Best supportive care in non-small cell lung cancer: is there a role for radiotherapy and chemotherapy?

Fractionated palliative thoracic radiotherapy in non-small cell lung cancer - futile or worth-while?

Background

Palliative thoracic radiotherapy (PTR) can relieve symptoms originating from intra-thoracic disease. The optimal timing and fractionation of PTR is unknown. Time to effect is 2 months. The primary aim of this retrospective study was to investigate survival after PTR, hypothesizing that a significant number of patients received futile fractionated PTR. The secondary aim was to find prognostic factors to guide treatment decisions.

Methods

Patients with non-small-cell lung cancer (NSCLC) planned for PTR in the period of 2010-2011 at the University Hospital of Copenhagen were included. We noted pathology, tumor, node and metastasis (TNM) classification of malignant tumors, stage, indication, start date, schedule for PTR, completed y/n, performance status (PS) and time of death. Analyses were performed as an intention-to-treat using Cox regression, Fishers exact test and Kaplan Meier.

Results

A total of 159 patients were included. Median overall survival (OS) was 4.2 months. Sixteen patients (10%) did either not begin or finish PTR. Of these, eight (5%) died prior to or during PTR. Of the 151 patients receiving PTR, sixteen patients (11%) died within 14 days, thirty-three (22%) within 30 days and fifty (33%) within 2 months. PS 0-1 and squamous cell carcinoma were correlated with a better survival.

Conclusions

Our study show that a significant number of patients who received PTR died before they could achieve optimal effect of the treatment. PS and histology were significant prognostic factors favoring PS 0-1 and squamous cell carcinoma. Based on our study, we suggest that patients with PS 0-1 should be considered for fractionated PTR whereas patients with PS ≥ 2 should be considered for high dose single fraction only or supportive palliative care.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0270-4) contains supplementary material, which is available to authorized users.

The results with the addition of metronomic cyclophosphamide to palliative radiotherapy for the treatment of non-small cell lung carcinoma

BACKGROUND

A considerable proportion of non-small cell lung carcinoma (NSCLC) patients are ineligible for radical therapies. Many are frail not to tolerate intravenous palliative chemotherapy either. These patients often receive palliative radiotherapy (RT), or supportive care alone. We intend to compare outcomes with palliative RT alone, versus palliative RT plus oral low dose metronomic cyclophosphamide.

METHODS

Data was mined from 139 eligible NSCLC patient records. Comparisons were made between 65 patients treated from January 2011 to March 2013 with palliative RT (20-30 Gray in 5-10 fractions) alone, versus 74 patients treated from April 2013 to December 2014 with palliative RT plus oral metronomic cyclophosphamide (50 mg once daily from day of initiation of RT until at least the day of disease progression). Response was assessed after 1-month post-RT by computed tomography. Patients with complete or partial response were recorded as responders. For the determination of progression free survival (PFS), progression would be declared in case of increase in size of lesions, development of new lesions, or development of effusions. The proportions of responders were compared with the Fisher exact test, and the PFS curves were compared with the log-rank test.

RESULTS

Differences in response rates were statistically insignificant. The PFS was significantly higher when metronomic chemotherapy was added to RT in comparison to treatment with RT alone (mean PFS 3.1 vs. 2.55 months; P=0.0501). Further histological sub-group analysis revealed that the enhanced outcomes with addition of metronomic cyclophosphamide to RT were limited to patients with adenocarcinoma histology (3.5 vs. 2.4 months; P=0.0053), while there was no benefit for those with squamous cell histology (2.6 vs. 2.6 months; P=1). At the dose of oral cyclophosphamide used, there was no recorded instance of any measurable hematological toxicity.

CONCLUSIONS

For pulmonary adenocarcinoma patients, the treatment with palliative RT plus oral metronomic cyclophosphamide is better than that with palliative RT alone. However, for pulmonary squamous cell carcinoma the addition of oral metronomic cyclophosphamide to palliative RT offered no benefit. Further studies with similar and different metronomic chemotherapy agents are justifiable.

