Progress in Standard of Care Therapy and Modest Survival Benefits in the Treatment of Non-small Cell Lung Cancer Patients in the Netherlands in the Last 20 Years

Making meaning of everyday life in the context of lung cancer treatment-a qualitative study of outpatients' perspectives

BACKGROUND

The increasing survival after a lung cancer diagnosis implies that patients live longer with the disease, which means that symptoms and side effects of the treatment become part of everyday life.

AIM

The study explored how older adults make meaning of everyday life when undergoing treatment for their lung cancer.

MATERIAL AND METHODS

A qualitative study using semi-structured interviews was conducted with 12 older adults with lung cancer undergoing various treatments. The analysis followed Giorgi's phenomenologic five-step method.

RESULTS

The analysis revealed three partly overlapping themes: meeting the health care system, losing identity, and struggling for meaning in everyday life. The patients appreciate clear and coherent communication at the oncology clinic. They had different needs for support from organised support groups, friends, communities, or relatives to make meaning of everyday life.

CONCLUSION

Creating meaning in everyday life is essential despite the disease and the treatments' side effects. Interpersonal relationships create meaningfulness in everyday life through a salutogenic perspective that makes everyday life comprehensible and manageable.

SIGNIFICANCE

The patients need an everyday life perspective on the disease and the side effects, which a salutogenic approach in the encounter with the health care system could support.

Mortality after radiotherapy or surgery in the treatment of early-stage non-small-cell lung cancer: a population-based data analysis in the clinical cancer registry of Brandenburg-Berlin

PURPOSE

Stereotactic body radiotherapy (SBRT) is an established treatment method with favorable toxicity for inoperable early-stage non-small-cell lung cancer (NSCLC) patients. This paper aims to evaluate the importance of SBRT in the treatment of early-stage lung cancer patients compared to surgery as standard of care.

METHODS

The German clinical cancer register of Berlin-Brandenburg was assessed. Cases of lung cancer were considered if they had a TNM stage (clinical or pathological) of T1-T2a and N0/x and M0/x, corresponding to UICC stages I and II. In our analyses, cases diagnosed between 2000 and 2015 were included. We adjusted our models with propensity score matching. We compared patients treated with SBRT or surgery regarding age, Karnofsky performance status (KPS), sex, histological grade, and TNM classification. Further, we assessed the association of cancer-related parameters with mortality; hazard ratios (HR) from Cox proportional hazards models were computed.

RESULTS

A total of 558 patients with UICC stages I and II NSCLC were analyzed. In univariate survival models, we found similar survival rates in patients who underwent radiotherapy compared with surgery (HR 1.2, 95% confidence interval [CI] 0.92-1.56; p = 0.2). Our univariate subgroup analyses of patients > 75 years showed a statistically nonsignificant survival benefit for patients treated with SBRT (HR 0.86, 95% CI 0.54-1.35; p = 0.5). Likewise, in our T1 subanalysis, survival rates were similar between the two treatment groups regarding overall survival (HR 1.12, 95% CI 0.57-2.19; p = 0.7). The availability of histological data might be slightly beneficial in terms of survival (HR 0.89, 95% CI 0.68-1.15; p = 0.4). This effect was also not significant. Regarding the availability of histological status in our subgroup analyses of elderly patients, we could show similar survival rates as well (HR 0.70, 95% CI 0.44-1.23; p = 0.14). T1-staged patients also had a statistically nonsignificant survival benefit if histological grading was available (HR 0.75, 95% CI 0.39-1.44; p = 0.4). Concerning adjusted covariates, better KPS scores were associated with better survival in our matched univariate Cox regression models. Further, higher histological grades and TNM stages were related to a higher mortality risk.

CONCLUSION

Using population-based data, we observed an almost equal survival of patients treated with SBRT compared to surgery in stage I and II lung cancer. The availability of histological status might not be decisive in treatment planning. SBRT is comparable to surgery in terms of survival.

A Satellite Account for Health in the United States

This paper develops a satellite account for the US health sector and measures productivity growth in health care for the elderly population between 1999 and 2012. We measure the change in medical spending and health outcomes for a comprehensive set of 80 conditions. Medical care has positive productivity growth over the time period, with aggregate productivity growth of 1.5% per year. However, there is significant heterogeneity in productivity growth. Care for cardiovascular disease has had very high productivity growth. In contrast, care for people with musculoskeletal conditions has been costly but has not led to improved outcomes.

