The impact of time between staging PET/CT and definitive chemo-radiation on target volumes and survival in patients with non-small cell lung cancer

Impact of time-to-treatment initiation on survival in single primary non-small cell lung Cancer: A population-based study

Background

Understanding the effects of a delayed time-to-treatment initiation(TTI) for non-small cell lung cancer (NSCLC) is vital.

Methods

We analyzed NSCLC data from the Surveillance, Epidemiology, and End Results database, focusing on lung adenocarcinoma (LUAD) and lung squamous carcinoma (LUSC). TTI was studied as both continuous and dichotomous variables. Restricted cubic splines were employed to identify potential nonlinear dependency between the hazard ratio (HR) and TTI. Propensity score matching was used to ensure a balanced patient allocation, and then survival differences between groups were assessed using Kaplan-Meier analysis and competing risk models. We used overall survival (OS) as the primary outcome and cancer-specific cumulative mortality (CSCM) as a complementary indicator. Finally, sensitivity analyses were performed on censored data.

Results

A total of 80,020 with NSCLC were analyzed. TTI was assessed as a continuous variable, showing a noticeable increase in the HR for stage I to II NSCLC with TTI >1 month. Conversely, the trend for stage III to IV NSCLC was the opposite. In stage I LUAD, the 'early' group demonstrated a higher OS compared to the 'delayed' group (Log-rank P = 0.002), while there was no significant difference in CSCM (Fine-gray P = 0.321). In stage I LUSC, there was no significant difference in OS(Log-rank P = 0.260), but the 'early' group had a lower CSCM (Fine-gray P = 0.018). For stage II-IV NSCLC, the 'delayed' group did not exhibit a negative impact on OS or CSCM. The sensitivity analysis further supported the results of the main analysis.

Conclusion

Prolongation of TTI ≥31 days has a negative impact on OS or CSCM in stage I NSCLC only. Further exploration and validation are needed to determine whether these results can be used as evidence for a 'safe' TTI threshold setting for future NSCLC.

The impact of staging FDG-PET/CT on treatment for stage III NSCLC - an analysis of population-based data from Ontario, Canada

Purpose

Fluoro-2-deoxyglucose positron-emission tomography (FDG-PET/CT) is now considered a standard investigation for the staging of new cases of stage III NSCLC. However, there is not published level 3 evidence demonstrating the impact of FDG-PET/CT on appropriate therapy in this setting. Using retrospective population-based data, we sought to examine the role and timing that FDG-PET/CT scans play in influencing treatment choice, as well as survival in patients diagnosed with stage III NSCLC.

Materials and methods

A retrospective cohort of patients diagnosed with stage III NSCLC from 2009-2017 in Ontario were identified from the IC/ES (formerly Institute of Clinical Evaluative Sciences) database. FDG-PET/CT utilization over time, trends in mediastinal biopsy technique and usage, the impact of FDG-PET/CT on overall survival (OS), and its influence on use of concurrent chemoradiotherapy (CRT) were explored. The impact of timing of pre-treatment FDG-PET/CT on OS was also analyzed (≤28 days prior to treatment, 29-56 days prior, and >56 days prior).

Results

Between 2007 and 2017, a total of 13 796 people were diagnosed with stage III NSCLC in Ontario. FDG-PET/CT utilization increased over time with 0% of cases in 2007 and 74% in 2017 with pre-treatment FDG-PET/CT scans. The number of patients who received a mediastinal biopsy similarly increased in this timeframe increasing from 41% to 53%. More patients with pre-treatment FDG-PET/CT scans received curative-intent therapy than those who did not: 23% vs 13% for CRT (p<0.001), and 23% vs 10% for surgery (p<0.001). Median OS was longer in those with FDG-PET/CT scans prior to treatment (17 vs 11 months), as was 5-year survival (22% vs 14%, p<0.001), and this held true on both univariate and multivariate analyses. Timing of FDG-PET/CT scan relative to treatment was not associated with differences in OS.

Conclusion

Improvements in OS were seen in this cohort of stage III NSCLC patients who underwent a pre-treatment FDG-PET/CT scan. This can likely be attributed to stage-appropriate therapy due to more complete staging using FDG-PET/CT. This study stresses the importance of complete staging for suspected stage III NSCLC using FDG-PET/CT, and a need for continued advocacy for increased access to FDG-PET/CT scans.

Impact of coronavirus disease 2019 on head and neck urgent suspected cancer referral pathways in rural Wales

Objective

To assess the impact of the coronavirus disease 2019 pandemic on head and neck urgent suspected cancer referral pathways in rural areas of Wales.

Method

A retrospective audit was conducted of 2234 head and neck urgent suspected cancer referrals received from January 2019 to November 2020.

Results

The referrals dropped by 35 per cent in 2020 compared to the same period in 2019. The time from general practitioner referral to the first ENT appointment improved during the pandemic (8.0 vs 10.0 days; p < 0.001). Of referrals, 92.1 per cent were seen within a 14-day period in 2020, compared with 79.6 per cent in 2019 (p < 0.001). There were no differences between 2020 and 2019 in terms of: the (confirmed cancer) conversion rate (10.6 per cent vs 9.7 per cent; p = 0.60), general practitioner referral to multidisciplinary team discussion time (35.5 vs 41.5 days; p = 0.40) or general practitioner referral to initiation of treatment time (68.0 vs 78.0 days; p = 0.16).

