the literature and past NICE appraisals. Sensitivity and scenario analyses assessed uncertainty around assumptions and parameter estimates. RESULTS In the base case analysis, atezolizumab therapy resulted in an expected gain of 1.87 quality-adjusted life-years (QALYs) corresponding to an incremental cost-effectiveness ratio of £20,392/QALY for atezolizumab vs BSC, demonstrating cost-effectiveness. Results were most influenced by discount effects and utility in the on-treatment DFS state. Scenario analyses were consistent with the base case results. CONCLUSION Atezolizumab after adjuvant chemotherapy is cost-effective for adults with NSCLC in the UK.
Collapse
Affiliation(s)
- Chui-Ying Yip
- Roche Products Ltd, Welwyn Garden City, United Kingdom.
| | - Alastair Greystoke
- Northern Centre for Cancer Care, Newcastle upon Tyne, UK, United Kingdom
| | | | | | | | - Peter Rouse
- Roche Products Ltd, Welwyn Garden City, United Kingdom
| | | |
Collapse
|
9
|
Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Thomas TS, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Association between imaging surveillance frequency and outcomes following surgical treatment of early-stage lung cancer. J Natl Cancer Inst 2023; 115:303-310. [PMID: 36442509 PMCID: PMC9996218 DOI: 10.1093/jnci/djac208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/14/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Recent studies have suggested that more frequent postoperative surveillance imaging via computed tomography following lung cancer resection may not improve outcomes. We sought to validate these findings using a uniquely compiled dataset from the Veterans Health Administration, the largest integrated health-care system in the United States. METHODS We performed a retrospective cohort study of veterans with pathologic stage I non-small cell lung cancer receiving surgery (2006-2016). We assessed the relationship between surveillance frequency (chest computed tomography scans within 2 years after surgery) and recurrence-free survival and overall survival. RESULTS Among 6171 patients, 3047 (49.4%) and 3124 (50.6%) underwent low-frequency (<2 scans per year; every 6-12 months) and high-frequency (≥2 scans per year; every 3-6 months) surveillance, respectively. Factors associated with high-frequency surveillance included being a former smoker (vs current; adjusted odds ratio [aOR] = 1.18, 95% confidence interval [CI] = 1.05 to 1.33), receiving a wedge resection (vs lobectomy; aOR = 1.21, 95% CI = 1.05 to 1.39), and having follow-up with an oncologist (aOR = 1.58, 95% CI = 1.42 to 1.77), whereas African American race was associated with low-frequency surveillance (vs White race; aOR = 0.64, 95% CI = 0.54 to 0.75). With a median (interquartile range) follow-up of 7.3 (3.4-12.5) years, recurrence was detected in 1360 (22.0%) patients. High-frequency surveillance was not associated with longer recurrence-free survival (adjusted hazard ratio = 0.93, 95% CI = 0.83 to 1.04, P = .22) or overall survival (adjusted hazard ratio = 1.04, 95% CI = 0.96 to 1.12, P = .35). CONCLUSIONS We found that high-frequency surveillance does not improve outcomes in surgically treated stage I non-small cell lung cancer. Future lung cancer treatment guidelines should consider less frequent surveillance imaging in patients with stage I disease.
Collapse
Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, MO, USA
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Theodore S Thomas
- VA St. Louis Health Care System, St. Louis, MO, USA
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- VA St. Louis Health Care System, St. Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- VA St. Louis Health Care System, St. Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- VA St. Louis Health Care System, St. Louis, MO, USA
| |
Collapse
|
10
|
Beyrer J, Nelson DR, Sheffield KM, Huang YJ, Lau YK, Hincapie AL. Development and Validation of Coding Algorithms to Identify Patients with Incident Non-Small Cell Lung Cancer in United States Healthcare Claims Data. Clin Epidemiol 2023; 15:73-89. [PMID: 36659903 PMCID: PMC9842515 DOI: 10.2147/clep.s389824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/23/2022] [Indexed: 01/13/2023] Open
Abstract
Purpose We sought to develop and validate an incident non-small cell lung cancer (NSCLC) algorithm for United States (US) healthcare claims data. Diagnoses and procedures, but not medications, were incorporated to support longer-term relevance and reliability. Methods Patients with newly diagnosed NSCLC per Surveillance, Epidemiology, and End Results (SEER) served as cases. Controls included newly diagnosed small-cell lung cancer and other lung cancers, and two 5% random samples for other cancer and without cancer. Algorithms derived from logistic regression and machine learning methods used the entire sample (Approach A) or started with a previous algorithm for those with lung cancer (Approach B). Sensitivity, specificity, positive predictive values (PPV), negative predictive values, and F-scores (compared for 1000 bootstrap samples) were calculated. Misclassification was evaluated by calculating the odds of selection by the algorithm among true positives and true negatives. Results The best performing algorithm utilized neural networks (Approach B). A 10-variable point-score algorithm was derived from logistic regression (Approach B); sensitivity was 77.69% and PPV = 67.61% (F-score = 72.30%). This algorithm was less sensitive for patients ≥80 years old, with Medicare follow-up time <3 months, or missing SEER data on stage, laterality, or site and less specific for patients with SEER primary site of main bronchus, SEER summary stage 2000 regional by direct extension only, or pre-index chronic pulmonary disease. Conclusion Our study developed and validated a practical, 10-variable, point-based algorithm for identifying incident NSCLC cases in a US claims database based on a previously validated incident lung cancer algorithm.
Collapse
Affiliation(s)
- Julie Beyrer
- Eli Lilly and Company, Indianapolis, IN, USA,Correspondence: Julie Beyrer, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA, Tel +1 317 651 8236, Email
| | | | | | | | | | - Ana L Hincapie
- University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| |
Collapse
|
11
|
Bowes K, Jovanoski N, Brown AE, Di Maio D, Belleli R, Chadda S, Abogunrin S. Treatment patterns and survival of patients with locoregional recurrence in early-stage NSCLC: a literature review of real-world evidence. Med Oncol 2023; 40:4. [PMID: 36308605 PMCID: PMC9617826 DOI: 10.1007/s12032-022-01790-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/06/2022] [Indexed: 01/17/2023]
Abstract
Approximately 10-50% of patients treated for early-stage (I-III), resectable non-small cell lung cancer (eNSCLC) will develop locoregional recurrence. There is a lack of prospective trials evaluating optimal post-surgery follow-up for this patient population, and treatment guidelines recommend salvage therapies such as surgery, local ablative therapy, and (chemo)radiotherapy. A literature review was conducted according to pre-defined criteria to identify observational studies describing treatment patterns and survival outcomes in patients with eNSCLC who experienced locoregional recurrence. Results showed that, in real-world clinical practice, around 80% of patients with locoregional recurrence underwent any form of active treatment. The most frequently administered treatments were chemotherapy (35.7%), chemoradiotherapy (31.2%), radiotherapy (20.3%), and surgery alone (12.8%). Chemoradiotherapy was associated with improved PFS and OS compared with radiotherapy, while no statistically significant survival benefits were observed for patients receiving surgery in addition to these treatments. The overall survival of patients following treatment for locoregional recurrence was generally poor, and the proportion of patients who experienced any form of post-treatment re-recurrence ranged from 35 to 72%. These findings highlight the need to develop more effective treatment strategies for locoregional recurrence, including preventative treatments, and strategies to improve the survival outcomes of those who do develop locoregional recurrence.
Collapse
|
12
|
Heiden BT, Eaton DB, Chang SH, Yan Y, Baumann AA, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Racial Disparities in the Surgical Treatment of Clinical Stage I Non-Small Cell Lung Cancer Among Veterans. Chest 2022; 162:920-929. [PMID: 35405111 PMCID: PMC9562435 DOI: 10.1016/j.chest.2022.03.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prior studies in the civilian population have reported racial disparities in lung cancer outcomes following surgical treatment, including inferior quality of care and worse survival. It is unclear if racial disparities exist in the Veterans Health Administration (VHA), the largest integrated health care system in the United States. RESEARCH QUESTION Do racial disparities affect early-stage non-small cell lung cancer (NSCLC) outcomes following surgical treatment within the VHA? STUDY DESIGN AND METHODS This retrospective cohort study was conducted in veterans with clinical stage I NSCLC undergoing surgical treatment in the VHA system. Demographic characteristics, access to care, surgical quality measures, and short- and long-term oncologic outcomes between White and Black veterans were evaluated. RESULTS From 2006 to 2016, a total of 18,800 veterans with clinical stage I NSCLC were included. The rates of definitive surgical treatment were similar between Black (57.3%) and White (58.1%) veterans (P = .42). The final study cohort included 9,842 patients receiving surgical treatment, of whom 8,356 (84.9%) were White and 1,486 (15.1%) were Black. Black patients were younger and more likely to smoke, although comorbidities were similar between the two groups. Black patients were somewhat less likely to receive adequate lymph node sampling (30.6% vs 33.3%; P = .050); however, other access-to-care metrics and surgical quality measures, including rates of anatomic lobectomy (71.9% vs 69.4%; P = .189) and positive margins (3.2% vs 3.1%; P = .955), were similar between the two groups. Although Black veterans were less likely to experience major postoperative complications, there was no difference in 30-day readmission, 30-day mortality, or disease-free survival between the two groups. Black patients had significantly better risk-adjusted overall survival (hazard ratio, 0.802; 95% CI, 0.729-0.883; P < .001). INTERPRETATION Among veterans with NSCLC undergoing surgical treatment through the VHA, Black patients received comparable care with equivalent if not superior outcomes compared with White patients.