Epidemiology and Survival Outcomes for Patients With NSCLC in Scandinavia in the Preimmunotherapy Era: A SCAN-LEAF Retrospective Analysis From the I-O Optimise Initiative

Introduction

SCAN-LEAF, part of the I-O Optimise initiative, is a retrospective, longitudinal study investigating the epidemiology, clinical care, and outcomes for patients with NSCLC in Scandinavia. We report overall survival (OS) trends for patients diagnosed with NSCLC in Sweden and Denmark between 2005 and 2015.

Methods

Swedish and Danish cohorts were established by linking national registries. Data on all adults diagnosed with incident NSCLC from January 1, 2005, to December 31, 2015, were included. For temporal analyses of OS trends, patients were stratified by TNM stage and histology.

Results

Between 2005 and 2015, a total of 30,067 and 31,939 patients from Sweden and Denmark, respectively, were diagnosed with NSCLC; the most common histological subtype was nonsquamous cell carcinoma (56.9% and 53.0%) and 48.4% and 51.6% were diagnosed at stage IV. Over the study period, significant improvements in short-term survival (1 y) were observed for patients with nonsquamous cell carcinoma in both countries, regardless of disease stage at diagnosis; however, improvements in longer-term survival (5 y) were limited to patients with stage I and II disease only. Conversely, among patients with squamous cell histology, improvements in short-term survival were only observed for stage I disease in Sweden and stage IIIA disease in Denmark, while significant improvements in longer-term survival were seen only for stage IIIA NSCLC in both countries.

Conclusions

Despite some survival improvements between 2005 and 2015, an unmet need remains for patients with advanced NSCLC, particularly those with squamous cell histology. Future analyses will evaluate the impact of newer treatments on OS in NSCLC.

Patterns of age disparities in colon and lung cancer survival: a systematic narrative literature review

OBJECTIVES

To identify patterns of age disparities in cancer survival, using colon and lung cancer as exemplars.

DESIGN

Systematic review of the literature.

DATA SOURCES

We searched Embase, MEDLINE, Scopus and Web of Science through 18 December 2020.

ELIGIBILITY CRITERIA

We retained all original articles published in English including patients with colon or lung cancer. Eligible studies were required to be population-based, report survival across several age groups (of which at least one was over the age of 65) and at least one other characteristic (eg, sex, treatment).

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the quality of included studies against selected evaluation domains from the QUIPS tool, and items concerning statistical reporting. We evaluated age disparities using the absolute difference in survival or mortality rates between the middle-aged group and the oldest age group, or by describing survival curves.

RESULTS

Out of 3047 references, we retained 59 studies (20 for colon, 34 for lung and 5 for both sites). Regardless of the cancer site, the included studies were highly heterogeneous and often of poor quality. The magnitude of age disparities in survival varied greatly by sex, ethnicity, socioeconomic status, stage at diagnosis, cancer site, and morphology, the number of nodes examined and treatment strategy. Although results were inconsistent for most characteristics, we consistently observed greater age disparities for women with lung cancer compared with men. Also, age disparities increased with more advanced stages for colon cancer and decreased with more advanced stages for lung cancer.

CONCLUSIONS

Although age is one of the most important prognostic factors in cancer survival, age disparities in colon and lung cancer survival have so far been understudied in population-based research. Further studies are needed to better understand age disparities in colon and lung cancer survival.

PROSPERO REGISTRATION NUMBER

CRD42020151402.

Identification and Analysis of Dysfunctional Genes and Pathways in CD8+ T Cells of Non-Small Cell Lung Cancer Based on RNA Sequencing

Lung cancer, the most common of malignant tumors, is typically of the non-small cell (NSCLC) type. T-cell-based immunotherapies are a promising and powerful approach to treating NSCLCs. To characterize the CD8⁺ T cells of non-small cell lung cancer, we re-analyzed the published RNA-Seq gene expression profiles of 36 CD8⁺ T cell isolated from tumor (TIL) samples and 32 adjacent uninvolved lung (NTIL) samples. With an advanced Monte Carlo method of feature selection, we identified the CD8⁺ TIL specific expression patterns. These patterns revealed the key dysfunctional genes and pathways in CD8⁺ TIL and shed light on the molecular mechanisms of immunity and use of immunotherapy.