Conclusion

Whilst coronavirus disease 2019 reduced the number of overall head and neck urgent suspected cancer referrals, the pathways were generally unchanged, if not slightly improved, in rural Wales.

Diagnosis-to-surgery interval and survival for different histologies of stage I-IIA lung cancer

Background

Guidelines on timeliness of lung cancer surgery are inconsistent. Lung cancer histologic subtypes have different prognosis and treatment. It is important to understand the consequences of delayed surgery for each lung cancer histologic subtype. This study aimed to examine the association between diagnosis-to-surgery time interval and survival for early stage lung cancer and selected histologic subtypes.

Methods

Patients diagnosed with stage I–IIA lung cancer between 2004 and 2015 receiving definitive surgery and being followed up until Dec. 31, 2018, were identified from Surveillance, Epidemiology, and End Results database. Histologic subtypes included adenocarcinoma, squamous or epidermoid carcinoma, bronchioloalveolar carcinoma, large cell carcinoma, adenosquamous carcinoma, carcinoid carcinoma, and small cell carcinoma. Diagnosis-to-surgery interval was treated as multi-categorical variables (<1, 1–2, 2–3, and ≥3 months) and binary variables (≥1 vs. <1 month, ≥2 vs. <2 months, and ≥3 vs. <3 months). Outcomes included cancer-specific and overall survival. Covariates included age at diagnosis, sex, race, marital status, tumor size, grade, surgery type, chemotherapy, radiotherapy, and study period. Kaplan-Meier survival curves and Cox proportional hazards regression models were applied to examine the survival differences.

Results

With a median follow-up time of 51 months, a total of 40,612 patients were analyzed, including 40.1% adenocarcinoma and 24.5% squamous or epidermoid carcinoma. The proportion of patients receiving surgery <1, 1–2, 2–3, and ≥3 months from diagnosis were 34.2%, 33.9%, 19.8%, and 12.1%, respectively. Delayed surgery was associated with worse cancer-specific and overall survival for all lung cancers, adenocarcinoma, squamous or epidermoid, bronchioloalveolar, and large cell carcinoma (20–40% increased risk). Dose-dependent effects (longer delay, worse survival) were observed in all lung cancers, adenocarcinoma, and squamous and epidermoid carcinoma. No significant association between surgery delay and survival was observed in adenosquamous, carcinoid, and small cell carcinoma.

Conclusions

Our findings support the guidelines of undertaking surgery within 1 month from diagnosis in patients with stage I–IIA lung cancer. The observed dose-dependent effects emphasize the clinical importance of early surgery. Future studies with larger sample size of less frequent histologic subtypes are warranted to provide more evidence for histology-specific lung cancer treatment guidelines.

Associations Between Time to Treatment Start and Survival in Patients With Lung Cancer

BACKGROUND

Time-to-treatment is defined as a quality indicator for cancer care but is not well documented. We investigated whether meeting Norwegian timeframes of 35/42 days from referral until start of chemotherapy or surgery/radiotherapy for lung cancer was associated with survival.

PATIENTS AND METHODS

The medical records of 439 lung cancer patients at a regional cancer center were reviewed and categorized according to treatment: (i) surgery; ii) radical radiotherapy; iii) stereotactic radiotherapy; iv) palliative treatment, no cancer symptoms; v) palliative treatment with severe cancer symptoms).

RESULTS

Proportions receiving timely treatment varied significantly at 39%, 48%, 10%, 44% and 89%, respectively (p<0.001). Overall, those starting treatment on time had the shortest median overall survival (10.6 vs. 22.6 months; p<0.001). This was also the case for palliative (5.3 vs. 11.4 months) (p<0.001) but not for curative treatment (not reached vs. 38.3 months) (p=0.038).

CONCLUSION

Timely treatment is not necessarily associated with improved survival.

Racial Disparity and Social Determinants in Receiving Timely Surgery Among Stage I-IIIA Non-small Cell Lung Cancer Patients in a U.S. Southern State

Delayed surgery is associated with worse lung cancer outcomes. Social determinants can influence health disparities. This study aimed to examine the potential racial disparity and the effects from social determinants on receipt of timely surgery among lung cancer patients in Louisiana, a southern state in the U.S. White and black stage I-IIIA non-small cell lung cancer patients diagnosed in Louisiana between 2004 and 2016, receiving surgical lobectomy or a more extensive surgery, were selected. Diagnosis-to-surgery interval >6 weeks were considered as delayed surgery. Social determinants included marital status, insurance, census tract level poverty, and census tract level urbanicity. Multivariable logistic regression and generalized multiple mediation analysis were conducted. A total of 3,616 white (78.9%) and black (21.1%) patients were identified. The median time interval from diagnosis to surgery was 27 days in whites and 42 days in blacks (P < 0.0001). About 28.7% of white and 48.4% of black patients received delayed surgery (P < 0.0001). Black patients had almost two-fold odds of receiving delayed surgery than white patients (adjusted odds ratio: 1.91; 95% confidence interval: 1.59-2.30). Social determinants explained about 26% of the racial disparity in receiving delayed surgery. Having social support, private insurance, and living in census tracts with lower poverty level were associated with improved access to timely surgery. The census tract level poverty level a stronger effect on delayed surgery in black patients than in white patients. Tailored interventions to improve the timely treatment in NSCLC patients, especially black patients, are needed in the future.