Collapse
Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, MO; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| |
Collapse
|
13
|
Jang SJ, Lee JW, Lee JH, Jo IY, Lee SM. Different Prognostic Values of Dual-Time-Point FDG PET/CT Imaging Features According to Treatment Modality in Patients with Non-Small Cell Lung Cancer. Tomography 2022; 8:1066-1078. [PMID: 35448721 PMCID: PMC9028882 DOI: 10.3390/tomography8020087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/01/2022] [Accepted: 04/06/2022] [Indexed: 01/02/2023] Open
Abstract
This study was aimed to investigate whether dual-time-point F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) imaging features had different prognostic values according to the treatment modality in patients with non-small cell lung cancer (NSCLC). We retrospectively reviewed 121 NSCLC patients with surgical resection (surgery group) and 69 NSCLC patients with chemotherapy and/or radiotherapy (CRT group), who underwent pretreatment dual-time-point FDG PET/CT. The maximum standardized uptake value (SUV), metabolic tumor volume (MTV), total lesion glycolysis (TLG), SUV histogram entropy of primary cancer, and the percent changes in these parameters (Δparameters) were measured. In multivariate analysis, MTV, TLG, and entropy on both early and delayed PET/CT scans were significantly associated with progression-free survival (PFS) in the surgery group, but all Δparameters failed to show a significant association. In the CRT group, TLG on the early PET, maximum SUV on the delayed PET, ΔMTV, and ΔTLG were significant independent predictors for PFS. In the surgery group, patients with high values of MTV, TLG, and entropy had worse survival, whereas, in the CRT group, patients with high values of ΔMTV and ΔTLG had better survival. Dual-time-point FDG PET/CT parameters showed different prognostic values between the surgery and CRT groups of NSCLC patients.
Collapse
Affiliation(s)
- Su Jin Jang
- Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea;
| | - Jeong Won Lee
- Department of Nuclear Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Simgok-ro 100 gil 25, Seo-gu, Incheon 22711, Korea;
| | - Ji-Hyun Lee
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea;
| | - In Young Jo
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6 gil, Dongnam-gu, Cheonan 31151, Korea;
| | - Sang Mi Lee
- Department of Nuclear Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6 gil, Dongnam-gu, Cheonan 31151, Korea
- Correspondence: ; Tel.: +82-41-570-3540
| |
Collapse
|
14
|
Lee SM, Lee JW, Lee JH, Jo IY, Jang SJ. Prognostic Value of Dual-Time-Point [18F]FDG PET/CT for Predicting Distant Metastasis after Treatment in Patients with Non-Small Cell Lung Cancer. J Pers Med 2022; 12:jpm12040592. [PMID: 35455708 PMCID: PMC9028993 DOI: 10.3390/jpm12040592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/21/2022] [Accepted: 04/06/2022] [Indexed: 02/05/2023] Open
Abstract
This study aimed to evaluate the prognostic significance of 2-Deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) uptake in the bone marrow (BM) and primary tumors on dual-time-point (DTP) PET/CT for predicting progression-free survival (PFS) and distant metastasis-free survival (DMFS) in patients with non-small cell lung cancer (NSCLC). We retrospectively analyzed DTP [18F]FDG PET/CT images from 211 patients with NSCLC. The maximum standardized uptake value (SUV) of primary lung cancer and mean [18F]FDG uptake of the BM (BM SUV) were measured from early and delayed PET/CT images, and the percent changes in these parameters (∆maximum SUV and ∆BM SUV) were calculated. On multivariate survival analysis, the maximum SUV and BM SUV on both early and delayed PET/CT scans were significantly associated with PFS, while the ∆maximum SUV and ∆BM SUV failed to show statistical significance. For DMFS, the ∆maximum SUV and ∆BM SUV were independent predictors along with the TNM stage. Distant progression was observed only in 1.3% of patients with low ∆maximum SUV and ∆BM SUV, whereas 28.2% of patients with high ∆maximum SUV and ∆BM SUV experienced distant progression. The ∆maximum SUV and ∆BM SUV on DTP [18F]FDG PET/CT were significant independent predictors for DMFS in patients with NSCLC.
Collapse
Affiliation(s)
- Sang Mi Lee
- Department of Nuclear Medicine, Soonchunhyang University Cheonan Hospital, Cheonan 31151, Korea;
| | - Jeong Won Lee
- Department of Nuclear Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Incheon 22711, Korea;
| | - Ji-Hyun Lee
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea;
| | - In Young Jo
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, Cheonan 31151, Korea;
| | - Su Jin Jang
- Department of Nuclear Medicine, CHA Bundang Medical Center, CHA University, Seongnam 13496, Korea
- Correspondence: ; Tel.: +82-31-780-5687
| |
Collapse
|
15
|
Zhao P, Zhen H, Zhao H, Zhao L, Cao B. Efficacy and safety of adjuvant EGFR-TKIs for resected non-small cell lung cancer: a systematic review and meta-analysis based on randomized control trials. BMC Cancer 2022; 22:328. [PMID: 35346117 PMCID: PMC8962534 DOI: 10.1186/s12885-022-09444-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/23/2022] [Indexed: 12/22/2022] Open
Abstract
Abstract
Background
Postoperative adjuvant cisplatin-based chemotherapy had been the standard care in patients with completely resected high-risk stage IB to IIIA non-small cell lung cancer (NSCLC) for decades. However, the survival benefits were far from satisfactory in clinical practice. Thus, this meta-analysis was performed to compare the efficacy and safety of adjuvant epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in patients with resected NSCLC based on updated literature and research.
Methods
A systematic literature search based on random control trials (RCTs) was conducted with keywords on PubMed, Embase and the Cochrane library databases. All articles compared EGFR-TKIs to placebo or chemotherapy as adjuvant therapies for early-stage resected NSCLC. A meta-analysis was performed to generate combined hazard ratio (HR) with 95% confidence intervals (CI) for disease-free survival (DFS), overall survival (OS), and risk ratio (RR) with 95% CI for disease recurrence and adverse events (AEs). The Stata statistical software (version 14.0) was used to synthesis the data.
Results
A total of 9 RCTs comprising 3098 patients were included. Adjuvant EGFR-TKIs could significantly prolong DFS in patient with resected NSCLC harboring epidermal growth factor receptor (EGFR) mutations (HR 0.46, 95% CI 0.29–0.72), but had no impact on OS (HR 0.87, 95% CI 0.69–1.11). The subgroup analyses indicated that adjuvant EGFR-TKIs were superior in regard to DFS in most subgroups, including varied smoking status, EGFR mutations type, gender, age, Eastern Cooperative Oncology Group performance status and adenocarcinoma. Osimertinib resulted in decreased brain recurrence than first generation of EGFR-TKIs (RR 0.12, 95% CI 0.04–0.34 vs. RR 1.07, 95% CI 0.64–1.78, respectively). The AEs were generally manageable and tolerable. The incidence of high-grade (≥ 3) AEs including diarrhea (RR 5.68, 95% CI 2.94–10.98) and rash (RR 27.74, 95% CI 11.43–67.30) increased after adjuvant EGFR-TKIs treatment.
Conclusions
Adjuvant EGFR-TKIs therapy could significantly prolong DFS in patients with completely resected early-stage EGFR mutation-positive NSCLC, but had no impact on OS. Adjuvant EGFR-TKIs could be an important treatment option in patients with resected early-stage EGFR-mutant NSCLC.