Lung cancer in Spain: information from the Thoracic Tumors Registry (TTR study)

Background

Lung cancer remains a leading cause of cancer incidence and mortality worldwide. Although Spain contributes to global statistics related to cancer, it is difficult to discern aspects linked to clinical presentation of the disease or molecular testing. The Thoracic Tumor Registry (TTR) was created with the aim of filling this gap.

Methods

Observational cohort multicenter study performed in Spain, including patients with lung cancer or other types of thoracic tumors undergoing active treatment or palliative care only. Enrollment took place between August 2016 and December 2018. The evaluation included a review of demographic, epidemiological, clinical and molecular data.

Results

A total of 6,600 patients diagnosed with non-small cell lung cancer (NSCLC) were recruited at 56 Spanish hospitals. The mean age at diagnosis was 64 years. The majority of patients (80%) presented with advanced disease, being adenocarcinoma the most frequent histological type. Up to 86% of patients were current- or ex-smokers, with men starting to smoke earlier than women (average age 17.9 vs. 19.2 years). Sixty-seven percent of patients underwent some type of molecular testing. Mutations in EGFR and KRAS genes were found in 18% and 28% of patients, respectively.

Conclusions

Our findings suggest that the TTR study accurately describes the clinical reality of lung cancer in Spain, including useful information on smoking status as well as molecular profiling and tumor histology, and can therefore be used to drive improvements in health care. Social and political pressure to reduce tobacco consumption among the population should be reinforced, particularly among youth.

Systematic evaluation of the efficacy-effectiveness gap of systemic treatments in metastatic nonsmall cell lung cancer

The divergence between clinical trial results and real-world outcomes is largely unknown for many cancer types. The present study aims overall to assess the efficacy-effectiveness gap (difference between outcomes in clinical trials and the real world) in systemic treatment for metastatic nonsmall cell lung cancer (NSCLC).All patients diagnosed with stage IV NSCLC between 2008 and 2014 within a network of seven Dutch large teaching hospitals (Santeon) were studied. For every patient, an efficacy-effectiveness (EE) factor was calculated by dividing individual patients' overall survival (OS) by the pooled median OS assessed from clinical trials with the respective treatment.From 2989 diagnosed patients, 1214 (41%) started with first-line treatment. For all studied regimens, real-world OS was shorter than OS reported in clinical trials. Overall, the EE factor was 0.77 (95% CI 0.70-0.85; p<0.001). Real-world patients completed their treatment plan less often and proceeded less frequently to further lines of treatment. These parameters together with Eastern Cooperative Oncology Group performance status explained 35% of the variation in EE factor.Survival of patients with metastatic NSCLC treated with chemotherapy or targeted therapy in real-world practice is nearly one-quarter shorter than for patients included in trials. Patients' performance status, earlier discontinuation and fewer subsequent lines of treatment partly explained this difference.

Salvage surgery for recurrent or persistent tumour after radical (chemo)radiotherapy for locally advanced non-small cell lung cancer: a systematic review

Background:

Once recurrent or persistent locoregional tumour after radical chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC) is identified, few curative-intent treatment options are available. Selected patients might benefit from surgical salvage. We performed a systematic review of the available literature for this emerging treatment option.

Methods:

A systematic literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Publications about persistent or (locoregional) recurrent disease after radical/definitive CRT for locally advanced non-small cell lung cancer were identified.

Results:

Eight full papers were found, representing 158 patients. All were retrospective series and data were heterogeneous: definition and indication for salvage surgery varied and the median time from radiotherapy to surgery was 4.1–33 months. Complete resection (R0) was achieved in 85–100%, with vital tumour in 61–100%. A large number of pneumonectomies were performed, and additional structures were often resected. Where reported, 90-day mortality was 0–11.4%. Reported survival metrics varied but included median overall survival 9–46 months and 5-year survival 20–75%.

Conclusion:

There are limited, low-level, heterogeneous data in support of salvage surgery after radical CRT. Based on this, perioperative mortality appears acceptable and long-term survival is possible in (highly) selected patients. In suitable patients (fit, no distant metastases, tumour appears completely resectable and preferably with confirmed viable tumour), this treatment option should be discussed in an experienced multidisciplinary lung cancer team.