Interventions for cough in cancer

BACKGROUND

This is an updated version of the original Cochrane review first published in Issue 9, 2010 on "Interventions for cough in cancer". Cough is a common symptom in patients with malignancies, especially in patients with lung cancer. Cough is not well controlled in clinical practice and clinicians have few management options to treat it.

OBJECTIVES

The primary objective was to determine the effectiveness of interventions, both pharmacological and non-pharmacological, (other than chemotherapy and external beam radiotherapy) in the management of cough in malignant disease (especially in lung cancer).

SEARCH METHODS

For this update, we searched for relevant studies in CENTRAL and DARE (The Cochrane Library); MEDLINE; EMBASE; PsycINFO; AMED and CINAHL to 9 June 2014. In addition, we searched for ongoing trials via the metaRegister of controlled trials (mRCT), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the UK Clinical Research Network Study Portfolio.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and clinical trials (quasi-experimental trials and trials where there is a comparison group but no mention of randomisation) in participants with primary or metastatic lung cancer or other cancers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts of all studies for inclusion, and extracted data from all included studies independently before reaching consensus. A third review author arbitrated on any disagreement. Meta-analysis was not attempted due to the heterogeneity of the studies.

MAIN RESULTS

For the original version of the review, 17 studies met the inclusion criteria and examined either brachytherapy, laser or photodynamic therapy (eight studies) or a variety of pharmacological therapies (nine studies). Overall, there was an absence of credible evidence and the majority of studies were of low methodological quality and at high risk of bias. Brachytherapy in a variety of doses seemed to improve cough in selected participants, suggesting that possibly the lowest effective dose should be used to minimise side effects. Photodynamic therapy was examined in one study and, while improvements in cough were observed, its role in relationship to other therapies for cough was unclear. Some indication of positive effect was observed with morphine, codeine, dihydrocodeine, levodropropizine, sodium cromoglycate and butamirate citrate linctus (cough syrup), although all studies had significant risk of bias. For this update, we did not identify any additional trials for inclusion. Two ongoing trials were identified but no study results were available.

AUTHORS' CONCLUSIONS

No new trials were included since the publication of the original version of this review, while 11 new studies that were identified were eventually excluded from this review. Therefore, our conclusions remain unchanged. No practice recommendations could be drawn from this review. There is an urgent need to increase the number and quality of studies evaluating the effects of interventions for the management of cough in cancer.

Advanced malignant lung disease: what the specialist can offer

Lung cancer is not only the most commonly diagnosed cancer worldwide, but it is still the leading cause for cancer-related death. The 5-year survival for lung cancer in Europe and in the USA is totally 16%. Therefore, a palliative therapy regimen is required to control the disease and reduce symptoms with the objective of enhancing quality of life of lung cancer patients. In addition to chemotherapy that is still one of the most important pillars in the treatment of advanced lung cancer, further interventional strategies can be offered to improve a patient's quality of life. A locoregional tumour progression is frequently associated with malignant pleural effusion or pericardial effusion, central airway obstruction, tracheo-oesophageal fistula, severe haemoptysis or superior vena cava (SVC) syndrome threatening life and necessitating urgent palliation. Recurrent pleural effusion causing dyspnoea can be managed by pleurodesis, serial thoracocentesis or insertion of an indwelling catheter. Symptomatic malignant pericardial effusion often requires an urgent pericardiocentesis. Furthermore, surgical procedures, instillation of sclerosing agents or local chemotherapy should be considered in refractory pericardial effusion. The therapy regimen of central airway stenosis includes mechanical and thermic endoscopic procedures providing rapid relief of symptoms. To prevent recurrence of airway obstruction, the insertion of a stent or palliative brachytherapy provide re-establishment of the patency of obstructed airways. Haemoptysis can be managed by bronchoscopic interventions as well as by arterial embolization or palliative thoracic radiotherapy. The therapy of SVC syndrome is dependent of histology. In small-cell lung cancer, chemotherapy is recommended. In non-small-cell lung cancer, stent insertion and/or radiotherapy are the therapeutic pillars.

