Providing clinicians and patients with actual prognosis: cancer in the context of competing causes of death

Time-varying associations of patient and tumor characteristics with cancer survival: an analysis of SEER data across 14 cancer sites, 2004-2017

PURPOSE

Surveillance, Epidemiology, and End Results (SEER) cancer registries provides information about survival duration and cause of death for cancer patients. Baseline demographic and tumor characteristics such as age, sex, race, year of diagnosis, and tumor stage can inform the expected survival time of patients, but their associations with survival may not be constant over the post-diagnosis period.

METHODS

Using SEER data, we examined if there were time-varying associations of patient and tumor characteristics on survival, and we assessed how these relationships differed across 14 cancer sites. Standard Cox proportional hazards models were extended to allow for time-varying associations and incorporated into a competing-risks framework, separately modeling cancer-specific and other-cause deaths. For each cancer site and for each of the five factors, we estimated the relative hazard ratio and absolute hazard over time in the presence of competing risks.

RESULTS

Our comprehensive consideration of patient and tumor characteristics when estimating time-varying hazards showed that the associations of age, tumor stage at diagnosis, and race/ethnicity with risk of death (cancer-specific and other-cause) change over time for many cancers; characteristics of sex and year of diagnosis exhibit some time-varying patterns as well. Stage at diagnosis had the largest associations with survival.

CONCLUSION

These findings suggest that proportional hazards assumptions are often violated when examining patient characteristics on cancer survival post-diagnosis. We discuss several interesting results where the relative hazards are time-varying and suggest possible interpretations. Based on the time-varying associations of several important covariates on survival after cancer diagnosis using a pan-cancer approach, the likelihood of the proportional hazards assumption being met or corresponding interpretation should be considered in survival analyses, as flawed inference may have implications for cancer care and policy.

The Indirect Effects of Negative Affect Reduction Motives on the Relationship Between Sex and Severity of Problems When Trying to Quit Among Black Adults Who Smoke

BACKGROUND

African American/Black (hereafter referred to as Black) persons who smoke constitute a tobacco disparities group in the United States. Within the Black population, female smokers experience a disproportionate percentage of these disparities and are less likely to quit cigarettes than their male counterparts. Two factors implicated in female smokers' relatively worse quit success are (1) motives to smoke to reduce negative affect and (2) expectancies that smoking will reduce negative affect.

OBJECTIVES

The present study sought to test sex differences in these two clinically relevant cognitive constructs and evaluate the indirect effects of sex and severity of problems when trying to quit via smoking motives and expectancies for negative affect reduction among Black adults who smoke. Participants included 103 Black adults who smoke daily (72% male; Mage = 44.5 years, SD = 11.5 years).

RESULTS

Results revealed sex differences in both negative affect reduction motives and expectancies, as well as a partial indirect effect for sex on the severity of problems when trying to quit through negative affect reduction motives (a1b1 = 0.18, 95% CI [0.04, 0.38]) but not negative affect reduction expectancies (a2b2 = -0.01, 95% CI [-0.11, 0.09]) in a simultaneous model of indirect effects.

CONCLUSIONS

These findings shed light on the complex relationship between race, sex, and severity of problems when trying to quit, particularly when complicated by smoking motives and expectancies. Current data should be considered when developing sex-specific, tailored smoking cessation interventions for Black women.

Squamous cell carcinoma of the urinary bladder in patients with chronic spinal cord injury: A case series

INTRODUCTION

Patients with spinal cord injury/disorder (SCI/D) and neurogenic lower urinary tract dysfunction (NLUTD) are on a 16-28 folder higher risk for bladder cancer [1]. Whereas in the general population 90% of bladder tumors are transitional cell carcinoma (TCC) patients with NLUTD have a shift to squamous cell carcinoma with 36,8% and only 46.3% TCC [2]. In addition, there is a significant increase in the bladder cancer-specific death rate in SCI patients (3rd most common) compared to the general population (10th most common) [2]. Chronic inflammation and mechanical irritation by permanent indwelling catheters are discussed as risk factors for developing bladder cancer. Typical symptoms of bladder cancer are often absent in patients with NLUTD and a reliable screening has not been established.

CASE PRESENTATION

We present a case series of six patients with SCI and with squamous cell carcinoma diagnosed in the last 5 years in our institution. In five patients, bladder management was performed by indwelling suprapubic catheters, one patient used reflex voiding. Three patients were diagnosed during the regular, annual neuro-urological check-up, the remaining due to increasing spasticity and autonomic dysregulation. Subsequently, five patients underwent cystectomy with ileal conduit or uretercutaneostomy, one patient refused further surgical treatment. Four patients died within one year after diagnosis.

DISCUSSION

Squamous cell carcinoma of the bladder is more common in patients with NLUTD. Chronic inflammation and mechanical irritation may be the reasons for carcinoma genesis. A regular check including cystoscopy is strongly recommended to detect tumor development early.

The nomogram for the prediction of overall survival after surgery in patients in early-stage NSCLC based on SEER database and external validation cohort

BACKGROUND & AIMS

Currently, there is a lack of effective tools for predicting the prognostic outcome of early-stage lung cancer after surgery. We aim to create a nomogram model to help clinicians assess the risk of postoperative recurrence or metastasis.

MATERIALS AND METHODS

This work obtained 16,459 NSCLC patients based on SEER database from 2010 to 2015. In addition, we also enrolled 385 NSCLC patients (2017/01-2019/06) into external validation cohort at Tianjin Medical University General Hospital. Univariable as well as multivariable Cox regression was carried out for identifying factors independently predicting OS. In addition, we built a nomogram by incorporating the above prognostic factors for the prediction of OS.

RESULTS

Tumor size was positively correlated with the risk of poor differentiation. Advanced age, male and adenocarcinoma patients were factors independently predicting poor prognosis. The risk of white race is higher, followed by Black race, Asians and Indians, which is consistent with previous study. Chemotherapy is negatively related to prognostic outcome in patients of Stage IA NSCLC and positively related to that in those of Stage IB NSCLC. Lymph node dissection can reduce the postoperative mortality of patients. AUCs of the nomograms for 1, 2, and 3-year OS was 0.705, 0.712, and 0.714 for training cohort, while those were 0.684, 0.688, and 0.688 for validation cohort.

CONCLUSIONS

The nomogram could be used as a tool to predict the postoperative prognosis of patients with Stage I non-small cell lung cancer.

Prediction of Risk of Metastatic Recurrence for Female Breast Cancer Patients in the Presence of Competing Causes of Death

BACKGROUND

To estimate risk of recurrence for women diagnosed with nonmetastatic breast cancer considering the risks of other causes mortality.

METHODS

We extend a method based on the diagnosis-metastasis-death pathway to include risks of other causes mortality. We estimate three probabilities as cumulative incidence of: (i) being alive and recurrence-free, (ii) death for other causes before a recurrence, and (iii) recurrence. We apply the method to female breast cancer relative survival from the Surveillance, Epidemiology, and End Results Program registries (2000-2018) data.

RESULTS

The cumulative incidence of recurrence shows a higher increase with more advanced cancer stage and is less influenced by age at diagnosis. At 5 years from diagnosis, the cumulative incidence of recurrence is less than 3% for those diagnosed with stage I, 10% to 13% for those diagnosed with stage II, and 37% to 47% for those diagnosed with stage III breast cancer. The estimates of recurrence considering versus ignoring the risks of dying from other causes were generally consistent, except for older women with more advanced stage, and longer time since diagnosis. In these groups, the net probability of recurrence, excluding the risks of dying from other causes, were overestimated.

CONCLUSIONS

For patients with cancer who are older or long-term survivors, it is important to include the risks of other cause mortality as the crude cumulative incidence of recurrence is a more appropriate measure.

IMPACT

These estimates are important in clinical decision making, as higher competing mortality may preclude the benefits of aggressive treatments.

Cancer mortality and competing causes of death in older adults with cancer: A prospective, multicentre cohort study (ELCAPA-19)

BACKGROUND

In older patients with cancer, comorbidities compete with cancer for cause of death. The objectives were to evaluate cancer mortality and factors associated, according to metastatic status.

METHODS

Between 2007 and 2014, patients with cancer aged ≥70 referred for pre-therapeutic geriatric assessment (GA) were included through the ELCAPA prospective cohort study. The underlying cause of death was defined according to the International Classification of Diseases, 10th Revision. The World Health Organisation definition was used to categorise the cause of death as cancer versus another disease (e.g. cardiovascular disease, infectious disease, etc.) Competing risk models were used.