Collapse
|
16
|
Mohamed SK, Walsh B, Timilsina M, Torrente M, Franco F, Provencio M, Janik A, Costabello L, Minervini P, Stenetorp P, Novácˇek V. On Predicting Recurrence in Early Stage Non-small Cell Lung Cancer. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2021:853-862. [PMID: 35308971 PMCID: PMC8861763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Early detection and mitigation of disease recurrence in non-small cell lung cancer (NSCLC) patients is a nontrivial problem that is typically addressed either by rather generic follow-up screening guidelines, self-reporting, simple nomograms, or by models that predict relapse risk in individual patients using statistical analysis of retrospective data. We posit that machine learning models trained on patient data can provide an alternative approach that allows for more efficient development of many complementary models at once, superior accuracy, less dependency on the data collection protocols and increased support for explainability of the predictions. In this preliminary study, we describe an experimental suite of various machine learning models applied on a patient cohort of 2442 early stage NSCLC patients. We discuss the promising results achieved, as well as the lessons we learned while developing this baseline for further, more advanced studies in this area.
Collapse
Affiliation(s)
- Sameh K Mohamed
- Data Science Institute, NUI Galway, Galway, Ireland
- Insight Centre for Data Analytics, NUI Galway, Galway, Ireland
| | - Brian Walsh
- Data Science Institute, NUI Galway, Galway, Ireland
- Insight Centre for Data Analytics, NUI Galway, Galway, Ireland
| | - Mohan Timilsina
- Data Science Institute, NUI Galway, Galway, Ireland
- Insight Centre for Data Analytics, NUI Galway, Galway, Ireland
| | - Maria Torrente
- Medical Oncology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Fabio Franco
- Medical Oncology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Mariano Provencio
- Medical Oncology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | | | | | - Vít Novácˇek
- Data Science Institute, NUI Galway, Galway, Ireland
- Faculty of Informatics, Masaryk University, Brno, Czech Republic
| |
Collapse
|
17
|
[Pattern of Recurrence and Metastasis after Radical Resection of
Non-small Cell Lung Cancer]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2022; 25:26-33. [PMID: 35078282 PMCID: PMC8796126 DOI: 10.3779/j.issn.1009-3419.2021.102.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The rate of recurrence and metastasis of non-small cell lung cancer after radical resection is still very high. The risk factors for recurrence and metastasis have been extensively studied, but the dynamic pattern of postoperative recurrence hazard over time is relatively lacking. The dynamic recurrence hazard rate curve is applied to describe the rate of recurrence at any point time among the "at-risk" patients. In this article, by reviewing the previous literature, the characteristics of the dynamic recurrence and metastasis pattern after radical resection of non-small cell lung cancer and the clinical factors affecting the recurrence and metastasis pattern are summarized, in order to screen out specific populations with high recurrence risk and give them personalized follow-up strategy and diagnosis and treatment.
.
Collapse
|
18
|
Zhu Z, Gong X, Li J, Shi Y, Zhang M. Long non-coding RNA receptor activator of nuclear factor-κ B ligand promotes cisplatin resistance in non-small cell lung cancer cells. Exp Ther Med 2021; 21:518. [PMID: 33815591 PMCID: PMC8014969 DOI: 10.3892/etm.2021.9949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) is a common malignancy associated with poor clinical outcomes and high mortality rate. The association between NSCLC development and long non-coding RNA (lncRNA) expression remains to be elucidated. The current study investigated the role of a novel lncRNA, receptor activator of nuclear factor-κ B ligand (RANKL), in the resistance of NSCLC to chemotherapy. RANKL expression was assessed via reverse transcription-quantitative PCR, cell death rate was evaluated using flow cytometry and sensitivity of cisplatin (DDP)-resistant A549/DDP cells to chemotherapy was determined using the Cell Counting Kit-8 assay. Western blotting was performed to quantify p53 protein levels. Compared with matched A549 cells, A549/DDP cells exhibited significant upregulation of RANKL expression. Sensitivity of A549/DDP cells to DDP was restored following RANKL knockdown. A549 cells overexpressing RANKL exhibited notably impaired DDP sensitivity compared with controls. Conversely, downregulated RANKL expression triggered cell death and inhibited cell migration via p53 stimulation and phosphatidylinositol 3-kinase/protein kinase B pathway suppression. The current findings indicate that RANKL contributes to DDP resistance in NSCLC and may represent a novel therapeutic target in this malignancy.
Collapse
Affiliation(s)
- Zhongcheng Zhu
- Department of Radiotherapy, Cangzhou Central Hospital, Cangzhou, Hebei 061000, P.R. China
| | - Xiaoyi Gong
- Return Visit Office, Cangzhou Central Hospital, Cangzhou, Hebei 061000, P.R. China
| | - Jing Li
- Return Visit Office, Cangzhou Central Hospital, Cangzhou, Hebei 061000, P.R. China
| | - Yufeng Shi
- Department of Radiotherapy, Cangzhou Central Hospital, Cangzhou, Hebei 061000, P.R. China
| | - Mingyun Zhang
- Department of Radiotherapy, Cangzhou Central Hospital, Cangzhou, Hebei 061000, P.R. China
| |
Collapse
|
19
|
Habr D, McRoy L, Papadimitrakopoulou VA. Age Is Just a Number: Considerations for Older Adults in Cancer Clinical Trials. J Natl Cancer Inst 2021; 113:1460-1464. [PMID: 33881547 PMCID: PMC8562957 DOI: 10.1093/jnci/djab070] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/23/2021] [Accepted: 04/05/2021] [Indexed: 12/11/2022] Open
Abstract
Older adults continue to be underrepresented in cancer clinical trials, despite most cancer occurrence peaking in the later decades of life. Consequently, diagnostic and management strategies are commonly extrapolated from data on younger patients, thus challenging the delivery of informed cancer care in this patient population. Several recommendations and calls to action have been released by cancer societies, advocacy organizations, and regulatory agencies to guide inclusion of older adults in clinical trials. Effective implementation, however, requires awareness and close collaboration between all stakeholders involved in the clinical trial journey. We herein provide insights and experience from a drug developer on key considerations to optimize participation and retention of older adults in cancer clinical trials and discuss those under 4 key domains: trial eligibility and design, assessments and endpoints, patients and oncologists, and data reporting.
Collapse
|
20
|
Chen RL, Sun LL, Cao Y, Chen HR, Zhou JX, Gu CY, Zhang Y, Wang SY, Hou W, Lin LZ. Adjuvant EGFR-TKIs for Patients With Resected EGFR-Mutant Non-Small Cell Lung Cancer: A Meta-Analysis of 1,283 Patients. Front Oncol 2021; 11:629394. [PMID: 33912453 PMCID: PMC8071858 DOI: 10.3389/fonc.2021.629394] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 03/12/2021] [Indexed: 12/25/2022] Open
Abstract
Background Cisplatin-based chemotherapy was previously considered as the standard adjuvant therapy for improved overall survival (OS) in patients with non-small cell lung cancer (NSCLC) after surgery. However, the benefit was limited due to high risks of recurrence and adverse events. In the present study, the efficacy of adjuvant epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) for EGFR-mutant patients after surgery was investigated using the latest updated data. Methods This meta-analysis included a comprehensive range of relevant studies identified from database searches. Disease-free survival (DFS) and OS with hazard ratios (HRs) were calculated using random-effect or fixed-effect models. Subgroup analysis was also performed. Results A total of seven randomized clinical trials were included in the meta-analysis and involved 1,283 NSCLC patients harboring EGFR mutations. In resected EGFR-mutant NSCLC patients, adjuvant EGFR-TKIs were significantly better than chemotherapy in terms of DFS (HR: 0.41; 95%CI: 0.24-0.70, P = 0.001), without showing any benefit in OS (HR: 0.72; 95%CI: 0.37-1.41, P = 0.336). No significant difference in DFS was observed between patients with EGFR exon 19 deletion and those with L858R mutation. Resected EGFR-mutant NSCLC patients treated with osimertinib experienced improved DFS and a lower risk of brain recurrence than those treated with gefitinib or erlotinib. Adjuvant EGFR-TKIs reduced the risk of bone and lung relapse, without decreasing the risk of local recurrence and liver relapse. Conclusion This meta-analysis shows that adjuvant EGFR-TKI therapy could significantly prolong DFS in patients with resected EGFR-mutant NSCLC. Treatment with osimertinib showed improved DFS with a lower risk of brain recurrence than treatment with gefitinib or erlotinib for resected disease.