Health Resource and Cost Savings Achieved in a Multidisciplinary Lung Cancer Clinic

Background: Lung cancer (LC) care is resource and cost intensive. We launched a Multidisciplinary LC Clinic (MDC), where patients with a new LC diagnosis received concurrent oncology consultation, resulting in improved time to LC assessment and treatment. Here, we evaluate the impact of MDC on health resource utilization, patient and caregiver costs, and secondary patient benefits. Methods: We retrospectively analyzed patients in a rapid assessment clinic with a new LC diagnosis pre-MDC (September 2016-February 2017) and post-MDC implementation (February 2017-December 2018). Data are reported as means; unpaired t-tests and ANOVA were used to assess for significance. We also conducted a cost analysis. Resource utilization, out-of-pocket costs, procedure-related costs, and indirect costs were evaluated from the societal perspective and presented in 2019 Canadian dollars (CAD); multi-way worst/best case and threshold sensitivity analyses were conducted. Results: We reviewed 428 patients (78 traditional model, 350 MDC). Patients in the MDC model required significantly fewer oncology visits from LC diagnosis to first LC treatment (1.62 vs. 2.68, p < 0.001), which was significant for patients with stage 1, 3, and 4 disease. Compared with the traditional model, there was no change in mean biopsies/patient (1.32 traditional vs. 1.17 MDC, p = 0.18) or staging investigations/patient (2.24 traditional vs. 2.02 MDC, p = 0.20). Post-MDC, there was an increase in invasive mediastinal staging for patients with stage 2/3 LC (15.0% vs. 60.0%, p < 0.001). Over 22 months, MDC resulted in savings of CAD 48,389 including CAD 24,167 CAD in direct patient out-of-pocket expenses. For the threshold analyses, MDC was estimated to cost CAD 25,708 per quality-adjusted life year (QALY), considered to be below current willingness to pay thresholds (at CAD 80,000 per QALY). MDC also facilitated oncology assessment for 29 non-LC patients. Conclusions: An MDC led to a reduction in patient visits and direct patient and caregiver costs.

Non-small cell lung cancer stage migration as a function of wait times from diagnostic imaging: A pooled analysis from five international centres

INTRODUCTION

Patients with non-small cell lung cancer (NSCLC) can experience rapid disease progression between initial staging FDG-PET scans and commencement of curative-intent radiotherapy (RT). Previous studies that estimated stage migration rates by comparing staging PET/CT and treatment-planning PET/CT images were limited by small sample sizes.

METHODS

This multicenter, international study combined prospective data from five institutions for PET-staged patients with NSCLC who were intended to receive curative-intent RT. TNM status was compared for staging and RT planning scans and the probability of TNM status and overall stage migration was analyzed as a function of the interval between PET/CT scans. The impacts of N classification, overall stage, and pathology were also studied.

RESULTS

Pooled data from 181 patients were analyzed. The median interval between PET/CT scans was 42 days (range, 2-208). Upstaging occurred in 32 % of patients. The overall rate of stage migration was higher for patients presenting with initial stage IIIB/IIIC disease (p = 0.006) and patients with N2-3 nodal disease (p = 0.019). Upstaging to M1 disease was significantly associated with initial stage IIIB/IIIC disease (HR = 15.2) and adenocarcinoma (HR = 10) histology.

CONCLUSION

Longer intervals between imaging and treatment in patients with NSCLC were associated with high rates disease progression with consequent risks of geographic miss in RT planning and futile treatment in patients with M1 disease. Patients with more extensive initial nodal involvement and those with adenocarcinoma had the highest rates of stage migration. Dedicated RT planning PET/CT imaging is recommended, especially if >3 weeks have elapsed after initial staging.

Non-oncologist Physician Knowledge of Radiation Therapy at an Urban Community Hospital

Radiation therapy (RT) is a crucial part of cancer care, but previous work suggests that many non-radiation oncologist physicians are uncomfortable referring for RT. To evaluate training and understanding of RT, the authors sent invitations to complete an online questionnaire to all physicians at a community hospital in Bronx, NY, which asked about oncology training and self-rated and objective knowledge of RT. Out of 247 invited participants, 87 responded (35%). Among responders, 19 were attending physicians (22%) and 66 (76%) were residents. Seventy-two percent of respondents reported caring for > 5 cancer patients in the past month, but 54% reported never referring patients for RT. Sixty-nine percent of respondents stated they received no radiation oncology training in medical school, and 36% reported no general oncology training. Approximately half believed themselves to be "somewhat knowledgeable" about RT indications (48%), benefits (53%), and side effects (55%). Objective assessment mean score was 6.2/12 (median 7) for all respondents; Respondents with internal medicine specialization scored higher than others (mean 7.7 vs 3.5; p < 0.01). Scores did not differ between attending and resident physicians, resident post-graduate levels, or receiving oncology training in medical school. The factors most commonly cited as affecting RT referral decisions were type of cancer, patient wishes, family wishes, poor functional status, and life expectancy. Many physicians are unaware of RT effectiveness or indications, which may affect referral patterns. Previous oncology training was not associated with higher knowledge scores.