RESULTS

Mean (SD) age of the 1445 included patients was 80.2 (5.8) and 48% were women. Most common tumour sites were colorectal (19%), breast (17%) and urinary (15%); 773 patients (49%) had metastases. After a 34-month median follow-up, 706 cancer deaths were observed among 843 deaths. The 6-month and 3-year cancer mortality rates (95% CI) were 12% (9-15) and 34% (29-38) for non-metastatic patients and 43% (39-47) and 79% (75-82) for metastatic patients, respectively. Dependency in activities of daily living and comorbidities were associated with 6-month and 3-year cancer mortality in non-metastatic (adjusted subhazard ratio [aSHR] = 1.68 [0.99-2.85] and 1.69 [1.16-2.45]; and 1.98 [1.08-3.63] and 3.38 [1.47-7.76], respectively) and metastatic patients (aSHR = 2.81 [2.01-3.93] and 2.95 [2.14-4.07]; and 1.63 [1.18-2.25] and 2.06 [1.39-3.05], respectively). Impaired Timed-Get-Up-and-Go test was associated with 6-month and 3-year cancer mortality in metastatic patients (aSHR = 1.5 [1.06-2.12] and 1.38 [1.06-1.81], respectively). Obesity was negatively associated with 3-year cancer death in non-metastatic (aSHR = 0.53 [0.29-0.97]) and metastatic patients (aSHR = 0.71 [0.51-1.00]).

CONCLUSIONS

The majority of older adults with cancer referred for pre-therapeutic GA die from cancer. Geriatric parameters are independently associated with cancer mortality and should be considered for prognosis assessment, decision-making and care.

Prevalence of comorbidities and their impact on survival among older adults with the five most common cancers in Taiwan: a population study

Because of the cancer incidence increase and population aging in Taiwan, we aimed to assess the cancer prevalence, to summarize the comorbidities of older patients with the five most common cancers (i.e., breast, colorectal, liver, lung, and oral), and to develop a Taiwan cancer comorbidity index (TCCI) for studying their actual prognosis. The linkage of the Taiwan Cancer Registry, Cause of Death Database, and National Health Insurance Research Database was used. We followed the standard statistical learning steps to obtain a survival model with good discriminatory accuracy in predicting death due to noncancer causes, from which we obtained the TCCI and defined comorbidity levels. We reported the actual prognosis by age, stage, and comorbidity level. In Taiwan, cancer prevalence nearly doubled in 2004-2014, and comorbidities were common among older patients. Stage was the major predictor of patients' actual prognoses. For localized and regional breast, colorectal, and oral cancers, comorbidities correlated with noncancer-related deaths. Compared with the US, the chances of dying from comorbidities in Taiwan were lower and the chances of dying from cancer were higher for breast, colorectal, and male lung cancers. These actual prognoses could help clinicians and patients in treatment decision-making and help policymakers in resource planning.

Risk assessment of disease recurrence in early breast cancer: A serum metabolomic study focused on elderly patients

BACKGROUND

We previously showed that metabolomics predicts relapse in early breast cancer (eBC) patients, unselected by age. This study aims to identify a "metabolic signature" that differentiates eBC from advanced breast cancer (aBC) patients, and to investigate its potential prognostic role in an elderly population.

METHODS

Serum samples from elderly breast cancer (BC) patients enrolled in 3 onco-geriatric trials, were retrospectively analyzed via proton nuclear magnetic resonance (1H NMR) spectroscopy. Three nuclear magnetic resonance (NMR) spectra were acquired for each serum sample: NOESY1D, CPMG, Diffusion-edited. Random Forest (RF) models to predict BC relapse were built on NMR spectra, and resulting RF risk scores were evaluated by Kaplan-Meier curves.

RESULTS

Serum samples from 140 eBC patients and 27 aBC were retrieved. In the eBC cohort, median age was 76 years; 77% of patients had luminal, 10% HER2-positive and 13% triple negative (TN) BC. Forty-two percent of patients had tumors >2 cm, 43% had positive axillary nodes. Using NOESY1D spectra, the RF classifier discriminated free-from-recurrence eBC from aBC with sensitivity, specificity and accuracy of 81%, 67% and 70% respectively. We tested the NOESY1D spectra of each eBC patient on the RF models already calculated. We found that patients classified as "high risk" had higher risk of disease recurrence (hazard ratio (HR) 3.42, 95% confidence interval (CI) 1.58-7.37) than patients at low-risk.

CONCLUSIONS

This analysis suggests that a "metabolic signature", identified employing NMR fingerprinting, is able to predict the risk of disease recurrence in elderly patients with eBC independently from standard clinicopathological features.

Overall survival analyses of female malignancies in Southern Brazil during 2008-2017: A closer look at breast, cervical and ovarian cancer

Background

The aim of this study was to report the overall survival and baseline factors associated with OS for breast, cervical and ovarian cancer in Florianópolis, Southern Brazil, a region with quality-of-life indicators comparable to high-income countries.

Methods

Cohort study was performed from probabilistic record linkage of the Mortality Information System and the Population-based cancer registry of Florianópolis. It was included breasts, cervical and ovarian cancer diagnosis during the period of 2008-2012 with a follow up of 60 months. Cox regression and Kaplan-Meier method were used for associations with overall survival and risk factors.

Findings

1857 cases of the three malignancies were included in the analysis. We identified 202 deaths in breast cancer subjects, 53 for cervical cancer and 51 for ovarian cancer. Metastatic disease at diagnosis was present in 31%, 9.6%, and 55% of the cases, respectively. Overall survival was statistically correlated with age, educational level and stage for breast cancer; age and stage for cervical cancer; age and stage for ovarian cancer.

Interpretation

Metastatic disease and age are the main prognostic factors for the malignancies studied, as they were associated with both overall survival and risk of death. Better screening and preventive tests for early diagnosis are needed.

Funding

Support of Research and Innovation in the State of Santa Catarina, Research Program for the Unified Health System (FAPESC/MS-DECIT/CNPQ/SES-SC-PPSUS); the Brazilian National Research Council (CNPq); and the Coordination for the Improvement of Higher Education Personnel (CAPES).

Survival nomogram for different grades of gastric cancer patients based on SEER database and external validation cohort

Background

Influencing factors varied among gastric cancer (GC) for different differentiation grades which affect the prognosis accordingly. This study aimed to develop a nomogram to effectively identify the overall survival (OS).

Methods

Totally, 9,568 patients with GC were obtained from the SEER database as the training cohort and internal validation cohort. We then retrospectively enrolled patients diagnosed with GC to construct the external validation cohort from the First Affiliated Hospital of Anhui Medical University. The prognostic factors were integrated into the multivariate Cox regression to construct a nomogram. To test the accuracy of the model, we used the calibration curves, receiver operating characteristics (ROC) curves, C-index, and decision curve analysis (DCA).

Results

Race chemotherapy, tumor size, and other four factors were significantly associated with the prognosis of Grade III GC Patients. On this basis, we developed a nomogram. The discrimination of the nomogram revealed good prognostic accuracy The results of the area under the curve (AUC) calculated by ROC for five-year survival were 0.828 and 0.758 in the training set and external validation cohort, higher than that of the TNM staging system. The calibration plot revealed that the estimated risk was close to the actual risk. DCA also suggested an excellent predictive value of the nomogram. Similar results were obtained in Grade-I and Grade-II GC patients.

Conclusions

The nomogram developed in this study and other findings could help individualize the treatment of GC patients and assist clinicians in their shared decision-making with patients.

Sociodemographic Survival Disparities for Lung Cancer in the United States, 2000-2016

BACKGROUND

Understanding the impact of patient and tumor characteristics on lung cancer survival can help build personalized prognostic models and identify health disparities.

METHODS

We identified 557 555 patients aged 25 years and older diagnosed with lung or bronchus carcinoma from the Surveillance, Epidemiology, and End Results database, 2000-2016. We estimated hazard ratios (HR) for demographic (sex, age, race and ethnicity), tumor (stage, histology, year of diagnosis), and geographic characteristics (census tract-level urbanicity, socioeconomic status [SES]), as well as selected interactions, on the rate of lung cancer-specific death using multivariable proportional hazards models.

RESULTS

Women had a higher survival (lower hazard) of lung cancer-specific death than men (HR = 0.83, 95% confidence interval [CI] = 0.82 to 0.83). Hazards differed by race and ethnicity. Regional (HR = 2.41, 95% CI = 2.37 to 2.44) and distant (HR = 6.61, 95% CI = 6.53 to 6.69) tumors were associated with a lower survival (higher hazard) than localized tumors. Small cell tumors were associated with a lower survival (HR = 1.19, 95% CI = 1.18 to 1.20) than non-small cell tumors. Patients diagnosed after 2009 had lower hazards (HR = 0.86, 95% CI = 085 to 0.86) than those diagnosed 2000-2009. Lung cancer-specific survival did not depend on urbanicity after adjusting for census tract-level SES, but survival decreased with decreasing census tract-level SES. Differences in survival between non-Hispanic Black and White patients were greater for younger patients and localized tumors and increased with census tract-level SES. Differences by sex were greatest for young patients and localized tumors.