Collapse
Affiliation(s)
- Rui-Lian Chen
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ling-Ling Sun
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yang Cao
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Han-Rui Chen
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jing-Xu Zhou
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chu-Ying Gu
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ying Zhang
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,Cancer Project Team of China Center for Evidence Based Traditional Chinese Medicine, Beijing, China
| | - Si-Yu Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer, Guangzhou, China
| | - Wei Hou
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,Cancer Project Team of China Center for Evidence Based Traditional Chinese Medicine, Beijing, China
| | - Li-Zhu Lin
- Integrative Cancer Centre, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| |
Collapse
|
21
|
Management of Pulmonary Nodules in Oncologic Patients: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2020; 216:1423-1431. [PMID: 33355489 DOI: 10.2214/ajr.20.24907] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cancer survivors are at higher risk than the general population for development of a new primary malignancy, most commonly lung cancer. Current lung cancer screening guidelines recommend low-dose chest CT for high-risk individuals, including patients with a history of cancer and a qualifying smoking history. However, major lung cancer screening trials have inconsistently included cancer survivors, and few studies have assessed management of lung nodules in this population. This narrative review highlights relevant literature and provides expert opinion for management of pulmonary nodules detected incidentally or by screening in oncologic patients. In patients with previously treated lung cancer, a new nodule most likely represents distant metastasis from the initial lung cancer or a second primary lung cancer; CT features such as nodule size and composition should guide decisions regarding biopsy, PET/CT, and CT surveillance. In patients with extrapulmonary cancers, nodule management requires individualized risk assessment; smoking is associated with increased odds of primary lung cancer, whereas specific primary cancer types are associated with increased odds of pulmonary metastasis. Nonneoplastic causes, such as infection, medication toxicity, and postradiation or postsurgical change, should also be considered. Future prospective studies are warranted to provide evidence-based data to assist clinical decision-making in this context.
Collapse
|
22
|
Striking a balance: Surveillance of non-small cell lung cancer after resection. J Thorac Cardiovasc Surg 2020; 162:680-684. [PMID: 33485663 DOI: 10.1016/j.jtcvs.2020.10.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 12/17/2022]
|
23
|
Comorbidity Patterns of Older Lung Cancer Patients in Northeast China: An Association Rules Analysis Based on Electronic Medical Records. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17239119. [PMID: 33291317 PMCID: PMC7729838 DOI: 10.3390/ijerph17239119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 12/12/2022]
Abstract
Purposes: This study aims to identify the comorbidity patterns of older men with lung cancer in China. Methods: We analyzed the electronic medical records (EMRs) of lung cancer patients over age 65 in the Jilin Province of China. The data studied were obtained from 20 hospitals of Jilin Province in 2018. In total, 1510 patients were identified. We conducted a rank–frequency analysis and social network analysis to identify the predominant comorbidities and comorbidity networks. We applied the association rules to mine the comorbidity combination with the values of confidence and lift. A heatmap was utilized to visualize the rules. Results: Our analyses discovered that (1) there were 31 additional medical conditions in older patients with lung cancer. The most frequent comorbidities were pneumonia, cerebral infarction, and hypertension. (2) The network-based analysis revealed seven subnetworks. (3) The association rules analysis provided 41 interesting rules. The results revealed that hypertension, ischemic cardiomyopathy, and pneumonia are the most frequent comorbid combinations. Heart failure may not have a strong implicating role in these comorbidity patterns. Cerebral infarction was rarely combined with other diseases. In addition, glycoprotein metabolism disorder comorbid with hyponatremia or hypokalemia increased the risk of anemia by more than eight times in older lung cancer patients. Conclusions: This study provides evidence on the comorbidity patterns of older men with lung cancer in China. Understanding the comorbidity patterns of older patients with lung cancer can assist clinicians in their diagnoses and contribute to developing healthcare policies, as well as allocating resources.
Collapse
|
24
|
Abbas AE. Commentary: The value of close surveillance after lung cancer surgery: How absence of evidence is not evidence of absence. J Thorac Cardiovasc Surg 2020; 162:686-687. [PMID: 33422324 DOI: 10.1016/j.jtcvs.2020.11.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Temple University Hospital and Fox Chase Comprehensive Cancer Center, Philadelphia, Pa.
| |
Collapse
|
25
|
Beyrer J, Nelson DR, Sheffield KM, Huang YJ, Ellington T, Hincapie AL. Development and validation of coding algorithms to identify patients with incident lung cancer in United States healthcare claims data. Pharmacoepidemiol Drug Saf 2020; 29:1465-1479. [PMID: 33012044 DOI: 10.1002/pds.5137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/01/2020] [Accepted: 09/09/2020] [Indexed: 11/11/2022]
Abstract
PURPOSE Our aim was to develop and validate a practical US healthcare claims algorithm for identifying incident lung cancer that improves on positive predictive value (PPV) and sensitivity observed in past studies. METHODS Patients newly diagnosed with lung cancer in Surveillance, Epidemiology, and End Results (SEER) (gold standard) were linked with Medicare claims. A 5% Medicare "other cancer" sample and noncancer sample served as controls. A split-sample validation approach was used. Rules-based, regression, and machine learning models for developing algorithms were explored. Algorithms were developed in the model building subset. Rules-based algorithms and those with the highest F scores were evaluated in the validation subset. F scores were compared for 1000 bootstrap samples. Misclassification was evaluated by calculating the odds of selection by the algorithm among true positives and true negatives. RESULTS A practical single-score algorithm derived from a logistic regression model had sensitivity = 78.22% and PPV = 78.50% (F score: 78.36). The algorithm was most likely to misclassify older patients (ages ≥80 years) or with missing data in the SEER registry, shorter follow-up time in Medicare (<3 months), insurance through Veterans Affairs, >1 cancer in SEER, or certain Charlson comorbidities (dementia, chronic pulmonary disease, liver disease, or myocardial infarction). CONCLUSION In this dataset, a practical point-based algorithm for identifying incident lung cancer demonstrated significant and substantial improvement (7.9% and 23.9% absolute improvement in sensitivity and PPV, respectively) compared with a current standard.
Collapse
Affiliation(s)
- Julie Beyrer
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | | | | | - Ana L Hincapie
- University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio, USA
| |
Collapse
|
26
|
Zeng B, Ji P, Chen C, Sun J, Gu C, Shang A, Wu J, Sun Z, Li D. A nomogram from the SEER database for predicting the prognosis of patients with non-small cell lung cancer. Int J Biochem Cell Biol 2020; 127:105825. [PMID: 32898690 DOI: 10.1016/j.biocel.2020.105825] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/07/2020] [Accepted: 08/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The purpose of this study was to establish and validate a nomogram to predict the prognosis in patients with non-small cell lung cancer (NSCLC) from multiple perspectives. RESULTS A total of 98,640 eligible patients were randomly divided into a training set (n = 69,048) and a validation set (n = 29,592). The baseline characteristics of the two sets were similar. We used clinical data from patients in the training set for univariate and multivariate Cox regression analyses. Twelve independent risk factors were incorporated for constructed a prognostic nomogram. And the nomogram with a concordance index of 0.777 (95 % CI, 0.775 to 0.779) for overall survival. The calibration curve results showed that the actual survival rate was consistent with the predicted survival rate. The area under curve of the receiver operating characteristic curves demonstrated that the nomogram has a high prediction of the overall survival rate in patients with NSCLC. CONCLUSION We have developed a nomogram with high prediction accuracy and discrimination ability, which can help clinicians making personalized survival predictions for NSCLC patients.
Collapse
Affiliation(s)
- Bingjie Zeng
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Ping Ji
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Chen Chen
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Junjun Sun
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Chenzheng Gu
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Anquan Shang
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Junlu Wu
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China
| | - Zujun Sun
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China.
| | - Dong Li
- Department of Clinical Laboratory, Shanghai Tongji Hospital, Tongji University School of Medicine, No. 389, Xincun Road, Shanghai, 200065, China.