Influence of timeliness and receipt of first treatment on geographic variation in non-small cell lung cancer mortality

Mortality from non-small cell lung cancer (NSCLC) exhibits substantial geographical disparities. However, there is little evidence on whether this variation could be attributed to patients' clinical characteristics and/or socioeconomic inequalities. This study evaluated the independent and relative contribution of the individual- and area-level risk factors on geographic variation in 2-year all-cause mortality among NSCLC patients. In the Hierarchical-related regression approach, we used the Bayesian spatial multilevel logistic regression model to combine individual- and area-level predictors with outcomes while accounting for geographically structured and unstructured correlation. Individual-level data included 3330 NSCLC cases reported to the Victoria Lung Cancer Registry between 2011 and 2016. Area-level data comprised socioeconomic disadvantage, remoteness and pollution data at the postal area level in Victoria, Australia. With the inclusion of significant individual- and area-level risk factors, timely (≤14 days) first definitive treatment (odds ratio [OR] = 0.73, 95% credible interval [Crl] = 0.56-0.94) and multidisciplinary meetings (MDM) (OR = 0.74, 95% Crl = 0.59-0.93) showed an independent association with a lower likelihood of NSCLC 2-year all-cause mortality. Timely and delayed (>14 days) first nondefinitive treatment, no treatment, advanced clinical stage, smoking, poor performance status, public hospital insurance and area-level deprivation were independently associated with a higher likelihood of 2- and 5-year all-cause mortality. NSCLC's 2-year all-cause mortality exhibited substantial geographic variation, mainly associated with timeliness and receipt of first definitive treatment, no treatment followed by patient prognostic factors with some contribution from area-level deprivation, MDM and public hospital insurance. This study highlights NSCLC patients should receive the first definitive treatment within the recommended 14-days from diagnosis.

Impact of time-to-treatment on overall survival of non-small cell lung cancer patients-an analysis of the national cancer database

Background

The association between time-to-treatment and outcomes for lung cancer has not been conclusively established. In this study, we evaluated the effect of time-to-treatment on the overall 5-year survival of patients with non-small cell lung cancer (NSCLC) with cancer stage at diagnosis.

Methods

We analyzed data in the National Cancer Data Base for adult patients newly diagnosed with NSCLC in 2003–2011 (N=693,554). Extended Cox regression with counting process was used to model the effect of time-to-treatment on survival, adjusted for demographic and clinical factors. Multivariable analyses were performed separately for the groups with different stages at diagnosis. Time-to-treatment was defined as the interval between diagnosis and treatment initiation, with the categories of (I) 0 day, (II) 1 day–4 weeks, (III) 4.1–6.0 weeks, and (IV) >6 weeks (the 1 day–4 weeks group was considered the reference group).

Results

Compared to treatment initiated between 1 day and 4 weeks after diagnosis, time-to-treatment at 4.1–6.0 weeks was associated with a lower risk of death for patients with early-stage cancer [adjusted HR (aHR), 0.84 (95% CI, 0.82–0.85)], with locally advanced cancer [aHR, 0.82 (95% CI, 0.80–0.83)], and with metastatic cancer [aHR, 0.75 (95% CI, 0.74–0.76)]. Similarly, a lower risk of death was associated with time-to-treatment longer than 6 weeks for patients with any cancer stage at diagnosis. However, a subset analysis for early-stage patients who received surgery only showed that extended time-to-surgery was associated a higher risk of death [aHR _{4.1-6.0 weeks}, 1.06 (95% CI, 1.03–1.09); aHR_{>6 weeks} 1.17 (95% CI, 1.14–1.20)].

Conclusions

The findings show that, although time-to-treatment should not be compromised, it is imperative to ensure that patients receive optimal pre-treatment assessments rather than rushing the treatment. Future research should focus on examining clinical characteristics to determine an optimal time-to-treatment to achieve the best possible survival for NSCLC patients.

Reduced delays in diagnostic pathways for non-small cell lung cancer after local and National initiatives

OBJECTIVES

Patients with non-small cell lung cancer (NSCLC) may experience progression and stage shift due to delays in a complex and time-consuming diagnostic work-up. We have analyzed the impact of both a local and national intervention on total time to treatment (TTT).

MATERIAL AND METHODS

All patients diagnosed with NSCLC at a Norwegian county hospital from 2007 to 2016 were reviewed. Logistic bottlenecks and delays were identified (2007-12) resulting in implementation of a local initiative with new diagnostic algorithm introduced by the beginning of 2013. In 2015, national diagnostic cancer pathways were implemented. TTT defined as time from received referral from the primary physician to start of treatment was compared in the three diagnostic time periods; baseline (2007-12), local (2013-14) and national (2015-16).

RESULTS

A total of 780 patients were included. Among patients treated with curative intent the median TTT decreased by 21 days, from 64 to 43 days (p < 0.001) while the mean number of diagnostic procedures increased from 3.5 to 3.9. In median regression analysis, the local initiative was associated with a reduction of estimated 7.8 days (95% CI 3.2, 12.3) in TTT, while the national initiative correlated with a reduction of estimated 14.9 days (95% CI 10.2, 19.6) compared to time at baseline. Covariates associated with longer TTT were stage I, use of PET-CT, diagnostic procedure at external hospital, and number of diagnostic procedures.

CONCLUSION

Local and national initiatives significantly reduced TTT in NSCLC. The effect was most pronounced among patients with disease available for curative treatment.