CONCLUSIONS

Disparities in survival after lung cancer diagnosis remain, with intersectional patterns suggesting differential access to and quality of care. Efforts are needed to ensure that high-risk groups receive guideline-concordant treatment.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

De novo and recurrent metastatic breast cancer - A systematic review of population-level changes in survival since 1995

BACKGROUND

Advances in breast cancer (BC) care have reduced mortality, but their impact on survival once diagnosed with metastasis is less well described. This systematic review aimed to describe population-level survival since 1995 for de novo metastatic BC (dnMBC) and recurrent MBC (rMBC).

METHODS

We searched MEDLINE 01/01/1995-12/04/2021 to identify population-based cohort studies of MBC reporting overall (OS) or BC-specific survival (BCSS) over time. We appraised risk-of-bias and summarised survival descriptively for MBC diagnoses in 5-year periods from 1995 until 2014; and for age, hormone receptor and HER2 subgroups.

FINDINGS

We identified 20 eligible studies (14 dnMBC, 1 rMBC, 5 combined). Potential sources of bias in these studies were confounding and shorter follow-up for the latest diagnosis period.For dnMBC, 13 of 14 studies reported improved OS or BCSS since 1995. In 2005-2009, the median OS was 26 months (range 24-30), a median gain of 6 months since 1995-1999 (range 0-9, 4 studies). Median 5-year OS was 23% in 2005-2009, a median gain of 7% since 1995-1999 (range -2 to 14%, 4 studies). For women ≥70 years, the median and 5-year OS was unchanged (1 study) with no to modest difference in relative survival (range: -1·9% (p = 0.71) to +2·1% (p = 0.045), 3 studies). For rMBC, one study reported no change in survival between 1998 and 2006 and 2007-2013 (median OS 23 months). For combined MBC, 76-89% had rMBC. Three of four studies observed no change in median OS after 2000. Of these, one study reported median OS improved for women ≤60 years (1995-1999 19·1; 2000-2004 22·3 months) but not >60 years (12·7, 11·6 months).

INTERPRETATION

Population-level improvements in OS for dnMBC have not been consistently observed in rMBC cohorts nor older women. These findings have implications for counselling patients about prognosis, planning cancer services and trial stratification.

FUNDING

SL was funded in part by a National Health and Medical Research Council (NHMRC) Project Grant ID: 1125433. NH was funded by the NBCF Chair in Breast Cancer Prevention grant (EC-21-001) and a NHMRC Investigator (Leader) grant (194410). BD and SAP were funded in part by the NHMRC Centre of Research Excellence in Medicines Intelligence (1196900).

Survival for endometrial cancer as a second primary malignancy

BACKGROUND

Endometrial cancer (EC) often occurs subsequently to a primary cancer arising from a different site. However, little is known regarding the survival experience of EC as a second primary (ECSP) malignancy, specifically in relation to the original primary site and prior treatment.

METHODS

Using Florida's cancer registry, all EC cases (first, second, or higher-order) diagnosed from 2005-2016 were analyzed. Kaplan-Meier methods and Cox Regression were used in a cause-specific survival analysis.

RESULTS

A total of 2879 clinically independent ECSPs and 42,714 first primary ECs were analyzed. The most common first primary sites for ECSPs were breast cancer (BC) (n = 1422) and colorectal cancer (CRC) (n = 359). Five-year cause-specific survival was 84.0% (95% CI: 83.6-84.3) for first primary ECs and 81.8% (95% CI: 80.0-83.4) for ECSPs. After adjusting for age, race/ethnicity, histology, and stage at diagnosis, ECSPs had a lower risk of EC mortality than first primary ECs (hazard ratios [HR] 0.88, 95% CI: 0.79-0.97). ECSPs with a first primary CRC had a higher risk of EC-specific death (HR 1.47, 95% CI: 1.04-2.06) compared to ECSPs that followed BC in multivariable analysis. Finally, women who had chemotherapy for ECSP and preceding BC did not have a higher risk of death (HR 0.80, 95% CI: 0.49-1.31) compared to those who only received chemotherapy for first primary EC.

CONCLUSIONS

ECSPs present a complex clinical profile. ECSP survival is superior to that of first primary EC. However, ECSPs following CRC may constitute a population of interest for their worse prognosis. Chemotherapy for a previous BC does not seem to impact the effectiveness of chemotherapy for ECs.

Advances in quantifying circulatory microRNA for early disease detection

Precision preventive healthcare aims to improve patient health by integrating preventive measures with early disease detection for timely intervention with precision medicine. Key to the delivery of preventive healthcare is the clinical adoption of novel assays that enable early disease detection. Such assays, typically based on biomarkers such as microRNAs (miRNAs) from liquid biopsy or excreta, are entering clinical practice after years of clinical development and validation. In this review, we discuss the clinical utility and validation of miRNA-based molecular diagnostics for early disease detection through large-cohort studies and key considerations for developing multi-analyte clinical assays. We also highlight recent advances in the ongoing development of integrated PCR-free miRNA detection systems for point-of-care testing.

Recreational Physical Activity and Outcomes After Breast Cancer in Women at High Familial Risk

Background

Recreational physical activity (RPA) is associated with improved survival after breast cancer (BC) in average-risk women, but evidence is limited for women who are at increased familial risk because of a BC family history or BRCA1 and BRCA2 pathogenic variants (BRCA1/2 PVs).

Methods

We estimated associations of RPA (self-reported average hours per week within 3 years of BC diagnosis) with all-cause mortality and second BC events (recurrence or new primary) after first invasive BC in women in the Prospective Family Study Cohort (n = 4610, diagnosed 1993-2011, aged 22-79 years at diagnosis). We fitted Cox proportional hazards regression models adjusted for age at diagnosis, demographics, and lifestyle factors. We tested for multiplicative interactions (Wald test statistic for cross-product terms) and additive interactions (relative excess risk due to interaction) by age at diagnosis, body mass index, estrogen receptor status, stage at diagnosis, BRCA1/2 PVs, and familial risk score estimated from multigenerational pedigree data. Statistical tests were 2-sided.

Results

We observed 1212 deaths and 473 second BC events over a median follow-up from study enrollment of 11.0 and 10.5 years, respectively. After adjusting for covariates, RPA (any vs none) was associated with lower all-cause mortality of 16.1% (95% confidence interval [CI] = 2.4% to 27.9%) overall, 11.8% (95% CI = -3.6% to 24.9%) in women without BRCA1/2 PVs, and 47.5% (95% CI = 17.4% to 66.6%) in women with BRCA1/2 PVs (RPA*BRCA1/2 multiplicative interaction P = .005; relative excess risk due to interaction = 0.87, 95% CI = 0.01 to 1.74). RPA was not associated with risk of second BC events.

Conclusion

Findings support that RPA is associated with lower all-cause mortality in women with BC, particularly in women with BRCA1/2 PVs.

The Survival Advantage of Lobectomy over Wedge Resection Lessens as Health-Related Life Expectancy Decreases

Introduction

Patients with early-stage NSCLC typically must choose between a surgery with superior local control (lobectomy) or one that preserves lung parenchyma (wedge). Recognizing that many patients with cancer have competing mortality risks unrelated to cancer, we investigated whether an established model of predicting life expectancy could be used to identify patients with stage I NSCLC for whom survival after wedge is not different from lobectomy.

Methods

A retrospective cohort study using the National Cancer Institute's Surveillance Epidemiology and End Results-Medicare was performed to evaluate survival among treatment-naive patients, diagnosed 2005-2015, who underwent lobectomy or wedge for stage I (≤2 cm tumors) NSCLC. Comorbidity-related life expectancy (CR-LE) was estimated using a standard life-table approach based on comorbid conditions, sex, and age. Cox models and perioperative complications were stratified by 5-year CR-LE.

Results

A total of 4560 patients (median age 74, interquartile range 70-78) were identified. CR-LE was greater than or equal to 5 years for 4016 patients (wedge = 23%). CR-LE was less than 5 years for 544 patients (wedge = 41%). Among patients with CR-LE greater than or equal to 5, wedge resection was associated with higher risk of mortality than lobectomy (hazard ratio: 1.68, 95% confidence interval: 1.52-1.86, p < 0.001). For those with CR-LE less than 5, there was no significant difference in mortality risk between lobectomy and wedge (hazard ratio: 1.19, 95% confidence interval: 0.96-1.47; p = 0.11). CR-LE less than five patients who underwent a lobectomy had higher 90-day mortality compared with wedge (9% versus 4%, p = 0.04).

Conclusion

The survival advantage of lobectomy over wedge for stage I NSCLC seems to dissipate among patients with shorter life expectancy owing to age and comorbidities. Wedge resection may be a reasonable option for patients at high risk of dying from non-cancer-related causes.