| |
Collapse
|
27
|
Ding R, Zhu D, He P, Ma Y, Chen Z, Shi X. Comorbidity in lung cancer patients and its association with medical service cost and treatment choice in China. BMC Cancer 2020; 20:250. [PMID: 32209058 PMCID: PMC7092481 DOI: 10.1186/s12885-020-06759-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/17/2020] [Indexed: 01/13/2023] Open
Abstract
Background It is evident that comorbidity exacerbate the complexity of the management of lung cancer, however, limited research has been conducted to investigate the impact of comorbidity on health service utilization and cost, as well as the treatment choice among lung cancer patients. We examined the association of comorbidity with medical service utilization, cost and treatment choice among lung cancer patients in China. Methods We used claims data from China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2013 to 2016 and data from Hospital Information System (HIS) Database in Beijing Cancer Hospital (BCH). Elixhauser Comorbidity Index was used to assess comorbidity. Negative binomial regression, generalized linear model (GLM) with a gamma distribution and a log link, and logistic regression was applied to assess the associations between comorbidity and medical service utilization, cost and treatment choice, respectively. Results Among 8655 patients with lung cancer, 31.3% of had at least one comorbid conditions. Having comorbidity was associated with increased number of annual outpatient visits (1.6, 95%CI: 1.3, 1.9) and inpatients admissions (0.8, 95%CI, 0.70, 0.90), increased outpatient (USD635.5, 95%CI: 490.3, 780.8) and inpatient expenditure (USD2 470.3, 95CI%: 1998.6, 2941.9), as well as increased possibility of choosing radio therapy (OR: 1.208, 95%CI:1.012–1.441) and chemotherapy (1.363, 1.196–1.554), and decreased possibility of choosing surgery (0.850, 0.730–0.989). The medical utilization and expenditure, the possibility of choosing radiotherapy increases, and the possibility of choosing surgery decreases with the increasing number of chronic conditions. There are variations in the association with medical service utilization and expenditure, and treatment choice among individuals with different types of comorbid conditions. Conclusion Comorbidity among lung cancer patients restricts the potential treatment choices and poses an extra substantial health care burden. Our findings provide implications for both the clinical management and health service planning and financing for lung cancer patients.
Collapse
Affiliation(s)
- Ruoxi Ding
- Institute of Population Research, Peking University, Beijing, 100871, China
| | - Dawei Zhu
- China Center for Health Development Studies, Peking University, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Ping He
- China Center for Health Development Studies, Peking University, No. 38 Xueyuan Road, Haidian District, Beijing, 100191, People's Republic of China.
| | - Yong Ma
- China Health Insurance Research Association, Beijing, 100013, China
| | - Zhishui Chen
- Department of Medical Insurance, Peking University Cancer Hospital and Institute, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Beijing, 100142, China
| | - Xuefeng Shi
- School of Management, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China.
| |
Collapse
|
28
|
Zhu X, Hou R, Li X, Jiang C, Xia W, Fu X. Predictive model of the first failure pattern in patients receiving definitive chemoradiotherapy for inoperable locally advanced non-small cell lung cancer (LA-NSCLC). Radiat Oncol 2020; 15:43. [PMID: 32070383 PMCID: PMC7029470 DOI: 10.1186/s13014-020-1467-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 01/15/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose To analyze patterns of failure in patients with LA-NSCLC who received definitive chemoradiotherapy (CRT) and to build a nomogram for predicting the failure patterns in this population of patients. Materials and methods Clinicopathological data of patients with LA-NSCLC who received definitive chemoradiotherapy and follow-up between 2013 and 2016 in our hospital were collected. The endpoint was the first failure after definitive chemoradiotherapy. With using elastic net regression and 5-fold nested cross-validation, the optimal model with better generalization ability was selected. Based on the selected model and corresponding features, a nomogram prediction model was built. This model was also validated by ROC curves, calibration curve and decision curve analysis (DCA). Results With a median follow-up of 28 months, 100 patients experienced failure. There were 46 and 54 patients who experience local failure and distant failure, respectively. Predictive model including 9 factors (smoking, pathology, location, EGFR mutation, age, tumor diameter, clinical N stage, consolidation chemotherapy and radiation dose) was finally built with the best performance. The average area under the ROC curve (AUC) with 5-fold nested cross-validation was 0.719, which was better than any factors alone. The calibration curve revealed a satisfactory consistency between the predicted distant failure rates and the actual observations. DCA showed most of the threshold probabilities in this model were with good net benefits. Conclusion Clinicopathological factors could collaboratively predict failure patterns in patients with LA-NSCLC who are receiving definitive chemoradiotherapy. A nomogram was built and validated based on these factors, showing a potential predictive value in clinical practice.
Collapse
Affiliation(s)
- Xueru Zhu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Runping Hou
- Department of Biomedical Engineering, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Xiaoyang Li
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Chang Jiang
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Wuyan Xia
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China
| | - Xiaolong Fu
- Department of Radiation Oncology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, 200030, China.
| |
Collapse
|
29
|
Sun H, Wang H, Shi L, Wang M, Li J, Shi J, Ni M, Hu X, Chen Y. Physician preferences for chemotherapy in the treatment of non-small cell lung cancer in China: evidence from multicentre discrete choice experiments. BMJ Open 2020; 10:e032336. [PMID: 32051302 PMCID: PMC7045216 DOI: 10.1136/bmjopen-2019-032336] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To evaluate physician risk-benefit preferences and trade-offs when making chemotherapy decisions for patients with non-small cell lung cancer (NSCLC). DESIGN A discrete choice experiment (DCE). SETTINGS Tertiary hospitals in Beijing, Shanghai, Guangzhou and Chengdu of China. PARTICIPANTS The participants were 184 physicians (mean age of 37 years) with more than 1 year of NSCLC chemotherapy practice. OUTCOMES The DCE survey was constructed by six attributes: progression-free survival (PFS), disease control rate (DCR), risk of moderate side effects, risk of severe side effects, mode of administration and out-of-pocket costs. Physicians' relative preferences and trade-offs in patient out-of-pocket costs for each attribute level were estimated using a mixed logit model, and interaction terms were added to the model to assess preferences variation among physicians with different sociodemographic factors. RESULTS Physicians had the strongest preferences for improvements in PFS, followed by reducing the risk of severe side effects. The DCR, risk of moderate side effects and mode of administration were ranked in decreasing order of importance. There was little variation in preferences among physicians with different sociodemographic characteristics. Physicians were willing to trade $4814 (95% CI $4149 to $5480) of patient out-of-pocket costs per month for a chemotherapy that guaranteed 11 months of PFS, followed by $1908 (95% CI $1227 to $2539) for reducing the risk of severe side effects to 2%. CONCLUSIONS With regard to chemotherapy for patients with NSCLC, prolonging PFS, reducing severe and moderate side effects were primary considerations for physicians in China. The mode of administration and treatment costs significantly influenced physicians' therapeutic decision. The current findings could add some evidence to inform NSCLC chemotherapy implementation and promote shared decision-making.
Collapse
Affiliation(s)
- Hui Sun
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China
- Department of Health Technology Assessment Research, Shanghai Health Development Research Center, Shanghai Medical Information Center, Shanghai, China
| | - Huishan Wang
- The Second Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lizheng Shi
- Health Systems Analytics Research Center, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Meifeng Wang
- Department of Health Technology Assessment Research, Shanghai Health Development Research Center, Shanghai Medical Information Center, Shanghai, China
| | - Junling Li
- Department of Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jufang Shi
- Department of Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Ni
- Department of Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xianzhi Hu
- Department of Human Resource, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yingyao Chen
- Key Lab of Health Technology Assessment, National Health Commission, School of Public Health, Fudan University, Shanghai, China
| |
Collapse
|
30
|
Gu Y, Zhang J, Zhou Z, Liu D, Zhu H, Wen J, Xu X, Chen T, Fan M. Metastasis Patterns and Prognosis of Octogenarians with NSCLC: A Population-based Study. Aging Dis 2020; 11:82-92. [PMID: 32010483 PMCID: PMC6961775 DOI: 10.14336/ad.2019.0414] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/14/2019] [Indexed: 12/28/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) is the most common cancer and the leading cause of cancer-related deaths worldwide. Age at diagnosis of advanced NSCLC is much older, but studies describing the practice patterns for octogenarians with distant metastasis NSCLC are limited. A retrospective, population-based study using national representative data from the Surveillance, Epidemiology, and End Results (SEER) program was conducted to evaluate 34 882 NSCLC patients with extrathoracic metastases from 2010 to 2013. Patients were classified into three groups (older group: ≥80 yrs, middle-aged group: 60-79 yrs, and younger group: ≤59 yrs). The role of different age at diagnosis of NSCLC in metastasis patterns was investigated, and survival of different age groups of metastatic NSCLC was assessed. The analysis revealed that older patients were more likely to only have bone or liver metastasis (p< 0.001), but less likely to have brain only metastasis (p<0.001) and multiple metastatic sites (p< 0.001) than other two groups. Age at diagnosis was an independent risk factor for different metastasis types. Older group had the worst overall survival (p<0.001) and cancer-specific survival (p<0.001). Furthermore, older age patients with only bone metastasis had the best cancer specific survival (p<0.05) while younger patients with only brain metastasis had the best prognosis (p<0.001). Over 60% octogenarians with metastatic NSCLC did not receive anti-cancer therapy and had the highest rate of cancer deaths among all patients. Our results may help clinicians make positive decisions regarding personalized treatment of metastatic NSCLC in the elderly.