Interventions for cough in cancer

BACKGROUND

Cough is a common symptom in patients with malignancies, especially in patients with lung cancer. Cough is not well controlled in clinical practice and clinicians have few management options to treat it.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of interventions, both pharmacological and non-pharmacological, (other than chemotherapy and external beam radiotherapy) in the management of cough in malignant disease (especially in lung cancer).

SEARCH STRATEGY

Databases searched included: The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) (The Cochrane Library issue 4, 2009); MEDLINE (1966 to May 2010); EMBASE (1980 to May 2010); CINAHL (1980 to May 2010); PSYCHINFO (1980 to May 2010); AMED (1985 to May 2010); SIGLE (1980 to May 2010); British Nursing Index (1985 to May 2010); CancerLit (1975 to May 2010). We searched for cough suppressants, antitussives and other drugs with antitussive activity as well as non-pharmacological interventions (see Appendices 1-4 for search terms).

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and clinical trials (quasi-experimental trials, and trials where there is a comparison group but no mention of randomisation) in participants with primary or metastatic lung cancer or other cancers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts of all studies, and extracted data from all selected studies before reaching consensus. A third review author arbitrated with any disagreement. Meta-analysis was not attempted due to the heterogeneity of studies.

MAIN RESULTS

Seventeen studies met inclusion criteria and examined either brachytherapy, laser or photodynamic therapy (eight studies) or a variety of pharmacological therapies (nine studies). Overall, there was absence of credible evidence and the majority of studies were of low methodological quality and high risk of bias. Brachytherapy seemed to improve cough in a variety of doses in selected participants, suggesting that possibly the lowest effective dose should be used to minimise side effects. Photodynamic therapy was examined in one study, and while improvements in cough were observed, its role over other therapies for cough is unclear. Some indication of effect was observed with morphine, codeine, dihydrocodeine, levodropropizine, sodium cromoglycate and butamirate citrate linctus (cough syrup), although all studies had significant risk of bias.

AUTHORS' CONCLUSIONS

No practice recommendations could be drawn from this review. There is an urgent need to increase the number and quality of studies evaluating the effects of interventions in the management of cough in cancer.

Health state utility scores in advanced non-small cell lung cancer

BACKGROUND

The aim of the study was to capture societal utility scores for health state descriptions of advanced, metastatic non-small cell lung cancer (NSCLC), as well as determine disutility associated with specific disease symptoms.

METHODS

NSCLC health states were produced based on an adaptation of existing health state descriptions for metastatic lung cancer. The health states were expanded to contrast disease state (responding disease and stable disease) and impact of specific severe symptoms (cough; dyspnoea; pain; or no additional severe symptoms). Interviews with five lung cancer clinicians were carried out to assess the content and face validity of the existing health states as descriptions specific to NSCLC. The interviews also sought to explore the impact of the disease symptoms of interest. The resulting health states were reviewed by two psychometric experts independently. The final health states were piloted in a conventional standard gamble interview which revealed no significant issues in interpretation or comprehension. In the main study, 101 members of the general public assessed their preference for each health state in a chained standard gamble (SG) interview and on a visual analogue scale (VAS) rating scale. All participants also completed the EQ-5D and a socio-demographic form.

RESULTS

The study sample was a relatively good match to the characteristics of the general public in England and Wales. A mixed model analysis revealed that age, gender, and HRQL were not significant predictors of utility, but a treatment response and each of the disease symptoms were. When adjusted to match census data, stable disease with no additional symptoms had a utility value of 0.626. Health state values declined by 0.069 with the addition of pain; 0.050 for dyspnoea; or 0.046 for cough. A treatment response would result in a utility gain of 0.086.

CONCLUSIONS

Members of the general public showed a preference for responding disease over stable disease and a stable health state with no additional symptoms over a stable health state with one of the three common NSCLC symptoms: cough, dyspnoea, and pain. The study highlights the value that society places on the avoidance of severe symptoms that some people with NSCLC can experience.