Competing Causes of Death in Older Adults with Thyroid Cancer

Background: Understanding the impact of comorbidities and competing risks of death when caring for older adults with thyroid cancer is key for personalized management. The objective of this study was to determine whether older adults with thyroid cancer are more likely to die from thyroid cancer or other etiologies, and determine patient factors associated with each. Methods: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients aged ≥66 years diagnosed with thyroid cancer (papillary, follicular, Hürthle cell, medullary, anaplastic, and other) between 2000 and 2015 (median follow-up, 50 months). We analyzed time to event (i.e., death from other causes or death from thyroid cancer) using cumulative incidence functions. Competing risk hazards regression was used to determine the association between patient (e.g., age at diagnosis and specific comorbidities) and tumor characteristics (e.g., SEER stage) with two competing mortality outcomes: death from other causes and death from thyroid cancer. Results: Of 21,509 patients with a median age of 72 years (range 66-106), 4168 (19.4%) died of other causes and 2644 (12.3%) died of thyroid cancer during the study period. For differentiated thyroid cancer patients, likelihood of dying from other causes exceeds likelihood of dying from thyroid cancer, whereas the opposite is true for anaplastic thyroid cancer. For medullary thyroid cancer, after 6.25 years patients are more likely to die from other etiologies than thyroid cancer. Using competing risks hazards regression, male sex (hazards ratio [HR] 1.47; 95% confidence interval [CI 1.37-1.57]), black race (HR 1.30; CI [1.16-1.46]), and comorbidities (e.g., heart disease, HR 1.34; CI [1.25-1.44]; chronic lower respiratory disease, HR 1.25; CI [1.17-1.34]) were associated with death from other causes. Tumor characteristics such as histology, tumor size, and stage correlated with death from thyroid cancer (e.g., distant SEER stage compared with localized, HR 12.65; CI [10.91-14.66]). Conclusions: The clinical context, including patients' specific comorbidities, should be considered when diagnosing and managing thyroid cancer. Our findings can be used to develop decision models that account for competing causes of death, as an aid for clinical decision making.

Competing Nomogram for Late-Period Breast Cancer-Specific Death in Patients with Early-Stage Hormone Receptor-Positive Breast Cancer

BACKGROUND

More than half of early breast cancer recurrences occur after 5 years from the initial diagnosis. An individualized estimate of the risk of late-period breast cancer-specific death (LP-BCSD) after 5 years of endocrine therapy (ET) can improve decision-making for extended endocrine therapy (EET).

MATERIALS AND METHODS

A total of 147,059 eligible patients with breast cancer who survived 5+ years after diagnosis between 1990 and 2007 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses based on the competing risk regression model were used to evaluate predictive factors for high risk of LP-BCSD or late-period non-breast cancer-specific death (LP-non-BCSD). Significant factors were used to build a nomogram to individualize estimates of LP-BCSD or LP-non-BCSD.

RESULTS

The 5- and 10-year LP-BCSD rates were 5.7% and 10.1%, respectively, and the 5- and 10-year LP-non-BCSD rates were 6.7% and 15.5%, respectively. Young age, black race, single marital status, poor differentiation, large tumor size, lymph node metastasis, and estrogen receptor-positive/progesterone receptor-negative (ER+/PR-) status were independent predictive factors for high risk of LP-BCSD. Age was the most important factor for predicting high risk of LP-non-BCSD. The nomograms, which were based on significant factors identified by the competing risk regression model. A risk score system based on the competing risk nomogram was established to describe the relative risk of LP-BCSD and LP-non-BCSD.

CONCLUSION

This study explored the novel endpoint of LP-BCSD for further clinical trials. The risk score system might be highly useful for patient counseling, especially in discussing EET options with elderly or comorbid patients.

Crude probability of death for cancer patients by spread of disease in New South Wales, Australia 1985 to 2014

BACKGROUND

To estimate trends in the crude probability of death for cancer patients by sex, age and spread of disease over the past 30 years in New South Wales, Australia.

METHODS

Population-based cohort of 716,501 people aged 15-89 years diagnosed with a first primary cancer during 1985-2014 were followed up to 31 December 2015. Flexible parametric relative survival models were used to estimate the age-specific crude probability of dying from cancer and other causes by calendar year, sex and spread of disease for all solid tumours combined and cancers of the colorectum, lung, female breast, prostate and melanoma.

RESULTS

Estimated 10-year sex, age and spread-specific crude probabilities of cancer death generally decreased over time for most cancer types, although the magnitude of the decrease varied. For example, out of 100 fifty-year old men with localized prostate cancer, 12 would have died from their cancer if diagnosed in 1985 and 3 in 2014. Greater degree of spread was consistently associated with higher probability of dying from cancer, although outcomes for lung cancer were consistently poor. For both males and females, the probability of non-cancer deaths was higher among older patients, those diagnosed with localized cancers and where cancer survival was higher.

CONCLUSION

Crude probabilities presented here may be useful in helping clinicians and their patients better understand prognoses and make informed decisions about treatment. They also provide novel insights into the relative contributions that early detection and improved treatments have on the observed temporal patterns in cancer survival.

Time-varying survival effects for squamous cell carcinomas at oropharyngeal and nonoropharyngeal head and neck sites in the United States, 1973-2015

BACKGROUND

Anatomical site is strongly associated with head and neck cancer etiology, and etiology and patient sociodemographic characteristics are prognostic factors for survival. It is not known whether the effects of these predictors persist over the postdiagnosis period or are strongest proximal to the time of diagnosis.

METHODS

Using survival times and causes of death for 180,434 patients with head and neck cancer in the Surveillance, Epidemiology, and End Results cancer registry (1973-2015), the empirical cumulative incidences of cancer-specific death and other-cause death were calculated with a competing risks framework, and the time-dependent effects (hazard ratios) of anatomical tumor site (oropharynx, oral cavity, or hypopharynx/larynx), age, sex, race, and year of diagnosis on cancer-specific death and other-cause death, stratified by tumor stage, were estimated.

RESULTS

All effects were significantly time-varying (P < .001). Patients with nonoropharyngeal cancer had a higher hazard of cancer-specific death but a similar cumulative fraction of deaths because of a higher rate of death from other causes. Cancer-specific survival has not changed for patients with nonoropharyngeal cancer over the past decades but has improved since 2000 for patients with oropharyngeal cancer. The effects of age and sex on cancer survival were strongest proximal to the diagnosis, whereas the effect of race persisted over time.

CONCLUSIONS

Recent improvements in survival for patients with oropharyngeal cancer may be due more to an increasing fraction of cancers attributable to human papillomavirus than to increasing treatment effectiveness. The prognostic strength of anatomical site and other predictors changes over the postdiagnosis period.

LAY SUMMARY

It is generally assumed that the effects of tumor and personal characteristics on the survival of patients with head and neck cancer are fixed over time, but this study shows that many factors are most important only in the first few years after diagnosis. Also, recent improvements in the survival of patients with head and neck cancer appear to benefit only patients with cancers of the oropharynx. The improvements may be due more to an increasing fraction of cancers caused by human papillomavirus (which generally have better outcomes) than to advances in head and neck cancer treatment overall.

Exercise and lung cancer surgery: A systematic review of randomized-controlled trials

Lung cancer patients undergoing surgery are often left physically deconditioned and/or with functional deficits. Exercise interventions may improve pulmonary and physical function before and after lung resection. We conducted a systematic review of randomized-controlled trials (RCTs) testing the impact of pre-, post-, and combined pre-and-post surgery exercise interventions on physical and pulmonary function in lung cancer patients. Exercise pre-surgery seems to substantially improve physical and pulmonary function, which are factors associated with improved ability to undergo surgery while reducing post-surgery complications. Evidence is inconsistent for post-surgery interventions, reporting no or moderate effects. Results from pre-and-post surgery interventions are limited to one study. In conclusion, pre- and post-surgery exercise interventions, individually, have shown beneficial effects for lung cancer patients undergoing surgery. The impact of interventions combining both pre- and post-surgery exercise programs remains unknown. More evidence is needed on the ideal exercise setting, and timing across the lung cancer care continuum.

Prospective double-blinded randomized controlled trial of Microwave versus RadioFrequency Ablation for hepatocellular carcinoma (McRFA trial)

BACKGROUND

Microwave (MWA) and radiofrequency ablation are the commonly used local ablation for hepatocellular carcinoma (HCC). Studies comparing both techniques are scarce. The aim of this study was to compare the efficacy of MWA versus RFA as a treatment for HCC.

METHODS

Patients with HCC who were suitable for local ablation were randomized into MWA or RFA. All patients were followed up regularly with contrast-enhanced computed tomography (CT) performed at 1, 3, 6 and 12 months after ablation. Both patients and the radiologists who interpreted the post-procedure CT scans were blinded to the treatment allocation. Treatment-related morbidity, overall and disease-free survivals were analyzed.