Radiotherapy Planning and Molecular Imaging in Lung Cancer

INTRODUCTION

In patients suitable for radical chemoradiotherapy for lung cancer, 18F-FDGPET/ CT is a proposed management to improve the accuracy of high dose radiotherapy. However, there is a high rate of locoregional failure in patients with locally advanced non-small cell lung cancer (NSCLC), probably due to the fact that standard dosing may not be effective in all patients. The aim of the present review was to address some criticisms associated with the radiotherapy image-guided in NSCLC.

MATERIALS AND METHODS

A systematic literature search was conducted. Only published articles that met the following criteria were included: articles, only original papers, radiopharmaceutical ([18F]FDG and any tracer other than [18F]FDG), target, only specific for lung cancer radiotherapy planning, and experimental design (eventually "in vitro" studies were excluded). Peer-reviewed indexed journals, regardless of publication status (published, ahead of print, in press, etc.) were included. Reviews, case reports, abstracts, editorials, poster presentations, and publications in languages other than English were excluded. The decision to include or exclude an article was made by consensus and any disagreement was resolved through discussion.

RESULTS

Hundred eligible full-text articles were assessed. Diverse information is now available in the literature about the role of FDG and new alternative radiopharmaceuticals for the planning of radiotherapy in NSCLC. In particular, the role of alternative technologies for the segmentation of FDG uptake is essential, although indeterminate for RT planning. The pros and cons of the available techniques have been extensively reported.

CONCLUSION

PET/CT has a central place in the planning of radiotherapy for lung cancer and, in particular, for NSCLC assuming a substantial role in the delineation of tumor volume. The development of new radiopharmaceuticals can help overcome the problems related to the disadvantage of FDG to accumulate also in activated inflammatory cells, thus improving tumor characterization and providing new prognostic biomarkers.

Local and regional treatment response by 18FDG-PET-CT-scans 4 weeks after concurrent hypofractionated chemoradiotherapy in locally advanced NSCLC

BACKGROUND AND PURPOSE

To investigate associations of early post-treatment ¹⁸Fluorodeoxyglucose-positron-emission-tomography (FDG-PET)-scans with local (LF), regional (RF), distant failure (DF) and overall survival (OS) in locally advanced non-small cell lung cancer (LA-NSCLC)-patients treated with concurrent chemoradiotherapy.

MATERIALS AND METHODS

Forty-seven stage IIIA-B NSCLC-patients included in a randomized phase II-trial (NTR2230) received 66 Gy (24x2.75 Gy) with low dose Cisplatin +/- Cetuximab. FDG-PET-scans were performed at baseline and 4 weeks post-treatment (range, 1.6-10.1). SUV_max, SUV_mean, metabolic tumor volume (MTV), total lesion glycolysis (TLG) and gross tumor volume were calculated separately for the primary tumor and the involved lymph nodes to generate baseline, post-treatment, and relative response metrics defined as (metric_pre-metric_post)/metric_pre. Univariable cox regression analyses were performed to investigate associations between PET-metrics and outcomes.

RESULTS

Metrics resulted from the post-treatment scan and relative response were associated with outcome, but baseline metrics were not. Primary tumor metrics were stronger associated with all outcomes than lymph node metrics. Both the volumetric (TLG/MTV) and intensity (SUV_max/SUV_mean) PET-metrics were associated with OS. The intensity metrics were associated with LF, while the volumetric PET-metrics were associated with RF/DF. This was in contrast to the nodal metrics, demonstrating only an association between RF and the relative response of TLG/MTV. No preference was found between PET volumetric and intensity metrics associated with outcome.

CONCLUSION

Early post-treatment PET-metrics are associated with treatment outcome in LA-NSCLC patients treated with chemoradiotherapy. Both volumetric and intensity PET-metrics are useful, but more for the primary tumor than for lymph nodes.

Reasons for prolonged time for diagnostic workup for stage I-II lung cancer and estimated effect of applying an optimized pathway for diagnostic procedures

BACKGROUND

Minimizing the time until start of cancer treatment is a political goal. In Norway, the target time for lung cancer is 42 days. The aim of this study was to identify reasons for delays and estimate the effect on the timelines when applying an optimal diagnostic pathway.

METHODS

Retrospective review of medical records of lung cancer patients, with stage I-II at baseline CT, receiving curative treatment (n = 100) at a regional cancer center in Norway.

RESULTS

Only 40% started treatment within 42 days. The most important delays were late referral to PET CT (n = 27) and exercise test (n = 16); repeated diagnostic procedures because bronchoscopy failed (n = 15); and need for further investigations after PET CT (n = 11). The time from referral to PET CT until the final report was 20.5 days in median. Applying current waiting time for PET CT (≤7 days), 48% would have started treatment within 42 days (p = 0.254). "Optimal pathway" was defined as 1) referral to PET CT and exercise test immediately after the CT scan and hospital visit, 2) tumor board discussion to decide diagnostic strategy and treatment, 3) referral to surgery or curative radiotherapy, 4) tissue sampling while waiting to start treatment. Applying the optimal pathway, current waiting time for PET CT and observed waiting times for the other procedures, 80% of patients could have started treatment within 42 days (p < 0.001), and the number of tissue sampling procedures could have been reduced from 112 to 92 (- 16%).

CONCLUSION

Changing the sequence of investigations would significantly reduce the time until start of treatment in curative lung cancer patients at our hospital and reduce the resources needed.