Low Dose Naltrexone and Lung Cancer: A Case Report and Discussion

Low dose naltrexone (LDN) has been promising as a complementary medication for patients with a broad range of medical disorders. Although not a proven cure, evidence from clinical trials supports LDN as being a valuable adjunct for disorders in which the immune system plays a centralized role. Additionally, clinical trials have proposed a unique mechanism(s) allowing LDN to affect tumors including non-small cell lung cancer (NSCLC) at the cellular level by augmenting the immune system. We present a case of a 50-year-old male with a prolonged survival and a past medical history of prostate and lung cancer.

Resection rate and operability of elderly patients with non-small cell lung cancer: Nationwide study from 1991 to 2014

OBJECTIVES

An increasing number of elderly patients are diagnosed with non-small cell lung cancer (NSCLC). We compared the surgical resection rate, operability and survival in this age group (≥75 years) to younger patients using centralized databases in Iceland.

METHODS

The study population comprised all patients diagnosed with NSCLC in Iceland from 1991 to 2014. A total of 140 elderly patients (≥75 years) with NSCLC underwent pulmonary resection and were compared with 550 surgically resected patients less than 75 years, with respect to resection rate, short and long-term survival and complications of surgery. Reasons for exclusion from surgery were registered for elderly surgical candidates (stages IA-IIB).

RESULTS

Surgical resection rate in the elderly group was 18% compared to 32% in the younger age group ( P <  0.001). The most frequent reasons for not operating on elderly patients in stages IA-IIB were poor pulmonary function (58%), heart disease (17%) or multiple comorbidities (17%). The rate of major complications following surgery was comparable in the elderly versus the younger age group, 13 vs 11%, respectively ( P =  0.578). The same was true for 30 day mortality (2 vs 1%, P =  0.397). Five-year overall survival was 40% vs 44% ( P =  0.019) and cancer-specific survival 51% vs 50% ( P =  0.802).

CONCLUSIONS

Elderly patients with resectable NSCLC according to stage are frequently excluded from surgery due to comorbid conditions. Although the operated patients may represent a selected group, their favourable 30-day and long-term survival indicate that more elderly patients with NSCLC could be operated on.

Causes of death and competing risk analysis of the associated factors for non-small cell lung cancer using the Surveillance, Epidemiology, and End Results database

PURPOSE

To investigate the probability of death (POD) from any causes by time after diagnosis of non-small cell lung cancer (NSCLC) and the factors associated with survival for NSCLC patients.

METHODS

A total of 202,914 patients with NSCLC from 2004 to 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The overall survival (OS) and lung cancer-specific survival (LCSS) were calculated and POD from any causes at different time periods after diagnosis was explored. The predictive factors for OS, LCSS and survival from non-lung cancer deaths were investigated using multivariate analysis with Cox proportional hazards regression and competing risk regression analysis.

RESULTS

The 5- and 10-year OS were 20.4% and 11.5%, accordingly that for LCSS were 25.5% and 18.4%, respectively. Lung cancer contributed 88.3% (n = 128,402) of the deaths. The POD from lung cancer decreased with time after diagnosis. In multivariate analysis, advanced age and advanced stage of NSCLC were associated with decreased OS and LCSS. Comparing to no surgery, any kind of resection conferred lower risk of death from lung cancer and higher risk of dying from non-lung cancer conditions except lobectomy or bilobectomy, which was associated with lower risk of death from both lung cancer and non-lung cancer conditions.

CONCLUSIONS

Most of the patients with NSCLC died from lung cancer. Rational surveillance and treatment policies should be made for them. Early stage and lobectomy or bilobectomy were associated with improved OS and LCSS. It is reasonable to focus on early detection and optimal surgical treatment for NSCLC.

Transfection with Livin and Survivin shRNA inhibits the growth and proliferation of non‑small cell lung cancer cells