RESULTS

A total of 93 patients were recruited. Among them, 47 and 46 patients were randomized to MWA and RFA respectively. Patients in two groups were comparable in baseline demographics and tumor characteristics. With a median follow-up of around 30 months, there were no significant difference in the treatment-related morbidity, overall and disease-free survivals. MWA had a significantly shorter overall ablation time when compared with RFA (12 min vs 24 min, p < 0.001).

CONCLUSIONS

MWA is no different to RFA with respect to completeness of ablation and survivals. It is, however, as safe and effective as RFA in treating small HCC.

Impact of nonspecific death on overall survival in early-stage epithelial ovarian cancer patients

OBJECTIVE

To estimate the impacts of nonovarian cancer-specific death (non-OCSD) and ovarian cancer-specific death (OCSD) on early-stage patients, and to determine which statistical method yielded survival results most similar to real-world situations.

METHODS

Data of patients with early-stage epithelial ovarian cancer from 1988 to 2015 registered in the Surveillance, Epidemiology, and End Results database were analyzed. The primary outcome events of epithelial ovarian cancer were OCSD, non-OCSD, or alive. Incidences of non-OCSD and OCSD with different clinicopathological factors, cumulative incidences of non-OCSD and OCSD, and overall survival impact of non-OCSD were analyzed.

RESULTS

A total of 1606 non-OCSD (8.9%) and 3022 OCSDs (16.8%) were analyzed. Several independent features were associated with non-OCSD, including age (>60 years), radiotherapy, and marital status. In patients with histology (eg, endometrioid or mucinous), well-differentiated cells, stage I disease, or widowed marital status, as well as age older than 60, non-OCSD rates of all causes of death notably distorted overall survival, resulting in inaccurate and biased interpretations.

CONCLUSIONS

Overall survival was greatly influenced by non-OCSD in early epithelial ovarian cancer. Future clinical trials should consider non-OCSD as a competing risk event, especially among patients older than 60 years and those with well-differentiated cells, no chemotherapy, and widowed marital status.

Prostate cancer in Pennsylvania: The role of older age at diagnosis, aggressiveness, and environmental risk factors on treatment and mortality using data from the Pennsylvania Cancer Registry

Background

To assess: (a) cancer treatment in prostate cancer survivors (PCS) by age at diagnosis (ADx) and prostate cancer (PC) aggressiveness; (b) potential impact on PC mortality; and (c) these results in the context of environmental/behavioral risk factors on PCS in Pennsylvania.

Methods

Prostate cancer survivors ages ≥40 years were identified from the 2004‐2014 Pennsylvania Cancer Registry (PCR). Demographic/clinical descriptors and PC treatment were extracted from PCR. Prostate cancer aggressiveness was defined by clinical/pathologic Gleason score and tumor stage. Logistic and Cox regression analyses tested associations between treatment received and PC‐specific mortality. County‐level data from the Pennsylvania BRFSS were used to estimate cancer‐related behavioral risk factors (eg, smoking, physical inactivity, fruit/vegetable consumption [FV], alcohol use) and used as covariates.

Results

There were 90 694 PCS ages 40‐105 years (mean age = 66.19 years, SD = 9.25) included. Most were non‐Hispanic white men (83%). Prostate cancer survivors ≥75 years were least likely to receive any treatment but men ages 65‐74 were more likely to receive combined therapies (OR = 1.47; 95% CI 1.28, 1.69) vs PCS ages 40‐54 years, controlling for covariates. Prostate cancer survivors 55‐75+ with aggressive PC who received any treatment vs no definitive treatment had significantly reduced mortality. Men from counties with high obesity and smoking rates were significantly less likely to receive any treatment than men living in counties with lower rates of these risk factors. Prostate cancer survivors who lived in counties with high rates of physical inactivity and had high rates of sufficient FV consumption were slightly more likely to receive cancer treatment vs no definitive treatment compared to men who lived in counties with high rates of physical activity and lower FV consumption.

Conclusions

We observed a general age‐related decline in receipt of treatment. Prostate cancer survivors ages ≥75 years were significantly less likely to get any cancer treatment compared to younger PCS. However, most men with more aggressive disease who received any treatment had greatly reduced PC mortality, regardless of age. Considering environmental/behavioral risk factors may attenuate PC risk and inform treatment options.

Temporal improvements in loco-regional failure and survival in patients with anal cancer treated with chemo-radiotherapy: treatment cohort study (1990-2014)

Background

We evaluated oncological changes in patients with squamous cell carcinoma of the anus (SCCA) treated by chemoradiotherapy (CRT) from a large UK institute, to derive estimates of contemporary outcomes.

Methods

We performed a treatment-cohort analysis in 560 patients with non-metastatic SCCA treated with CRT over 25 years. The primary outcomes were 3-year loco-regional failure (LRF), 5-year overall survival (OS), and 5-year cancer-specific survival (CSS). We developed prediction models; and overlaid estimates on published results from historic trials.

Results

Age distributions, proportions by gender and cT stage remained stable over time. The median follow-up was 61 (IQR: 36–79) months. Comparing the first period (1990–1994) with the last period (2010–2014), 3-year LRF declined from 33 to 16% (P_trends < 0.001); 5-year OS increased from 60% to 76% (P_trends = 0.001); and 5-year CCS increased from 62% in to 80% (P_trends = 0.001). For 2020, the models predicted a 3-year LRF of 14.7% (95% CIs: 0–31.3); 5-year OS of 74.7% (95% CIs: 54.6–94.9); and 5-year CSS of 85.7% (95% CIs: 75.3–96.0). Reported oncological outcomes from historic trials generally underestimated contemporary outcomes.

Conclusions

Current and predicted rates for 3-year LRF and 5-year survivals are considerably improved compared with those in historic trials.

A high serum-free fatty acid level is associated with cancer

PURPOSE

The objectives of this work were to investigate whether the serum-free fatty acid (FFA) level is meaningful in cancer patients and its role in cancer diagnosis.

METHODS

A total of 2206 patients were divided into a cancer group (n = 1019) and a noncancer group (n = 1187). Age, sex, body mass index (BMI), and serum FFA and serum albumin levels were collected. Cancer patients were divided into subgroups according to the location of the cancer. We then compared serum FFA levels among the tumor subgroups. A receiver operating characteristic (ROC) curve analysis was performed to further evaluate the diagnostic ability of the FFA level. SPSS 22.0 software was used to analyze the results.

RESULTS

The FFA level was higher in the cancer group than in the noncancer group. According to the multivariate analysis, there was also an increased risk of cancer associated with a high FFA level after adjusting for old age, female sex, and a low BMI. In the subgroup analysis, the FFA level in patients with lung cancer, gastric cancer, thyroid cancer, rectal cancer, colon cancer, and ovarian cancer was significantly higher than that in noncancer patients. The area under the effect-time curve (AUC) of FFAs in the whole cancer group was 0.58, while the thyroid cancer, rectal cancer, and ovarian cancer subgroups had AUCs > 0.6.

CONCLUSION

Our study provides clinical evidence to support that fatty acid metabolism is associated with cancers and demonstrates that a high FFA level in the serum may be an indicator of cancer.

Conditional crude probabilities of death for English cancer patients

Background

Cancer survival statistics are typically reported by using measures discounting the impact of other-cause mortality, such as net survival. This is a hypothetical measure and is interpreted as excluding the possibility of cancer patients dying from other causes. Crude probability of death partitions the all-cause probability of death into deaths from cancer and other causes.

Methods

The National Cancer Registration and Analysis Service is the single cancer registry for England. In 2006–2015, 1,590,477 malignant tumours were diagnosed for breast, colorectal, lung, melanoma and prostate cancer in adults. We used a relative survival framework, with a period approach, providing estimates for up to 10-year survival. Mortality was partitioned into deaths due to cancer or other causes. Unconditional and conditional (on surviving 1-years and 5-years) crude probability of death were estimated for the five cancers.

Results

Elderly patients who survived for a longer period before dying were more likely to die from other causes of death (except for lung cancer). For younger patients, deaths were almost entirely due to the cancer.

Conclusion

There are different measures of survival, each with their own strengths and limitations. Careful choices of survival measures are needed for specific scenarios to maximise the understanding of the data.

Therapeutic potential of PI3K signaling in distinct entities of B-cell lymphoma

Introduction: Aberrant phosphatidylinositide 3-kinase (PI3K) signaling drives survival and proliferation of malignant B-cells of different lymphoma entities. Thus, inhibition of PI3K isoforms represents a novel and promising therapeutic approach for the treatment of patients with B-cell lymphomas.Areas covered: Here the authors provide an overview about the PI3K signaling pathway as well as available preclinical and clinical results of different PI3K inhibitors in both indolent and aggressive lymphoma entities.Expert opinion: PI3K inhibitors have shown to be efficacious in different entities of B-cell lymphoma, at this stage particularly in relapsed/refractory settings. However, responses of PI3K inhibitors widely vary among different lymphomas. Additionally, especially infectious and immune-mediated toxicities limit their use at this stage. Thus, the decision to use PI3K inhibitors needs to be balanced between the potential efficacy and associated toxicities as well as the availability of other therapeutic options. Future research might eventually lead to the stratification of patients according to the specific oncogenic addictions of the underlying lymphoma. Additionally, PI3K inhibitors will need to be combined with other therapeutic agents for more specific and effective treatment regimens.