[The impact of the patient's age on the delay of the lung cancer treatment]

INTRODUCTION

The results from the medical literature regarding the influence of patient's age on the delay of treatment in lung cancer are controversial in the absence of a consensual definition. The aim of this study was to determine the impact of the patient's age on the delay of the lung cancer treatment.

METHODS

A retrospective monocentric study was performed including patients treated for a lung cancer in our department between November 1, 2014 and October 31, 2015. The delay of treatment was defined by the delay between the first abnormal imaging and the first treatment. The patients were divided into three groups depending on their age: group 1 with≤60 years old, group 2 between 60 and 70 years old, and group 3 with>70 years old. The statistical analysis was realized with Pearson's chi-squared and the Anova tests.

RESULTS

Two-hundred and forty-six patients were included with a mean age at 65±10 years. The mean delay of the treatment was 97±41 days. The mean delay of the treatment in patients with>70 years old was statically longer than the delay of treatment in patients with≤60 years old (116±98 days vs. 76±65 days, P=0.04), secondary to an extended time for the lung cancer surgery (129±75 days vs. 88±54 days, P=0.03).

CONCLUSION

In patients with>70 years old, the delay of treatment is longer than in other groups, secondary to an extended time for the preoperative assessment. An improvement in therapeutic management is necessary in our care system to shorten this delay.

Small cell lung cancer in the young: Characteristics, diagnosis and outcome data

BACKGROUND

Patients with small cell lung cancer (SCLC) younger than 40 years are limited in number. Our research aimed to assess the characteristics, diagnosis and outcomes of this patient population.

METHODS

Records of patients under the age of 40 with SCLC at the Chinese Academy of Medical Sciences between January 2006 and December 2015 were reviewed and evaluated.

RESULTS

One hundred and three patients (67.0% limited stage, 33.0% extensive stage) were included, along with 54 (52.4%) never-smokers. The median diagnostic interval and the median survival time (MST) were 51.0 days and 24.0 months, respectively. A total of 41 (39.8%) patients claimed to have undergone antibiotic treatment before diagnosis, with a median duration of 2 weeks. In univariate analysis, survival was better for the limited stage group than the extensive stage group (MST, 28.0 vs. 13.0 months, P < 0.0001). Also, patients who received concurrent radiochemotherapy had better survival than those who received chemotherapy alone (MST, 29.0 vs. 18.0 months, P = 0.001). Patients with antibiotic treatment before SCLC diagnosis have worse prognosis than those without (MST, 21.0 vs. 27.0 months, P = 0.008). Moreover, a timely diagnosis (≤1 month) exerted a positive impact on the overall survival in limited stage patients (48.0 vs. 26.0 months, P = 0.047) and on progression-free survival in extensive stage patients (6.0 vs. 3.0 months, P = 0.030). Multivariate analysis suggested that disease stage, history of antibiotic treatment before SCLC diagnosis and performance status independently correlated with survival.

CONCLUSION

Our study identified distinct characteristics and prognostic factors of SCLC patients under 40 years. More timely care may improve patient prognosis.

Computational delineation and quantitative heterogeneity analysis of lung tumor on 18F-FDG PET for radiation dose-escalation

Quantitative measurement and analysis of tumor metabolic activities could provide a more optimal solution to personalized accurate dose painting. We collected PET images of 58 lung cancer patients, in which the tumor exhibits heterogeneous FDG uptake. We design an automated delineation and quantitative heterogeneity measurement of the lung tumor for dose-escalation. For tumor delineation, our algorithm firstly separates the tumor from its adjacent high-uptake tissues using 3D projection masks; then the tumor boundary is delineated with our stopping criterion of joint gradient and intensity affinities. For dose-escalation, tumor sub-volumes with low, moderate and high metabolic activities are extracted and measured. Based on our quantitative heterogeneity measurement, a sub-volume oriented dose-escalation plan is implemented in intensity modulated radiation therapy (IMRT) planning system. With respect to manual tumor delineations by two radiation oncologists, the paired t-test demonstrated our model outperformed the other computational methods in comparison (p < 0.05) and reduced the variability between inter-observers. Compared to standard uniform dose prescription, the dosimetry results demonstrated that the dose-escalation plan statistically boosted the dose delivered to high metabolic tumor sub-volumes (p < 0.05). Meanwhile, the doses received by organs-at-risk (OAR) including the heart, ipsilateral lung and contralateral lung were not statistically different (p > 0.05).

Timeliness of Care and Lung Cancer Tumor-Stage Progression: How Long Can We Wait?

BACKGROUND

Timely care of lung cancer is presumed critical, yet clear evidence of stage progression with delays in care is lacking. We investigated the reasons for delays in treatment and the impact these delays have on tumor-stage progression.

METHODS

We queried our retrospective database of 265 veterans who underwent cancer resection from 2005 to 2015. We extracted time intervals between nodule identification, diagnosis, and surgical resection; changes in nodule radiographic size over time; final pathologic staging; and reasons for delays in care. Pearson's correlation and Fisher's exact test were used to compare cancer growth and stage by time to treatment.