Lung cancer is reported to be a major public health issue worldwide and the overall prognosis of patients remains poor. The expression levels of Livin and Survivin, of the inhibitors of apoptosis (IAP) family, are associated with prognostic significance in the majority of solid tumors. Therefore, in the presents study, short hairpin (sh)RNA expression vectors inhibiting the Livin and Survivin genes were constructed to examine the effects of the transfection of Livin shRNA and/or Survivin shRNA on the biological functions of tumor cells. The transfection efficiency was measured using fluorescence reverse transcription‑quantitative polymerase chain reaction and western blot analyses. The cell growth inhibition ratio was measured using a CCK assay. Cell apoptosis following transfection and in tumor tissues were measured using a TUNEL assay, and a cancer xenograft model was used to investigate the effect of Livin shRNA and/or Survivin shRNA on tumor growth. The results indicated that the mRNA and protein expression levels were suppressed following the transfection of Livin and Survivin shRNA into tumor cells (P<0.05, compared with control group). The growth of tumor cells in vivo and in vitro was significantly inhibited following transfection with Livin and Survivin shRNA, compared with that in the other groups (P<0.05). Taken together, the transfection of cells with Livin and Survivin inhibited tumor growth in vivo and in vitro, with the co‑transfection of Livin and Survivin shRNA showing increased efficiency, compared with transfection of either the Livin vector or Survivin vector alone. The combined inhibition of Livin and Survivin may be a promising multitargeted gene therapeutic strategy in cancer treatment.

Trends in treatment and relative survival among Non-Small Cell Lung Cancer patients in the Netherlands (1990-2014): Disparities between younger and older patients

BACKGROUND

This study aimed to describe trends over time regarding disparities in treatment and relative survival (RS) between younger and older patients with non-small cell lung cancer (NSCLC).

METHODS

All patients diagnosed with pathologically verified NSCLC in 1990-2014 were included from the Netherlands Cancer Registry (n=187,315). Treatment and RS (adjusted for sex, histology and treatment) were analyzed according to age group (<70 years versus ≥70 years), stage and five-year period of diagnosis.

RESULTS

Between 1990 and 2014, five-year RS increased from 17 to 22% among younger patients and from 12 to 16% among elderly. The application of surgery increased over time for elderly with stage I NSCLC, decreased for elderly with stage II, and was stable but higher for younger patients. Disparities in RS between age groups with stage I became smaller since 2000-2004, but did not change over time for stage II. For stage III and IV, both age groups showed strong increases over time in chemoradiotherapy and chemotherapy from 2000 onwards, although considerably less among elderly. One-, three- and five-year RS increased more strongly over time for the younger group leading to larger disparities between age groups with stage III or IV NSCLC.

CONCLUSION

More curative-intent treatment and improved RS for NSCLC were seen over time, but were less profound among elderly. Disparities herein between age groups seemed to become smaller over time for stage I NSCLC, did not change for stage II, and were widening for stage III and IV at the expense of elderly. Future prospective studies should focus on optimizing treatment selection and outcomes for elderly.

Stage III Non-Small Cell Lung Cancer in the elderly: Patient characteristics predictive for tolerance and survival of chemoradiation in daily clinical practice

BACKGROUND

In unselected elderly with stage III Non-Small Cell Lung Cancer (NSCLC), evidence is scarce regarding motives and effects of treatment modalities.

METHODS

Hospital-based multicenter retrospective study including unresectable stage III NSCLC patients aged ⩾70 and diagnosed between 2009 and 2013 (N=216). Treatment motives and tolerance (no unplanned hospitalizations and completion of treatment), and survival were derived from medical records and the Netherlands Cancer Registry.

RESULTS

Patients received concurrent chemoradiation (cCHRT, 33%), sequential chemoradiation (sCHRT, 24%), radical radiotherapy (RT, 16%) or no curative treatment (27%). Comorbidity, performance status (58%) and patient refusal (15%) were the most common motives for omitting cCHRT. Treatment tolerance for cCHRT and sCHRT was worse in case of severe comorbidity (OR 6.2 (95%CI 1.6-24) and OR 6.4 (95%CI 1.8-22), respectively). One-year survival was 57%, 50%, 49% and 26% for cCHRT, sCHRT, RT and no curative treatment, respectively. Compared to cCHRT, survival was worse for no curative treatment (P=0.000), but not significantly worse for sCHRT and RT (P=0.38).

CONCLUSION

Although relatively fit elderly were assigned to cCHRT, treatment tolerance was worse, especially for those with severe comorbidity. Survival seemed not significantly better as compared to sCHRT or RT. Prospective studies in this vital and understudied area are needed.

Assessment of Referral and Chemotherapy Treatment Patterns for Elderly Patients With Non-small-Cell Lung Cancer

BACKGROUND

Physiologic changes of aging in combination with greater comorbidity could lead to treatment nihilism for elderly patients (≥ 70 years old) with non-small-cell lung cancer (NSCLC). Randomized trials have shown improved survival with chemotherapy since 1999, but it remains unclear whether these data have translated into practice.