De-escalating chemotherapy for stage II colon cancer?

BACKGROUND

Although adjuvant chemotherapy is recommended for patients with stage II colon cancer characterized by poor prognostic features, its pros and cons remain a controversial issue. We aim to evaluate the real effectiveness of chemotherapy on stage II colon cancer as well as select suitable patients.

METHODS

Patients during 1988-2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The competing risk regression model and propensity score matching method were used to evaluate colon-cancer-specific death (CCSD) and non-CCSD. Also, a competing-risk nomogram was constructed to identify risk of patients. Risk score (RS) was calculated according to nomogram.

RESULTS

A total of 58,133 patients were included, 25.66% received chemotherapy, and 74.34% were without chemotherapy. In total, 19.95% and 25.78% of patients died of CCSD and non-CCSD, respectively. Univariate and multivariate analyses showed that receiving chemotherapy appears to be associated with more CCSD and less non-CCSD (HR 1.23, 95% CI 1.18-1.28; HR 0.45, 95% CI 0.43-0.47, respectively), even after adjustment for covariates and propensity score weighting. A competing-risk nomogram was established; the model was relatively good with a C-index of 0.661. Based on the RS, risk stage could only predict prognosis but failed to predict the benefit from chemotherapy.

CONCLUSIONS

The value of chemotherapy is much less than we thought. It is time to de-escalate chemotherapy for stage II colon cancer. CCSD, rather than overall survival, should be considered as an appropriate primary end point for future trials in stage II colon cancer.

Models predicting survival to guide treatment decision-making in newly diagnosed primary non-metastatic prostate cancer: a systematic review

OBJECTIVES

Men diagnosed with non-metastatic prostate cancer require standardised and robust long-term prognostic information to help them decide on management. Most currently-used tools use short-term and surrogate outcomes. We explored the evidence base in the literature on available pre-treatment, prognostic models built around long-term survival and assess the accuracy, generalisability and clinical availability of these models.

DESIGN

Systematic literature review, pre-specified and registered on PROSPERO (CRD42018086394).

DATA SOURCES

MEDLINE, Embase and The Cochrane Library were searched from January 2000 through February 2018, using previously-tested search terms.

ELIGIBILITY CRITERIA

Inclusion required a multivariable model prognostic model for non-metastatic prostate cancer, using long-term survival data (defined as ≥5 years), which was not treatment-specific and usable at the point of diagnosis.

DATA EXTRACTION AND SYNTHESIS

Title, abstract and full-text screening were sequentially performed by three reviewers. Data extraction was performed for items in the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies checklist. Individual studies were assessed using the new Prediction model Risk Of Bias ASsessment Tool.

RESULTS

Database searches yielded 6581 studies after deduplication. Twelve studies were included in the final review. Nine were model development studies using data from over 231 888 men. However, only six of the nine studies included any conservatively managed cases and only three of the nine included treatment as a predictor variable. Every included study had at least one parameter for which there was high risk of bias, with failure to report accuracy, and inadequate reporting of missing data common failings. Three external validation studies were included, reporting two available models: The University of California San Francisco (UCSF) Cancer of the Prostate Risk Assessment score and the Cambridge Prognostic Groups. Neither included treatment effect, and both had potential flaws in design, but represent the most robust and usable prognostic models currently available.

CONCLUSION

Few long-term prognostic models exist to inform decision-making at diagnosis of non-metastatic prostate cancer. Improved models are required to inform management and avoid undertreatment and overtreatment of non-metastatic prostate cancer.

Misclassification of the actual causes of death and its impact on analysis: A case study in non-small cell lung cancer

OBJECTIVES

Cumulative incidence of lung cancer deaths (LC-CID) is an important metric to understand cancer prognosis and to determine treatment options. However, credible estimates of LC-CID rely on accurate cause-of-death coding in death certificates. Results from lung cancer screening trials estimated 15% under-reporting and 1% over-reporting of lung cancer deaths due to misclassification. This study investigated the impact of cause-of-death misclassification on the estimation of LC-CID.

MATERIALS AND METHODS

Patients with stage I/II non-small cell lung cancer (NSCLC) from the Surveillance, Epidemiology, and End Results registry were included. LC-CID was estimated using the competing-risk approach in two ways: (1) reporting observed estimates that ignore potential cause-of-death misclassification and (2) correcting for plausible misclassification rates reported in the literature (15% under-reporting and 1% over-reporting). Bias was quantified as the difference between observed and corrected 10-year LC-CIDs: positive values indicated that observed LC-CID overestimated true LC-CID, whereas negative values indicated the opposite.

RESULTS

Among 66,179 patients, the impact of over-reporting on 10-year LC-CID was negligible across all age groups. In contrast, under-reporting resulted in substantial underestimation of 10-year LC-CID. The biases increased as age increased due to higher LC-CIDs: 10-year LC-CIDs among stage I patients 18-44, 45-59, 60-74 and ≥75 years were 25%, 32%, 41%, and 50%, respectively, and the corresponding biases given the plausible misclassification rates were -4.4%, -5.6%, -7.1%, and -8.6%. Because the observed LC-CIDs among patients with stage II disease were higher than those with stage I disease, the biases were greater among stage II patients, up to -12.5% in the oldest age group.

CONCLUSIONS

In lung cancer, LC-CID may be severely underestimated due to under-reporting of lung cancer deaths, particularly among older patients or those with late-stage disease. Future studies that involve such subpopulations should present the corrected LC-CIDs based on plausible misclassification rates alongside the observed LC-CIDs.

Cause-specific mortality among Medicare beneficiaries with newly diagnosed non-Hodgkin lymphoma subtypes

BACKGROUND

As the US population ages and non-Hodgkin lymphoma (NHL)-specific mortality declines, deaths from causes other than NHL will become increasingly important in treatment decision making for older patients with NHL. The objective of the current study was to describe how the 5-year cumulative incidence of NHL-specific and other-cause mortality varies by subtype, age, comorbidity level, and time since diagnosis in older patients.

METHODS

Using the Surveillance, Epidemiology, and End Results cancer registry data linked to Medicare claims, patients aged ≥66 years were identified at the time of diagnosis with a first, primary NHL diagnosis from 2004 through 2013. Death certificate data and Fine-Gray competing risks models were used to estimate the 5-year cumulative incidence of NHL-specific and other-cause mortality by NHL subtype, age, and comorbidity level. Estimates were displayed over time using stacked cumulative incidence curves.

RESULTS

Among 30,666 patients with NHL, 32% died of NHL and 13% died of other causes within 5 years of diagnosis. The cumulative incidence of other-cause mortality increased with age and comorbidity level for all subtypes. Among patients with aggressive NHL subtypes, NHL-specific mortality exceeded other-cause mortality across all age groups, comorbidity levels, and number of years after diagnosis. For patients with indolent NHL subtypes, other-cause mortality was similar to or exceeded NHL-specific mortality, especially among older patients with severe comorbidity or with the indolent marginal zone, lymphoplasmacytic, and mycosis fungoides subtypes.

CONCLUSIONS

The findings of the current study suggest that mortality from causes other than NHL are important for patients of an older age, with a higher comorbidity level, and with indolent disease. Evidence from the current study can guide the development of tools for estimating individual prognosis that inform treatment discussions in patients with NHL.

Competing Risk of Death in Elderly Patients with Newly Diagnosed Stage I Breast Cancer

BACKGROUND

The majority of newly diagnosed breast cancers in the US are in women aged older than 65 years who can have additional comorbidities. Balancing the risks and benefits of treatment should take into account these competing risks of death.

STUDY DESIGN

The Surveillance, Epidemiology, and End Results Program-Medicare database was used to identify women with stage I breast cancer undergoing operations from 2004-2012. Using neural network analysis, comorbidities associated with mortality were grouped into clinically relevant categories. Cumulative incidence graphs and Fine and Gray competing risk regression analyses were used to study the association of age, race, comorbidity groupings, and tumor variables with 3 competing mortality outcomes: dead of disease (DOD), dead of other cancers (DOC), and non-cancer death (NCD).