RESULTS

Median time from referral to surgical evaluation was 11 days (interquartile range, 8 to 17). Median time from identification to therapeutic resection was 98 days (interquartile range, 66 to 139), and from diagnosis to resection, 53 days (interquartile range, 35 to 77). Sixty-eight patients (26%) were diagnosed at resection; the remainder had preoperative tissue diagnoses. No significant correlation existed between tumor growth and time between nodule identification and resection, or between tumor growth and time between diagnosis and resection. Among 197 patients with preoperative diagnoses, 42% (83) had intervals longer than 60 days between diagnosis and resection. Most common reasons for delay were cardiac clearance, staging, and smoking cessation. Larger nodules had fewer days between identification and resection (p = 0.03).

CONCLUSIONS

Evaluation, staging, and smoking cessation drive resection delays. The lack of association between tumor growth and time to treatment suggests other clinical or biological factors, not time alone, underlie growth risk. Until these factors are identified, delays to diagnosis and treatment should be minimized.

Anatomic, functional and molecular imaging in lung cancer precision radiation therapy: treatment response assessment and radiation therapy personalization

This article reviews key imaging modalities for lung cancer patients treated with radiation therapy (RT) and considers their actual or potential contributions to critical decision-making. An international group of researchers with expertise in imaging in lung cancer patients treated with RT considered the relevant literature on modalities, including computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). These perspectives were coordinated to summarize the current status of imaging in lung cancer and flag developments with future implications. Although there are no useful randomized trials of different imaging modalities in lung cancer, multiple prospective studies indicate that management decisions are frequently impacted by the use of complementary imaging modalities, leading both to more appropriate treatments and better outcomes. This is especially true of ¹⁸F-fluoro-deoxyglucose (FDG)-PET/CT which is widely accepted to be the standard imaging modality for staging of lung cancer patients, for selection for potentially curative RT and for treatment planning. PET is also more accurate than CT for predicting survival after RT. PET imaging during RT is also correlated with survival and makes response-adapted therapies possible. PET tracers other than FDG have potential for imaging important biological process in tumors, including hypoxia and proliferation. MRI has superior accuracy in soft tissue imaging and the MRI Linac is a rapidly developing technology with great potential for online monitoring and modification of treatment. The role of imaging in RT-treated lung cancer patients is evolving rapidly and will allow increasing personalization of therapy according to the biology of both the tumor and dose limiting normal tissues.

Impact of Timing of Lobectomy on Survival for Clinical Stage IA Lung Squamous Cell Carcinoma

BACKGROUND

Because the relationship between the timing of surgery following diagnosis of lung cancer and survival has not been precisely described, guidelines on what constitutes a clinically meaningful delay of resection of early-stage lung cancer do not exist. This study tested the hypothesis that increasing the time between diagnosis and lobectomy for stage IA squamous cell carcinoma (SCC) would be associated with worse survival.

METHODS

The association between timing of lobectomy and survival for patients with clinical stage IA SCC in the National Cancer Data Base (2006-2011) was assessed using multivariable Cox proportional hazards analysis and restricted cubic spline (RCS) functions.

RESULTS

The 5-year overall survival of 4,984 patients who met study inclusion criteria was 58.3% (95% CI, 56.3-60.2). Surgery was performed within 30 days of diagnosis in 1,811 (36%) patients, whereas the median time to surgery was 38 days (interquartile range, 23, 58). In multivariable analysis, patients who had surgery 38 days or more after diagnosis had significantly worse 5-year survival than patients who had surgery earlier (hazard ratio, 1.13 [95% CI, 1.02-1.25]; P = .022). Multivariable RCS analysis demonstrated the hazard ratio associated with time to surgery increased steadily the longer resection was delayed; the threshold time associated with statistically significant worse survival was ∼90 days or greater.

CONCLUSIONS

Longer intervals between diagnosis of early-stage lung SCC and surgery are associated with worse survival. Although factors other than the timing of treatment may contribute to this finding, these results suggest that efforts to minimize delays beyond those needed to perform a complete preoperative evaluation may improve survival.

Multidisciplinary Care

Optimal multidisciplinary care of the lung cancer patient at all stages should encompass integration of the key relevant medical specialties, including not only medical, surgical, and radiation oncology, but also pulmonology, interventional and diagnostic radiology, pathology, palliative care, and supportive services such as physical therapy, case management, smoking cessation, and nutrition. Multidisciplinary management starts at staging and tissue diagnosis with pathologic and molecular phenotyping, extends through selection of a treatment modality or modalities, management of treatment and cancer-related symptoms, and to survivorship and end-of-life care. Well-integrated multidisciplinary care may reduce treatment delays, improve cancer-specific outcomes, and enhance quality of life. We address key topics and areas of ongoing investigation in multidisciplinary decision making at each stage of the lung cancer treatment course for early-stage, locally advanced, and metastatic lung cancer patients.

Time to treatment as a quality metric in lung cancer: Staging studies, time to treatment, and patient survival

PURPOSE

Prompt staging and treatment are crucial for non-small cell lung cancer (NSCLC). We determined if predictors of treatment delay after diagnosis were associated with prognosis.

MATERIALS AND METHODS

Medicare claims from 28,732 patients diagnosed with NSCLC in 2004-2007 were used to establish the diagnosis-to-treatment interval (ideally ⩽35days) and identify staging studies during that interval. Factors associated with delay were identified with multivariate logistic regression, and associations between delay and survival by stage were tested with Cox proportional hazard regression.