Collapse
Affiliation(s)
- Yu Gu
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Junhua Zhang
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhirui Zhou
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Di Liu
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Hongcheng Zhu
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Junmiao Wen
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xinyan Xu
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Tianxiang Chen
- 3Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Min Fan
- 1Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China.,2Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| |
Collapse
|
31
|
Schneider BJ, Ismaila N, Aerts J, Chiles C, Daly ME, Detterbeck FC, Hearn JWD, Katz SI, Leighl NB, Levy B, Meyers B, Murgu S, Nekhlyudov L, Santos ES, Singh N, Tashbar J, Yankelevitz D, Altorki N. Lung Cancer Surveillance After Definitive Curative-Intent Therapy: ASCO Guideline. J Clin Oncol 2019; 38:753-766. [PMID: 31829901 DOI: 10.1200/jco.19.02748] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide evidence-based recommendations to practicing clinicians on radiographic imaging and biomarker surveillance strategies after definitive curative-intent therapy in patients with stage I-III non-small-cell lung cancer (NSCLC) and SCLC. METHODS ASCO convened an Expert Panel of medical oncology, thoracic surgery, radiation oncology, pulmonary, radiology, primary care, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 2000 through 2019. Outcomes of interest included survival, disease-free or recurrence-free survival, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 14 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS Patients should undergo surveillance imaging for recurrence every 6 months for 2 years and then annually for detection of new primary lung cancers. Chest computed tomography imaging is the optimal imaging modality for surveillance. Fluorodeoxyglucose positron emission tomography/computed tomography imaging should not be used as a surveillance tool. Surveillance imaging may not be offered to patients who are clinically unsuitable for or unwilling to accept further treatment. Age should not preclude surveillance imaging. Circulating biomarkers should not be used as a surveillance strategy for detection of recurrence. Brain magnetic resonance imaging should not be used for routine surveillance in stage I-III NSCLC but may be used every 3 months for the first year and every 6 months for the second year in patients with stage I-III small-cell lung cancer who have undergone curative-intent treatment.
Collapse
Affiliation(s)
| | | | - Joachim Aerts
- Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands
| | | | - Megan E Daly
- University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | | | | | - Sharyn I Katz
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Natasha B Leighl
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Benjamin Levy
- Johns Hopkins Sidney Kimmel Cancer Center at Sibley Memorial Hospital, Washington, DC
| | | | | | | | | | - Navneet Singh
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | |
Collapse
|
32
|
Reed M, Patrick C, Quevillon T, Walde N, Voutsadakis IA. Prediction of hospital admissions and grade 3-4 toxicities in cancer patients 70 years old and older receiving chemotherapy. Eur J Cancer Care (Engl) 2019; 28:e13144. [PMID: 31429128 DOI: 10.1111/ecc.13144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 05/24/2019] [Accepted: 08/01/2019] [Indexed: 12/19/2022]
Abstract
AIM To predict chemotherapy toxicity and hospitalisations in elderly patients using clinical and laboratory parameters. METHODS Records of cancer patients 70 years old or older who received adjuvant chemotherapy or first-line chemotherapy for a cancer in a single centre were reviewed. Factors associated with hospitalisations, grade 3-4 toxicities and dose reductions during treatment were evaluated. RESULTS A total of 275 patients included in the study. Most patients (53.8%) were 70 to 75 years old. One hundred and five patients (38.2%) had a hospital admission during or within a month after their chemotherapy treatment. The only factor associated with admissions in the multivariate analysis was ECOG performance status (PS) >1 (p = .008, odds ratio 2.66, 95% CI: 1.28-5.53) and hypoalbuminaemia approached significance. Grade 3 and 4 toxicities were associated with a lower creatinine clearance in the multivariate analysis (p = .01, odds ratio 0.98, 95% CI: 0.97-1.0), and dose reductions were associated with metastatic stage (p = .03, odds ratio 1.88, 95% CI: 1.05-3.35). A combined index with all four parameters was associated with all three outcomes of interest. CONCLUSION ECOG PS, stage, albumin and creatinine clearance may be predictive of hospital admissions, grade 3-4 toxicities and dose reduction rates in cancer patients 70 years old and older receiving chemotherapy.
Collapse
Affiliation(s)
- Melissa Reed
- Clinical Trials Unit, Sault Area Hospital, Sault Ste. Marie, Ontario, Canada
| | - Caitlyn Patrick
- Clinical Trials Unit, Sault Area Hospital, Sault Ste. Marie, Ontario, Canada
| | - Travis Quevillon
- Clinical Trials Unit, Sault Area Hospital, Sault Ste. Marie, Ontario, Canada
| | - Natalie Walde
- Clinical Trials Unit, Sault Area Hospital, Sault Ste. Marie, Ontario, Canada
| | - Ioannis A Voutsadakis
- Algoma District Cancer Program, Sault Area Hospital, Sault Ste. Marie, Ontario, Canada.,Section of Internal Medicine, Division of Clinical Sciences, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| |
Collapse
|
33
|
Geriatric oncology health services research: Cancer and Aging Research Group infrastructure core. J Geriatr Oncol 2019; 11:350-354. [PMID: 31326392 DOI: 10.1016/j.jgo.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/06/2023]
|
34
|
Raymond DP. Commentary: Pursuit of the green jacket: Mastery of the long and short games. J Thorac Cardiovasc Surg 2019; 157:1644-1645. [DOI: 10.1016/j.jtcvs.2018.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 11/25/2022]
|
35
|
Xu ST, Xi JJ, Zhong WZ, Mao WM, Wu L, Shen Y, Liu YY, Chen C, Cheng Y, Xu L, Wang J, Fei K, Li XF, Li J, Huang C, Liu ZD, Xu S, Chen KN, Xu SD, Liu LX, Yu P, Wang BH, Ma HT, Yan HH, Yang XN, Zhang YX, Yin JC, Wang Q, Wu YL. The Unique Spatial-Temporal Treatment Failure Patterns of Adjuvant Gefitinib Therapy: A Post Hoc Analysis of the ADJUVANT Trial (CTONG 1104). J Thorac Oncol 2019; 14:503-512. [DOI: 10.1016/j.jtho.2018.11.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/18/2018] [Accepted: 11/18/2018] [Indexed: 12/25/2022]
|
36
|
Palazzo LL, Sheehan DF, Tramontano AC, Kong CY. Disparities and Trends in Genetic Testing and Erlotinib Treatment among Metastatic Non-Small Cell Lung Cancer Patients. Cancer Epidemiol Biomarkers Prev 2019; 28:926-934. [PMID: 30787053 DOI: 10.1158/1055-9965.epi-18-0917] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 11/13/2018] [Accepted: 02/14/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Despite reports of socioeconomic disparities in rates of genetic testing and targeted therapy treatment for metastatic non-small cell lung cancer (NSCLC), little is known about whether such disparities are changing over time. METHODS We performed a retrospective analysis to identify disparities and trends in genetic testing and treatment with erlotinib. Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified 9,900 patients with stage IV NSCLC diagnosed in 2007 to 2011 at age 65 or older. We performed logistic regression analyses to identify patient factors associated with odds of receiving a genetic test and erlotinib treatment, and to assess trends in these differences with respect to diagnosis year. RESULTS Patients were more likely to receive genetic testing if they were under age 75 at diagnosis [odds ratio (OR), 1.55] independent of comorbidity level, and this age-based gap showed a decrease over time (OR, 0.93). For untested patients, erlotinib treatment was associated with race (OR, 0.58, black vs. white; OR, 2.45, Asian vs. white), and was more likely among female patients (OR, 1.45); for tested patients, erlotinib treatment was less likely among low-income patients (OR, 0.32). Most of these associations persisted or increased in magnitude. CONCLUSIONS Race and sex are associated with rates of erlotinib treatment for patients who did not receive genetic testing, and low-income status is associated with treatment rates for those who did receive testing. The racial disparity remained stable over time, while the income-based disparity grew larger. IMPACT Attention to reducing disparities is needed as precision cancer treatments continue to be developed.