RESULTS

The overall cumulative incidence of mortality was 4.9% for DOD, 3.7% for DOC, and 21.3% for NCD for the 47,220 patients studied. For all patients, the 5- and 8-year probability of DOD was 3% and 4.7%, for DOC 1.9% and 3.5%, and for NCD 9.8% and 18.9%, respectively. The presence of any major comorbidity (eg cardiovascular or neurologic disorders) significantly increased the probability of NCD, and estrogen receptor status was the strongest predictor of DOD. Given patient age, comorbidity, and estrogen receptor status, an estimate of competing risks of death from DOD, DOC, and NCD can be calculated.

CONCLUSIONS

To aid clinical decision making, we quantify competing risks of death in patients with stage I breast cancer by taking into account patient age, comorbidity, and estrogen receptor status.

Communicating prognosis to women with early breast cancer - overview of prediction tools and the development and pilot testing of a decision aid

Background

Shared decision-making in oncology requires information on individual prognosis. This comprises cancer prognosis as well as competing risks of dying due to age and comorbidities. Decision aids usually do not provide such information on competing risks. We conducted an overview on clinical prediction tools for early breast cancer and developed and pilot-tested a decision aid (DA) addressing individual prognosis using additional chemotherapy in early, hormone receptor-positive breast cancer as an example.

Methods

Systematic literature search on clinical prediction tools for the effects of drug treatment on survival of breast cancer. The DA was developed following criteria for evidence-based patient information and International Patient Decision Aids Standards. We included data on the influence of age and comorbidities on overall prognosis. The DA was pilot-tested in focus groups. Comprehension was additionally evaluated through an online survey with women in breast cancer self-help groups.

Results

We identified three prediction tools: Adjuvant!Online, PREDICT and CancerMath. All tools consider age and tumor characteristics. Adjuvant!Online considers comorbidities, CancerMath displays age-dependent non-cancer mortality. Harm due to therapy is not reported.

Twenty women participated in focus groups piloting the DA until data saturation was achieved. A total of 102 women consented to participate in the online survey, of which 86 completed the survey. The rate of correct responses was 90.5% and ranged between 84 and 95% for individual questions.

Conclusions

None of the clinical prediction tools fulfilled the requirements to provide women with all the necessary information for informed decision-making. Information on individual prognosis was well understood and can be included in patient decision aids.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3988-2) contains supplementary material, which is available to authorized users.

Hydrolysis of ATP, ADP, and AMP is increased in blood plasma of prostate cancer patients

Prostate cancer is among the major malignancies that affect men around the world. Adenine nucleotides are important signaling molecules that mediate innumerous biological functions in pathophysiological conditions, including cancer. These molecules are degraded by several ectoenzymes named ectonucleotidases that produce adenosine in the extracellular medium. Some of these ecto-enzymes can be found in soluble in the blood stream. Thus, the present study aimed to evaluate the hydrolysis of adenine nucleotides (ATP, ADP, and AMP) in the plasma blood of patients with prostate cancer. Peripheral blood samples were collected, and questionnaires were filled based on the clinical data of the medical records. The nucleotide hydrolysis was performed by Malachite Green method using ATP, ADP, and AMP as substrates. Plasma from prostate cancer patients presented an elevated hydrolysis of all nucleotides evaluated when compared to healthy individuals. NTPDase inhibitor (ARL67156) and the alkaline phosphatase inhibitor (levamisole) did not alter ATP hydrolysis. However, AMP hydrolysis was reduced by the CD73 inhibitor, APCP, and by levamisole, suggesting the action of a soluble form of CD73 and alkaline phosphatase. On microvesicles, it was observed that there was a low expression and activity of CD39 and almost absent of CD73. The correlation of ATP, ADP, and AMP hydrolysis with clinic pathological data demonstrated that patients who received radiotherapy showed a higher AMP hydrolysis than those who did not, and patients with lower clinical stage (CS-IIA) presented an elevated ATP hydrolysis when compared to those with more advanced clinical stages (CS-IIB and CS-III). Patients of all clinical stages presented an elevated AMPase activity. Therefore, we can suggest that the nucleotide hydrolysis might be attributed to soluble ecto-enzymes present in the plasma, which, in a coordinate manner, produce adenosine in the blood stream, favoring prostate cancer progression.

Impact of old age on resectable colorectal cancer outcomes

Objective

This study was performed to identify a reasonable cutoff age for defining older patients with colorectal cancer (CRC) and to examine whether old age was related with increased colorectal cancer-specific death (CSD) and poor colorectal cancer-specific survival (CSS).

Methods

A total of 76,858 eligible patients from the surveillance, epidemiology, and end results (SEER) database were included in this study. The Cox proportional hazard regression model and the Chow test were used to determine a suitable cutoff age for defining the older group. Furthermore, a propensity score matching analysis was performed to adjust for heterogeneity between groups. A competing risk regression model was used to explore the impact of age on CSD and non-colorectal cancer-specific death (non-CSD). Kaplan-Meier survival curves were plotted to compare CSS between groups. Also, a Cox regression model was used to validate the results. External validation was performed on data from 1998 to 2003 retrieved from the SEER database.

Results

Based on a cutoff age of 70 years, the examined cohort of patients was classified into a younger group (n = 51,915, <70 years of old) and an older group (n = 24,943, ≥70 years of old). Compared with younger patients, older patients were more likely to have fewer lymph nodes sampled and were less likely to receive chemotherapy and radiotherapy. When adjusted for other covariates, age-dependent differences of 5-year CSD and 5-year non-CSD were significant in the younger and older groups (15.84% and 22.42%, P < 0.001; 5.21% and 14.21%, P < 0.001). Also an age of ≥70 years remained associated with worse CSS comparing with younger group (subdistribution hazard ratio, 1.51 95% confidence interval (CI) [1.45-1.57], P < 0.001). The Cox regression model as a sensitivity analysis had a similar result. External validation also supported an age of 70 years as a suitable cutoff, and this older group was associated with having reduced CSS and increased CSD.

Conclusions

A total of 70 is a suitable cutoff age to define those considered as having elderly CRC. Elderly CRC was associated with not only increased non-CSD but also with increased CSD. Further research is needed to provide evidence of whether cases of elderly CRC should receive stronger treatment if possible.

EMT network-based feature selection improves prognosis prediction in lung adenocarcinoma

Various feature selection algorithms have been proposed to identify cancer prognostic biomarkers. In recent years, however, their reproducibility is criticized. The performance of feature selection algorithms is shown to be affected by the datasets, underlying networks and evaluation metrics. One of the causes is the curse of dimensionality, which makes it hard to select the features that generalize well on independent data. Even the integration of biological networks does not mitigate this issue because the networks are large and many of their components are not relevant for the phenotype of interest. With the availability of multi-omics data, integrative approaches are being developed to build more robust predictive models. In this scenario, the higher data dimensions create greater challenges. We proposed a phenotype relevant network-based feature selection (PRNFS) framework and demonstrated its advantages in lung cancer prognosis prediction. We constructed cancer prognosis relevant networks based on epithelial mesenchymal transition (EMT) and integrated them with different types of omics data for feature selection. With less than 2.5% of the total dimensionality, we obtained EMT prognostic signatures that achieved remarkable prediction performance (average AUC values >0.8), very significant sample stratifications, and meaningful biological interpretations. In addition to finding EMT signatures from different omics data levels, we combined these single-omics signatures into multi-omics signatures, which improved sample stratifications significantly. Both single- and multi-omics EMT signatures were tested on independent multi-omics lung cancer datasets and significant sample stratifications were obtained.

Functional insights into nucleotide-metabolizing ectoenzymes expressed by bone marrow-resident cells in patients with multiple myeloma

Human myeloma cells grow in a hypoxic acidic niche in the bone marrow. Cross talk among cellular components of this closed niche generates extracellular adenosine, which promotes tumor cell survival. This is achieved through the binding of adenosine to purinergic receptors into complexes that function as an autocrine/paracrine signal factor with immune regulatory activities that i) down-regulate the functions of most immune effector cells and ii) enhance the activity of cells that suppress anti-tumor immune responses, thus facilitating the escape of malignant myeloma cells from immune surveillance. Here we review recent findings confirming that the dominant phenotype for survival of tumor cells is that where the malignant cells have been metabolically reprogrammed for the generation of lactic acidosis in the bone marrow niche. Adenosine triphosphate and nicotinamide-adenine dinucleotide extruded from tumor cells, along with cyclic adenosine monophosphate, are the main intracellular energetic/messenger molecules that serve as leading substrates in the extracellular space for membrane-bound ectonucleotidases metabolizing purine nucleotides to signaling adenosine. Within this mechanistic framework, the adenosinergic substrate conversion can vary significantly according to the metabolic environment. Indeed, the neoplastic expansion of plasma cells exploits both enzymatic networks and hypoxic acidic conditions for migrating and homing to a protected niche and for evading the immune response. The expression of multiple specific adenosine receptors in the niche completes the profile of a complex regulatory framework whose signals modify multiple myeloma and host immune responses.