RESULTS

Median diagnosis-to-treatment interval was 27days. Receipt of PET was associated with delays (57.4% of patients with PET delayed [n=6646/11,583] versus 22.8% of those without [n=3908/17,149]; adjusted OR=4.48, 95% CI 4.23-4.74, p<0.001). Median diagnosis-to-PET interval was 15days; PET-to-clinic, 5days; and clinic-to-treatment, 12days. Diagnosis-to-treatment intervals <35days were associated with improved survival for patients with localized disease and those with distant disease surviving ⩾1year but not for patients with distant disease surviving <1year.

CONCLUSION

Delays between diagnosing and treating NSCLC are common and associated with use of PET for staging. Reducing time to treatment may improve survival for patients with manageable disease at diagnosis.

PET/CT imaging for target volume delineation in curative intent radiotherapy of non-small cell lung cancer: IAEA consensus report 2014

This document describes best practice and evidence based recommendations for the use of FDG-PET/CT for the purposes of radiotherapy target volume delineation (TVD) for curative intent treatment of non-small cell lung cancer (NSCLC). These recommendations have been written by an expert advisory group, convened by the International Atomic Energy Agency (IAEA) to facilitate a Coordinated Research Project (CRP) aiming to improve the applications of PET based radiation treatment planning (RTP) in low and middle income countries. These guidelines can be applied in routine clinical practice of radiotherapy TVD, for NSCLC patients treated with concurrent chemoradiation or radiotherapy alone, where FDG is used, and where a calibrated PET camera system equipped for RTP patient positioning is available. Recommendations are provided for PET and CT image visualization and interpretation, and for tumor delineation using planning CT with and without breathing motion compensation.

Respiratory-gated (4D) FDG-PET detects tumour and normal lung response after stereotactic radiotherapy for pulmonary metastases

BACKGROUND

Response assessment after stereotactic ablative body radiotherapy (SABR) in lung can be confounded by radiation-induced inflammation, fibrosis and subsequent alteration of tumour motion. The purpose of this prospective pilot study was to evaluate the utility of four-dimensional (4D) FDG-PET/CT for post-SABR tumour and normal lung response assessment in pulmonary oligometastases.

MATERIAL AND METHODS

Patients enrolled from February 2010 to December 2011 in this prospective ethics approved study had 1-2 pulmonary metastases on staging FDG-PET. Serial contemporaneous 3D and 4D FDG-PET/CT scans were performed at baseline, 14 days and 70 days after a single fraction of 26 Gy SABR. Tumour response was evaluated in 3D and 4D using SUVmax, RECIST and PERCIST criteria. Normal lung radiotoxicity was evaluated using SUVmean within 0-2 Gy, 2-5 Gy, 5-10 Gy, 10-20 Gy and 20 + Gy isodose volumes.

RESULTS

In total, 17 patients were enrolled of which seven were ineligible due to interval progression from staging PET to baseline 4D-PET. The mean time between scans was 62 days. At a median follow-up of 16 months, 10 patients with 13 metastases received SABR, with no patient having local progression. The vector of tumour motion was larger in patients with discordant 3D and 4D PET PERCIST response (p < 0.01), with a mean (± SEM) motion of 10.5 mm (± 0.96 mm) versus 6.14 mm (± 0.81 mm) in those patients with concordant 3D and 4D response. Surrounding normal lung FDG uptake at 70 days was strongly correlated to delivered radiation dose (r(2) = 0.99, p < 0.01), with significant elevations across all dose levels (p ≤ 0.05), except the < 2 Gy volume (p = 0.30).

CONCLUSIONS

We demonstrate high rates of interval progression between staging PET scans in patients with oligometastases. We found that tumour response on conventional 3D PET is not concordant with 4D PET for tumours with large motion. Normal lung metabolic uptake is strongly dose dependent after SABR, a novel finding that should be further validated.

Recent advances in radiotherapy for thoracic tumours

Radiation Oncology technology has continued to advance at a rapid rate and is bringing significant benefits to patients. This review outlines some of the advances in technology and radiotherapy treatment of thoracic cancers including brachytherapy, stereotactic radiotherapy, tomotherapy and intensity modulated radiotherapy. The importance of functional imaging with PET and management of movement are highlighted. Most of the discussion relates to non-small cell lung cancer but management of mesothelioma and small cell lung cancer are also covered. This technology has substantial benefits to patients in terms of decreasing toxicity both in the short and longer term.

Use of PET/CT for patient selection and radiation therapy target volume definition in patients with non-small-cell lung cancer

SUMMARY PET scanning is having an increasing impact on the treatment of non-small-cell lung cancer with radiation therapy (RT) and chemoRT. It has a powerful impact on staging, often revealing evidence of more advanced, frequently incurable, disease in patients who would otherwise be considered suitable for treatment with potentially curative definitive RT. Approximately a third of curative RT candidates are found to be unsuitable for this often highly toxic form of treatment after PET, thereby ensuring that this intensive treatment is only given to those patients who might benefit from it. If a patient remains suitable for treatment with RT after PET staging, PET can play a further critical role in the targeting of the RT. Without the use of PET in this way, a quarter of patients or more would experience geographic misses, in which some tumor regions would be either underdosed or excluded entirely from treatment, thereby compromising the chances of a successful outcome. There is emerging evidence that the overall results of treatment with RT can be improved by the appropriate use of PET in non-small-cell lung cancer.