Collapse
Affiliation(s)
- Lauren L Palazzo
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Deirdre F Sheehan
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela C Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts. .,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
37
|
Disparities in broad-based genomic sequencing for patients with advanced non-small cell lung cancer. J Geriatr Oncol 2019; 10:669-672. [PMID: 30718180 DOI: 10.1016/j.jgo.2019.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/11/2019] [Accepted: 01/22/2019] [Indexed: 11/22/2022]
|
38
|
Treatment of clinical T4 stage superior sulcus non-small cell lung cancer: a propensity-matched analysis of the surveillance, epidemiology, and end results database. Biosci Rep 2019; 39:BSR20181545. [PMID: 30647107 PMCID: PMC6356038 DOI: 10.1042/bsr20181545] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/06/2018] [Accepted: 01/13/2019] [Indexed: 02/02/2023] Open
Abstract
Purpose/Objective(s): Treatments for superior sulcus non-small cell lung cancer (SS-NSCLC) have evolved, but adequate treatments of T4 disease have not been found. The aim of our study was to evaluate the prognostic factors and optimal treatment strategy for patients with T4 SS-NSCLC. Materials/Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) database (1973–2015) to identify patients diagnosed with T4 stage SS-NSCLC (according to the 7th edition American Joint Committee on Cancer (AJCC) staging system) from 2004 to 2015; those with M1 disease were excluded. Propensity score matching (PSM) with Kaplan–Meier and Cox proportional hazards’ models was performed to estimate prognosis. Results: A total of 384 patients were included. The majority was male (59.4%) at stage IIIB (56.6%), with N2 accounting for 45.3%. A total of 47 patients underwent cancer-directed surgery, while radiotherapy alone was received by 60.2% of patients. Median overall survival (OS) and lung cancer-specific survival (LCSS) were 12 and 17 months, respectively, and the 5-year OS and LCSS rates were 15.8 and 25.4%, respectively. In the matched population, the median survival outcomes were better following surgery (OS: 25 compared with 9.0 months, P<0.001; LCSS: not available (NA) compared with 11.0 months, P<0.001). Multivariate Cox analysis showed that ages ≥ 66 years (hazard ratio (HR) = 1.639, P=0.001), unmarried status (HR = 1.356, P=0.034), and tumor size ≥ 6.0 cm (HR = 1.694, P<0.001) were associated with inferior OS. Cancer-directed surgery (HR = 0.537, P=0.009) and radiotherapy (HR = 0.644, P=0.006) were independent prognostic factors for patients with T4 SS-NSCLC. Conversely, in the subgroup analysis, favorable impacts of radiotherapy were observed for nonsurgical patients (OS: HR = 0.58, P<0.001; LCSS: HR = 0.55, P<0.001). Conclusion: Our study showed that T4 stage SS-NSCLC patients had a poor prognosis. Surgical resection remains the best option for those with resectable disease. For nonsurgical T4 SS-NSCLC patients, radiotherapy should be actively considered.
Collapse
|
39
|
Subramanian M, Liu J, Greenberg C, Schumacher J, Chang GJ, McMurry TL, Francescatti AB, Semenkovich TR, Hudson JL, Meyers BF, Puri V, Kozower BD. Imaging Surveillance for Surgically Resected Stage I Non-Small Cell Lung Cancer: Is More Always Better? J Thorac Cardiovasc Surg 2018; 157:1205-1217.e2. [PMID: 31130741 DOI: 10.1016/j.jtcvs.2018.09.119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective Routine surveillance imaging for patients with resected non-small cell lung cancer is standard for the detection of disease recurrence and new primary lung cancers. However, surveillance intensity varies widely in practice, and its impact on long-term outcomes is poorly understood. We hypothesized that surveillance intensity was not associated with 5-year overall survival in patients with resected stage I non-small cell lung cancer. Additionally, we examined patterns of recurrence and new primary lung cancer development. Methods Cancer registrars at Commission on Cancer accredited institutions re-abstracted records to augment National Cancer Database patient data with information on comorbidities, imaging surveillance including intent and result of imaging, and recurrence (2007-2012). Pathologic stage I non-small cell lung cancer patients undergoing computed-tomography surveillance were placed into three imaging surveillance groups based on clinical practice guidelines: high intensity (3 month), moderate intensity (6 month), and low intensity (annual). Kaplan Meier analysis and Cox regression were used to compare overall survival among the three surveillance groups. Results 2442 patients were identified, with 805 (33%), 1216 (50%), and 421 (17%) patients in the high, moderate, and low surveillance intensity groups, respectively. Five-year overall survival was similar between intensity groups (p=0.547). Surveillance on asymptomatic patients detected 210 (63%) cases of locoregional recurrences and 128 (72%) cases of new primary lung cancer. Conclusions In a unique national dataset of long-term outcomes for stage I non-small cell lung cancer, surveillance intensity was not associated with 5-year overall survival.
Collapse
Affiliation(s)
- Melanie Subramanian
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Jingxia Liu
- Washington University School of Medicine, Division of Public Health Sciences
| | - Caprice Greenberg
- University of Wisconsin School of Medicine and Public Health, Department of Surgery
| | - Jessica Schumacher
- University of Wisconsin School of Medicine and Public Health, Department of Surgery
| | - George J Chang
- University of Texas MD Anderson Cancer Center, Department of Surgical Oncology
| | - Timothy L McMurry
- University of Virginia School of Medicine, Department of Public Health Sciences
| | | | - Tara R Semenkovich
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Jessica L Hudson
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Bryan F Meyers
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Varun Puri
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| | - Benjamin D Kozower
- Washington University School of Medicine, Division of Cardiothoracic Surgery
| |
Collapse
|
40
|
McMurry TL, Stukenborg GJ, Kessler LG, Colditz GA, Wong ML, Francescatti AB, Jones DR, Schumacher JR, Greenberg CC, Chang GJ, Winchester DP, McKellar DP, Kozower BD. More Frequent Surveillance Following Lung Cancer Resection Is Not Associated With Improved Survival: A Nationally Representative Cohort Study. Ann Surg 2018; 268:632-639. [PMID: 30004919 PMCID: PMC6419100 DOI: 10.1097/sla.0000000000002955] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate whether an association exists between the intensity of surveillance following surgical resection for non-small cell lung cancer (NSCLC) and survival. BACKGROUND Surveillance guidelines following surgical resection of NSCLC vary widely and are based on expert opinion and limited evidence. METHODS A Special Study of the National Cancer Database randomly selected stage I to III NSCLC patients for data reabstraction. For patients diagnosed between 2006 and 2007 and followed for 5 years through 2012, registrars documented all postsurgical imaging with indication (routine surveillance, new symptoms), recurrence, new primary cancers, and survival, with 5-year follow-up. Patients were placed into surveillance groups according to existing guidelines (3-month, 6-month, annual). Overall survival and survival after recurrence were analyzed using Cox Proportional Hazards Models. RESULTS A total of 4463 patients were surveilled with computed tomography scans; these patients were grouped based on time from surgery to first surveillance. Groups were similar with respect to age, sex, comorbidities, surgical procedure, and histology. Higher-stage patients received more surveillance. More frequent surveillance was not associated with longer risk-adjusted overall survival [hazard ratio for 6-month: 1.16 (0.99, 1.36) and annual: 1.06 (0.86-1.31) vs 3-month; P value 0.14]. More frequent imaging was also not associated with postrecurrence survival [hazard ratio: 1.02/month since imaging (0.99-1.04); P value 0.43]. CONCLUSIONS These nationally representative data provide evidence that more frequent postsurgical surveillance is not associated with improved survival. As the number of lung cancer survivors increases over the next decade, surveillance is an increasingly important major health care concern and expenditure.