Pulmonary Metastases from an Undifferentiated Embryonal Sarcoma of the Liver: A Case Report and Review

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare malignant hepatic tumor that occurs primarily in children. Only a limited number of cases have been reported in the literature due to low incidence of one per million, and reports of metastatic lesion of UESL are even rarer. We hereby describe the case of a 13-year-old male who presented with a palpable mass with imaging findings suggestive of a large complex tumor in the right lobe of the liver. He underwent extended right hepatectomy followed by adjuvant chemotherapy. The tumor was confirmed to be UESL by postoperative pathology and immunohistochemical staining analysis. Four years later, surveillance imaging revealed a small lung nodule in the left lower lobe. Complete removal of the lung tumor by wedge resection was performed, and a histological diagnosis of metastatic UESL was made. The patient also received postoperative adjuvant chemotherapy and is currently in a good general condition and tumor-free in the present eight-month period. This case is presented with emphasis on clinicopathological and immunohistochemical findings of the primary UESL and lung metastases with the aim of collecting more data and expanding our understanding of this rare malignancy.

The influence of insurance type on stage at presentation, treatment, and survival between Asian American and non-Hispanic White lung cancer patients

The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (OR_adj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (OR_adj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (OR_adj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart.

Overall Dietary Intake and Prognosis after Breast Cancer: A Systematic Review

Breast cancer survivors often seek information about how lifestyle factors, such as diet, may influence their prognosis. Previous studies have reviewed evidence around single nutrients, individual foods or food groups. We reviewed studies examining relationships between overall dietary intake and prognosis in breast cancer survivors. A systematic search was conducted to identify studies, published until June 2016, which assessed associations between overall dietary intake (i.e., quality; score; pattern) and mortality and/or recurrence in breast cancer survivors. We identified seven eligible studies. Studies were heterogeneous regarding diet assessment timing (before/after diagnosis); mean age and menopausal status; and dietary intake measure (statistically derived/a priori defined indices). Better overall dietary intake (i.e., better quality; healthy/prudent pattern; less inflammatory diet) was associated with decreased risk of overall and non-breast cancer mortality, in most studies. Insufficient evidence is available to draw conclusions regarding breast cancer-specific survival and disease recurrence. Following breast cancer diagnosis, better overall dietary intake may independently improve overall and non-breast cancer survival. Survivors may improve prognosis by adopting more healthful dietary patterns consistent with dietary guidelines and/or prudent diet. Future adequately powered studies should consider measuring dietary intake consistently to better understand the role of diet in disease-specific outcomes.

Development and validation of risk prediction equations to estimate survival in patients with colorectal cancer: cohort study

Objective To develop and externally validate risk prediction equations to estimate absolute and conditional survival in patients with colorectal cancer. Design Cohort study.Setting General practices in England providing data for the QResearch database linked to the national cancer registry.Participants 44 145 patients aged 15-99 with colorectal cancer from 947 practices to derive the equations. The equations were validated in 15 214 patients with colorectal cancer from 305 different QResearch practices and 437 821 patients with colorectal cancer from the national cancer registry.Main outcome measures The primary outcome was all cause mortality and secondary outcome was colorectal cancer mortality.Methods Cause specific hazards models were used to predict risks of colorectal cancer mortality and other cause mortality accounting for competing risks, and these risk estimates were combined to obtain risks of all cause mortality. Separate equations were derived for men and women. Several variables were tested: age, ethnicity, deprivation score, cancer stage, cancer grade, surgery, chemotherapy, radiotherapy, smoking status, alcohol consumption, body mass index, family history of bowel cancer, anaemia, liver function test result, comorbidities, use of statins, use of aspirin, clinical values for anaemia, and platelet count. Measures of calibration and discrimination were determined in both validation cohorts at 1, 5, and 10 years.Results The final models included the following variables in men and women: age, deprivation score, cancer stage, cancer grade, smoking status, colorectal surgery, chemotherapy, family history of bowel cancer, raised platelet count, abnormal liver function, cardiovascular disease, diabetes, chronic renal disease, chronic obstructive pulmonary disease, prescribed aspirin at diagnosis, and prescribed statins at diagnosis. Improved survival in women was associated with younger age, earlier stage of cancer, well or moderately differentiated cancer grade, colorectal cancer surgery (adjusted hazard ratio 0.50), family history of bowel cancer (0.62), and prescriptions for statins (0.77) and aspirin (0.83) at diagnosis, with comparable results for men. The risk equations were well calibrated, with predicted risks closely matching observed risks. Discrimination was good in men and women in both validation cohorts. For example, the five year survival equations on the QResearch validation cohort explained 45.3% of the variation in time to colorectal cancer death for women, the D statistic was 1.86, and Harrell's C statistic was 0.80 (both measures of discrimination, indicating that the scores are able to distinguish between people with different levels of risk). The corresponding results for all cause mortality were 42.6%, 1.77, and 0.79.Conclusions Risk prediction equations were developed and validated to estimate overall and conditional survival of patients with colorectal cancer accounting for an individual's clinical and demographic characteristics. These equations can provide more individualised accurate information for patients with colorectal cancer to inform decision making and follow-up.

Reproducibility, reliability and validity of population-based administrative health data for the assessment of cancer non-related comorbidities

BACKGROUND

Patients with comorbidities do not receive optimal treatment for their cancer, leading to lower cancer survival. Information on individual comorbidities is not straightforward to derive from population-based administrative health datasets. We described the development of a reproducible algorithm to extract the individual Charlson index comorbidities from such data. We illustrated the algorithm with 1,789 laryngeal cancer patients diagnosed in England in 2013. We aimed to clearly set out and advocate the time-related assumptions specified in the algorithm by providing empirical evidence for them.

METHODS

Comorbidities were assessed from hospital records in the ten years preceding cancer diagnosis and internal reliability of the hospital records was checked. Data were right-truncated 6 or 12 months prior to cancer diagnosis to avoid inclusion of potentially cancer-related comorbidities. We tested for collider bias using Cox regression.

RESULTS

Our administrative data showed weak to moderate internal reliability to identify comorbidities (ICC ranging between 0.1 and 0.6) but a notably high external validity (86.3%). We showed a reverse protective effect of non-cancer related Chronic Obstructive Pulmonary Disease (COPD) when the effect is split into cancer and non-cancer related COPD (Age-adjusted HR: 0.95, 95% CI:0.7-1.28 for non-cancer related comorbidities). Furthermore, we showed that a window of 6 years before diagnosis is an optimal period for the assessment of comorbidities.

CONCLUSION

To formulate a robust approach for assessing common comorbidities, it is important that assumptions made are explicitly stated and empirically proven. We provide a transparent and consistent approach useful to researchers looking to assess comorbidities for cancer patients using administrative health data.

Different survival analysis methods for measuring long-term outcomes of Indigenous and non-Indigenous Australian cancer patients in the presence and absence of competing risks

Background

Net survival is the most common measure of cancer prognosis and has been used to study differentials in cancer survival between ethnic or racial population subgroups. However, net survival ignores competing risks of deaths and so provides incomplete prognostic information for cancer patients, and when comparing survival between populations with different all-cause mortality. Another prognosis measure, “crude probability of death”, which takes competing risk of death into account, overcomes this limitation. Similar to net survival, it can be calculated using either life tables (using Cronin-Feuer method) or cause of death data (using Fine-Gray method). The aim of this study is two-fold: (1) to compare the multivariable results produced by different survival analysis methods; and (2) to compare the Cronin-Feuer with the Fine-Gray methods, in estimating the cancer and non-cancer death probability of both Indigenous and non-Indigenous cancer patients and the Indigenous cancer disparities.

Methods

Cancer survival was investigated for 9,595 people (18.5% Indigenous) diagnosed with cancer in the Northern Territory of Australia between 1991 and 2009. The Cox proportional hazard model along with Poisson and Fine-Gray regression were used in the multivariable analysis. The crude probabilities of cancer and non-cancer methods were estimated in two ways: first, using cause of death data with the Fine-Gray method, and second, using life tables with the Cronin-Feuer method.

Results

Multivariable regression using the relative survival, cause-specific survival, and competing risk analysis produced similar results. In the presence of competing risks, the Cronin-Feuer method produced similar results to Fine-Gray in the estimation of cancer death probability (higher Indigenous cancer death probabilities for all cancers) and non-cancer death probabilities (higher Indigenous non-cancer death probabilities for all cancers except lung cancer and head and neck cancers). Cronin-Feuer estimated much lower non-cancer death probabilities than Fine-Gray for non-Indigenous patients with head and neck cancers and lung cancers (both smoking-related cancers).

Conclusion

Despite the limitations of the Cronin-Feuer method, it is a reasonable alternative to the Fine-Gray method for assessing the Indigenous survival differential in the presence of competing risks when valid and reliable subgroup-specific life tables are available and cause of death data are unavailable or unreliable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-016-0118-9) contains supplementary material, which is available to authorized users.