Treatment options in end-of-life care: the role of palliative chemotherapy

Advances in medical science and technology, combined with the primary goal of medical care to restore or maintain health as far as possible, often result in the transition from active to palliative care being blurred. Treatment choices are limited in advanced disease; but paradoxically, which therapy to choose is becoming an increasingly complex decision (Weissman, 2004). The role of chemotherapy in this phase remains a controversial subject, but data are emerging to show that an increasing number of patients nearing the end of life are receiving chemotherapy (Matsuyama et al, 2006), and there is a mounting body of evidence for its use in symptom palliation (Cullen, 2003; Bowcock et al, 2004; Davis, 2005). Therefore, the traditional view that medical oncology and palliative care are two distinct disciplines may need to be modified.

Evaluation of an inflammation-based prognostic score in patients with advanced ovarian cancer

BACKGROUND

There is increasing evidence that the presence of an ongoing systemic inflammatory response is associated with poor outcome in patients with advanced cancer. The aim of this study was to validate whether an inflammation-based prognostic score (Glasgow Prognostic Score, GPS) is associated with survival in patients with advanced stage (stage III/IV) ovarian cancer.

PATIENTS AND METHODS

An audit was conducted of patients with a new diagnosis of stage III or IV ovarian cancer presenting to the West London Gynae-Oncology Centre between October 2003 and June 2006 (n=154). The GPS was constructed as follows: Patients with both an elevated C-reactive protein (>10 mg/l) and hypoalbuminaemia (<35 g/l) were allocated a score of 2. Patients in whom only one or none of these biochemical abnormalities was present were allocated a score of 1 or 0, respectively.

RESULTS

On univariate analysis GPS, histological type, ALP, performance status, primary surgery and ascites were predictors of overall survival. On multivariate a high GPS score, non-serous histology, high ALP and no initial surgery were independent predictors of worse overall survival in this population.

CONCLUSIONS

The presence of a systemic inflammatory response, as measured by the GPS, is an independent predictor of poor overall survival in patients with advanced ovarian cancer independent of treatment received.

Staging of Lung Cancer

Imaging techniques play a vital role in the diagnosis, staging, and follow-up of patients who have lung cancer. For this purpose, PET has become an important adjunct to conventional imaging techniques such as chest radiography, CT, ultrasonography, and MR imaging. The ability of PET to differentiate the metabolic properties of tissues allows more accurate assessment of undetermined lung lesions, mediastinal lymph nodes, or extrathoracic abnormalities, tumor response after induction treatment, and detection of disease recurrence.

Non-small-cell lung cancer in the elderly

The world population is getting increasingly older. In Western countries, lung cancer in the most frequent cancer and more than 50% of patients who contract non-small-cell lung cancer (NSCLC) are close to 70 years old. It is therefore fundamentally important that we identify an overall strategy of screening, diagnosis and therapy designed specifically for elderly patients. NSCLC research still has relatively little material dedicated exclusively to the elderly, but recently interest has been growing, possibly due to the positive results of the most recent trials (Elderly Lung Cancer Vinorelbine Study Group (ELVIS), Southern Italy Cooperative Oncology Group (SICOG), Multicenter Italian Lung Cancer in the Elderly Study (MILES)). In particular, the integration of geriatric and oncological information has led to better recognition of elderly candidates for more aggressive therapy which is usually reserved for younger patients, while recognizing more fragile patients who need only support therapy.

Chronic Cough Due to Lung Tumors

GOALS/OBJECTIVES: To review the scientific evidence on cough associated with tumors in the lungs.

METHODS

MEDLINE literature review (through March 2004) for all studies published in the English language, including case series and case reports, since 1966 using the medical subject heading terms "cough" and "lung neoplasms."

RESULTS

Primary bronchogenic carcinoma is the most common lethal neoplasm in the United States. Malignancies that arise in other organs will often metastasize to the lungs. Any form of cancer involving the lungs may be associated with cough. However, cough is far more likely to indicate involvement of the airways than the lung parenchyma because of the location of cough receptors. Cough is present in >65% of patients at the time lung cancer is diagnosed, and productive cough is present in >25% of patients. While cough as a presenting symptom of lung cancer is common, many studies have shown that lung cancer is the cause of chronic cough in <or=2% of all patients who present with a chronic cough.