Collapse
Affiliation(s)
- Timothy L McMurry
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - George J Stukenborg
- Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Larry G Kessler
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Graham A Colditz
- Divisions of Cardiothoracic Surgery and Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | - Melisa L Wong
- Divisions of Hematology/Oncology, University of California San Francisco, San Francisco, CA
| | | | - David R Jones
- Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - George J Chang
- Department of Surgical Oncology and Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David P Winchester
- Commission on Cancer and Cancer Programs, American College of Surgeons, Chicago, IL
| | - Daniel P McKellar
- Commission on Cancer and Cancer Programs, American College of Surgeons, Chicago, IL
| | - Benjamin D Kozower
- Divisions of Cardiothoracic Surgery and Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
41
|
Yutaka Y, Sonobe M, Kawaguchi A, Hamaji M, Nakajima D, Ohsumi A, Menju T, Chen-Yoshikawa TF, Sato T, Date H. Prognostic impact of preoperative comorbidities in geriatric patients with early-stage lung cancer: Significance of sublobar resection as a compromise procedure. Lung Cancer 2018; 125:192-197. [PMID: 30429019 DOI: 10.1016/j.lungcan.2018.09.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/21/2018] [Accepted: 09/27/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVES In high-risk operable geriatric patients undergoing palliative sublobar resection (SR), noncancerous comorbidities may contribute to unfavorable outcomes. The purpose of this retrospective study was to evaluate the perioperative safety and long-term survival of palliative SR in this patient population. MATERIALS AND METHODS We reviewed 232 patients (141 male, 91 female) aged ≥75 years who underwent surgical resection of clinical stage I lung cancer from 2006 to 2014. The patients were divided into two groups, lobectomy and SR, and preoperative comprehensive comorbidities were assessed using the Adult Comorbidity Evaluation 27 (ACE-27) and compared between the two groups. The operative safety was compared using the Clavien-Dindo classification. Survival rates were calculated with a Kaplan-Meier model under propensity score matching, and prognostic factors were analyzed using a Cox proportional hazard model. RESULTS Lobectomy was performed in 156 patients and SR in 76 (segmentectomy, n = 50; wedge resection, n = 26). Age (p = 0.0137), tumor size on computed tomography (p < 0.0001), central tumor location (p = 0.0008), and high ACE-27 scores (p = 0.0202) were significantly associated with selection of SR. No mortality occurred, and the incidence of Grade 3b or greater postoperative complications in lobectomy and SR was 5.1% and 5.3%, respectively. According to the analysis of propensity score-matched patients (n = 57, tumor size = 23 mm, and consolidation/tumor ratio = 83%), the 5-year survival rate in lobectomy and SR was 81.1% and 73.5%, respectively (p = 0.4374). The ACE-27 score was a more significant prognostic factor than the type of surgical procedure, as well as consolidation/tumor ratio and nodal metastatic status. CONCLUSIONS The severity of preoperative comorbidities is a significant prognostic factor, and SR as a compromise surgical procedure may provide promising short- and long-term outcomes in selected geriatric patients with clinical stage I lung cancer.
Collapse
Affiliation(s)
- Yojiro Yutaka
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan; Institute for Advancement for Clinical and Translational Science, Kyoto University, 54, Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Makoto Sonobe
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan.
| | - Atsushi Kawaguchi
- Center for Comprehensive Community Medicine, Faculty of Medicine, Saga University, 67, Asahi-cho, Kurume city, Fukuoka 830-0011, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Daisuke Nakajima
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Toshi Menju
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Toyofumi F Chen-Yoshikawa
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Toshihiko Sato
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan; Institute for Advancement for Clinical and Translational Science, Kyoto University, 54, Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto 6068507, Japan
| |
Collapse
|
42
|
Wong ML, McMurry TL, Schumacher JR, Hu CY, Stukenborg GJ, Francescatti AB, Greenberg CC, Chang GJ, McKellar DP, Walter LC, Kozower BD. Comorbidity Assessment in the National Cancer Database for Patients With Surgically Resected Breast, Colorectal, or Lung Cancer (AFT-01, -02, -03). J Oncol Pract 2018; 14:e631-e643. [PMID: 30207852 DOI: 10.1200/jop.18.00175] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Accurate comorbidity measurement is critical for cancer research. We evaluated comorbidity assessment in the National Cancer Database (NCDB), which uses a code-based Charlson-Deyo Comorbidity Index (CCI), and compared its prognostic performance with a chart-based CCI and individual comorbidities in a national sample of patients with breast, colorectal, or lung cancer. PATIENTS AND METHODS Through an NCDB Special Study, cancer registrars re-abstracted perioperative comorbidities for 11,243 patients with stage II to III breast cancer, 10,880 with stage I to III colorectal cancer, and 9,640 with stage I to III lung cancer treated with definitive surgical resection in 2006-2007. For each cancer type, we compared the prognostic performance of the NCDB code-based CCI (categorical: 0 or missing data, 1, 2+), Special Study chart-based CCI (continuous), and 18 individual comorbidities in three separate Cox proportional hazards models for postoperative 5-year overall survival. RESULTS Comorbidity was highest among patients with lung cancer (13.2% NCDB CCI 2+) and lowest among patients with breast cancer (2.8% NCDB CCI 2+). Agreement between the NCDB and Special Study CCI was highest for breast cancer (rank correlation, 0.50) and lowest for lung cancer (rank correlation, 0.40). The NCDB CCI underestimated comorbidity for 19.1%, 29.3%, and 36.2% of patients with breast, colorectal, and lung cancer, respectively. Within each cancer type, the prognostic performance of the NCDB CCI, Special Study CCI, and individual comorbidities to predict postoperative 5-year overall survival was similar. CONCLUSION The NCDB underestimated comorbidity in patients with surgically resected breast, colorectal, or lung cancer, partly because the NCDB codes missing data as CCI 0. However, despite underestimation of comorbidity, the NCDB CCI was similar to the more complete measures of comorbidity in the Special Study in predicting overall survival.
Collapse
Affiliation(s)
- Melisa L Wong
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Timothy L McMurry
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Jessica R Schumacher
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Chung-Yuan Hu
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - George J Stukenborg
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Amanda B Francescatti
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Caprice C Greenberg
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - George J Chang
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Daniel P McKellar
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Louise C Walter
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| | - Benjamin D Kozower
- University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, CA; University of Virginia Health System, Charlottesville, VA; University of Wisconsin, Madison, WI; The University of Texas MD Anderson Cancer Center, Houston, TX; American College of Surgeons, Chicago, IL; and Washington University, St. Louis, MO
| |
Collapse
|
43
|
Grossi F, Crinò L, Logroscino A, Canova S, Delmonte A, Melotti B, Proto C, Gelibter A, Cappuzzo F, Turci D, Gamucci T, Antonelli P, Marchetti P, Santoro A, Giusti S, Di Costanzo F, Giustini L, Del Conte A, Livi L, Giannarelli D, de Marinis F. Use of nivolumab in elderly patients with advanced squamous non-small-cell lung cancer: results from the Italian cohort of an expanded access programme. Eur J Cancer 2018; 100:126-134. [PMID: 30014881 DOI: 10.1016/j.ejca.2018.05.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/06/2018] [Accepted: 05/21/2018] [Indexed: 02/03/2023]
Abstract
AIM This analysis evaluated the efficacy and safety of nivolumab, an immune checkpoint inhibitor, in elderly patients with stage IIIB or IV squamous non-small-cell lung cancer (NSCLC) enrolled in the expanded access programme (EAP) in Italy. METHODS Nivolumab was available on physician request. Safety data included adverse events (AEs). Efficacy data included investigator-assessed tumour response, progression date and survival information. Results were analysed for patients aged <65, 65-<75 and ≥75 years and for the overall population. RESULTS A total of 371 patients with squamous NSCLC were enrolled at 96 centres between April 2015 and September 2015; 34% (n = 126), 47% (n = 175) and 19% (n = 70) were aged <65, 65-<75 and ≥75 years, respectively. Efficacy was similar among patients aged <65, 65-<75 and ≥75 years and the overall population (objective response rates: 18%, 18%, 19% and 18%, respectively; disease control rates: 49%, 47%, 43% and 47%, respectively). Median overall survival was reduced in patients aged ≥75 years (5.8 months) versus patients aged <65; years (8.6 months), patients aged 65-<75 years (8.0 months) and the overall population (7.9 months). The incidence of grade 3-4 treatment-related AEs was low in patients aged 65, 65-<75 and ≥75 years and the overall population (3%, 9%, 3%, 6%, respectively). Discontinuation rates due to treatment-related AEs were low irrespective of age (4-5%). CONCLUSIONS These EAP results suggest that elderly patients with advanced squamous NSCLC benefit from nivolumab, with tolerability similar to that in the overall population.
Collapse
Affiliation(s)
| | - Lucio Crinò
- Istituto Scientifico Romagnolo per Lo Studio e La Cura Dei Tumori (IRST), Meldola, Italy
| | - Antonio Logroscino
- Clinical Cancer Center IRCCS Istituto Tumori "Giovanni Paolo II" Bari, Italy
| | - Stefania Canova
- Department of Oncology, ASST Monza, Presidio San Gerardo, Monza, Italy
| | - Angelo Delmonte
- Istituto Scientifico Romagnolo per Lo Studio e La Cura Dei Tumori (IRST), IRCCS, Meldola, Italy
| | | | | | - Alain Gelibter
- Università Degli Studi di ROMA "La Sapienza", Rome, Italy
| | | | - Daniele Turci
- AUSL Della Romagna Presidi Ospedalieri di Ravenna, Faenza, Italy
| | - Teresa Gamucci
- ASL Frosinone - Presidio Ospedaliero SS Trinità, Sora, Italy
| | - Paola Antonelli
- ASST Valle Olona, Presidio Ospedaliero di Busto Arsizio, Busto Arsizio, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|