CONCLUSIONS

Bronchoscopy is usually indicated when there is suspicion of airway involvement by a malignancy. Conversely, bronchoscopy usually should not be performed to assess a cough for the possibility of lung cancer when there is little risk for lung cancer (nonsmokers) and when there are normal findings on a plain chest radiograph. If the lung cancer can be removed surgically, cough will usually abate. Radiation therapy, chemotherapy (especially with gemcitabine), and endobronchial treatment methods likely will improve cough caused by lung cancer. Centrally acting narcotic antitussive agents are usually administered for the control of cough caused by lung cancer when other treatment methods fail.

Psychosocial aspects of lung cancer

BACKGROUND

Lung cancer is one of the commonest cancers in the industrialised world, and persons with this grave disease must deal not only with the physical effects but also with the psychosocial aspects.

METHODS

This review is based on an examination of intervention, prospective and case-control studies with more than 50 participants published between 1966 and 2003.

RESULTS

The studies show that on average one out of four persons with lung cancer experience periods of depression or other psychosocial problems during their illness. Persons who are not offered treatment for their cancer and persons with small-cell lung cancer have a higher risk compared to other groups of lung cancer patients. The degree of depression can be reduced by psychosocial interventions.

CONCLUSIONS

We suggest that psychosocial screening of persons with lung cancer could prevent depression and might result in improved quality of care.

Comparison of an inflammation-based prognostic score (GPS) with performance status (ECOG) in patients receiving platinum-based chemotherapy for inoperable non-small-cell lung cancer

The value of an inflammation-based prognostic score (GPS) was compared with performance status (ECOG) in patients (n=109) receiving platinum-based chemotherapy for inoperable non-small-cell lung cancer. On multivariate analysis with ECOG, white cell count and the GPS entered as covariates, only the GPS was a significant independent predictor of survival (HR 1.88, 95% CI 1.25–2.84, P=0.002).

Evaluation of cumulative prognostic scores based on the systemic inflammatory response in patients with inoperable non-small-cell lung cancer

A score based on the combination of the systemic inflammatory response and albumin hazards ratio (HR) 1.70, 95% CI 1.23 - 2.35, P=0.001) was comparable in prognostic value to that based on stage and performance status (HR 1.48, 95% CI 1.12 - 1.95, P=0.006) in patients with inoperable non-small-cell lung cancer. The former is simple to measure and well standardised.

Influence of cisplatin-use, age, performance status and duration of chemotherapy on symptom control in advanced non-small cell lung cancer: detailed symptom analysis of a randomised study comparing cisplatin-vindesine to gemcitabine

BACKGROUND

We previously reported that treatment of patients with symptomatic advanced non-small cell lung cancer with single agent Gemcitabine (GEM) resulted in a superior clinical-benefit response rate (RR) compared to cisplatin-based combination chemotherapy. We now report the detailed individual symptom control analysis, and the influence of cisplatin-use, age, performance status (PS) and duration of treatment.

PATIENTS AND METHODS

Patients received either GEM (1000 mg/m(2), days 1, 8 and 15) or cisplatin (100 mg/m(2), day 1) plus Vindesine (3 mg/m(2), days 1 and 15) (PV), both every 4 weeks. Scores of 9 symptoms were listed weekly by the patient on visual analogue scales. Improvement of a symptom was defined as 2 consecutive cycles of improvement over baseline.

RESULTS

Baseline symptoms in the 169 patients were well balanced between the 2 arms (84 GEM, 85 PV). Both patients with objective response and disease stabilisation had clearly better symptom control than those with disease progression. Symptom control in both arms was similar for 'disease-specific' symptoms such as cough, dyspnea, pain or haemoptysis. Compared to PV, a significantly larger number of GEM-patients had better scores for 'constitutional' items such as anorexia (P=0.007), ability to carry on with daily activities (P=0.04) and overall impression of quality-of-life (P=0.008). Symptom control was very similar in younger (<65 years) versus older (>/=65 years) patients, and only slightly better in those with a Karnofsky PS >/=80% compared to those <80%. Most of the symptom improvement occurred in the first 3 cycles, with some further symptom improvement in the following cycles in the GEM-arm only.

CONCLUSIONS

Both GEM and PV yield a symptom control rate much higher than expected by the objective tumour RR. GEM is equally effective in controlling 'disease-specific' symptoms, but superior in controlling 'constitutional' symptoms. Most of the symptom control was achieved during the first 3 cycles of treatment, with some further improvement thereafter in the GEM-arm only.

Short course radiation therapy for elderly cancer patients. Evidences from the literature review

The choice of the appropriate treatment strategy for elderly cancer patients may be a difficult challenge. Radiation therapy is commonly offered to these patients, but treatment duration may represent a limiting factor, as many patients cannot tolerate a conventional course of radiotherapy (RT) due to age-related medical or logistic problems. Hypofractionated RT may represent a very convenient choice, but it entails an increased risk of late toxicity occurrence. We made a literature review to define the possible role of hypofractionated RT for elderly cancer patients. As expected, we found out that short irradiation schedules are more commonly employed for treatments with palliative aims but a more widespread use of these regimes is still controversial. The lack of prospective trials tailored for these patients makes even more difficult to tailor the choice of treatment on standardised treatment guidelines. Nevertheless our review highlights that for several tumour types RT can be scheduled conveniently and effectively in order to achieve local disease control and/or symptom relief with the least discomfort and treatment-related morbidity for elderly patients.

Best supportive care versus palliative chemotherapy in nonsmall-cell lung cancer

The incidence of lung cancer continues to rise. The need and demand for more effective treatment to improve survival and palliate symptoms increases at a great rate. The most recent evidence for the use of chemotherapy in the palliative setting is summarized in this review of the literature from the last few years. It indicates that in advanced nonsmall-cell lung cancer survival, symptom control and physical functioning can be improved with the use of chemotherapy not only in the first-line but also in the second-line setting, in the elderly, and at disease relapse.

Advances in cancer pain management

Although most patients with cancer pain can attain a favorable balance between analgesia and side effects with a conventional approach to opioid therapy, a substantial minority cannot. For these patients, an important subgroup of whom have neuropathic pain, alternative therapeutic strategies are needed. With a detailed assessment, clinicians should be able to choose among the large and diverse group of options available and implement an approach, or combination of approaches, that have a high probability of improving analgesic outcomes.

New drugs for the anorexia-cachexia syndrome

Anorexia and cachexia accompany advancing cancer to a greater extent than any other symptom. Cachexia alone causes 22% of cancer deaths. The pathophysiology of cachexia is distinctly different from that of starvation. Resting energy expenditures are elevated, and abnormal intermediary metabolism, proteolysis, and lipolysis occur independently of caloric intake. A facilatative interaction between catecholamines, prostaglandins, and inflammatory cytokines is responsible for cachexia. Successful treatment requires reduction of energy expenditures, reversal of anorexia, and correction of abnormal intermediary metabolism, lipolysis, and proteolysis. Multiple appetite stimulants can be used in combination. Several new potentially useful biologic agents have been tested in animal tumor models. Several of the anticachectic agents have demonstrated in vivo or in vitro antitumor activity. The biologic and clinical activity of each drug is reviewed herein, and potentially useful combinations are listed.

Local complications of non-small-cell lung cancer

Because of the stage-specific treatment of lung cancer, significant strides have been made in the treatment strategies for patients with non-small-cell carcinoma. Unfortunately, despite aggressive therapy, most patients will die within 5 years of diagnosis. Although the predominant cause of death will be secondary to the systemic nature of the cancer, most patients also will suffer significant decrements in their quality of life and functional status secondary to local complications. Addressing and treating the local complications of lung cancer aggressively may directly and immediately improve the quality of life and functional status of patients with extensive lung cancer. Improvements in the treatment of local complications of lung cancer that lead to improved performance status also may have an impact on the long-term survival of these patients.

Genomics and cancer

Genetic and environmental factors are responsible for the genomic lesions that cause cancer, a complex genetic disease associated with genomic instability. Studies aimed at deciphering the lesions in cancer have focused mainly on one or a few genes, despite the genomic scope of the disease. The recently decoded human DNA sequence is anticipated to foster understanding of human evolution and disease and the role of environment and heredity in the human condition. This review addresses the opportunities and challenges that the availability of the human genome sequence holds for cancer research.