PATIENTS AND METHODS

We conducted a retrospective, population-based cohort study of NSCLC cases diagnosed in Ontario, Canada from 2000 to 2010. We compared referral and treatment patterns among patients aged < 70 versus ≥ 70 years. Multivariable analyses evaluated predictors of referral to medical oncology or treatment with chemotherapy.

RESULTS

Of 61,646 patients with NSCLC, 32,131 (52.1%) were ≥ 70 years. Fewer adenocarcinomas were diagnosed in the elderly (29.8% vs. 44%), and more elderly patients lacked microscopic confirmation of malignancy (20.1% vs. 6.2%). Charlson co-morbidity scores ≥ 2 (14.0% vs. 7.4%) were higher in the elderly. Only 59.5% of elderly patients with NSCLC were referred to a medical oncologist, versus 78.5% of younger patients. Elderly patients were less likely to receive chemotherapy (18.3% vs. 46.7%), even among those referred to a medical oncologist (30.1% vs. 58.6%). Neither referral nor treatment changed substantially over time. The elderly also had a shorter median survival (5.8 vs. 9.6 months); however, there was less difference in median survival (13.6 vs. 14.9 months) among patients receiving chemotherapy.

CONCLUSION

Elderly patients are less likely to be considered for systemic therapy for NSCLC, and evidence of benefit has had minimal impact on practice. We believe this disparity could be improved through systematically using tools to comprehensively assess elderly patients.

The positive prognostic effect of stromal CD8+ tumor-infiltrating T cells is restrained by the expression of HLA-E in non-small cell lung carcinoma

INTRODUCTION

Tumor-infiltrating CD8+ T cells are associated with improved clinical outcomes in non-small cell lung cancer (NSCLC). Here we studied their prognostic effect in the context of the expression of HLA molecules that are key in tumor recognition (HLA-A, B and C) or suppression of immunity (HLA-E) as this is still unknown.

METHODS

Tumor tissue of 197 patients with resected pulmonary adenocarcinoma was analyzed for the presence of CD8+ T cells and the expression of β2-microglobulin, HLA-A, HLA-B/C and HLA-E. The relation of these parameters with overall survival (OS) was assessed.

RESULTS

Loss and low expression of HLA-A or HLA-B/C was found in 44% and 75% of cases respectively. A high CD8+ tumor infiltration was strongly associated with clinical benefit only when the tumors retained good expression of HLA-A and HLA-B/C (p=0.004). In addition, more than 70% of the tumors were found to display a high expression of HLA-E. The expression of HLA-E by tumor cells was an independent negative prognostic factor for OS (p=0.031). Importantly, a dense stromal CD8+ T cell infiltration was strongly associated with improved OS only in HLA-E negative tumors (p=0.005) and its prognostic effect was completely abolished when tumors highly expressed HLA-E (p=0.989).

CONCLUSIONS

CD8+ T cell infiltration strongly contributes to a better prognosis in NSCLC when the tumor cells retain the expression of classical HLA class I and do not express HLA-E. Therefore, analysis of HLA-A, -B/C and HLA-E expression should be included as biomarkers to predict the response to immunotherapy.

Cost-components of lung cancer care within the first three years after initial diagnosis in context of different treatment regimens

OBJECTIVES

Although lung cancer is of high epidemiological relevance in Germany, evidence on its economic implications is scarce. Sound understanding of current care structures and associated expenditures is required to comprehensively judge the additional benefit of novel interventions in lung cancer care. Adopting a payer perspective, our study aims to analyze expenditures for individuals with incident lung cancer.

MATERIAL AND METHODS

Patients with an initial diagnosis of lung cancer (ICD-10 code C34) in 2009 were searched in a large, nationwide base of health insurance claims data and grouped according to initial treatment (Surgery, Chemotherapy/Radiotherapy, No specific treatment). All-cause SHI and lung cancer-related spending was assessed for a patient-individual three-year time frame after initial diagnosis. Expenditures per case and expenditures per year survived were calculated via Generalized Linear Gamma Models adjusted for age, gender, living region, baseline metastases, multiple tumors and initial treatment regimen using time under observation as a weighting factor.

RESULTS

17,478 individuals were identified. Lung cancer-related expenditures peaked within the first six months after initial diagnosis. Following, they declined subsequently and so did their share in all-cause SHI spending. Lung cancer-related expenditures per case were estimated at €20,400 (53% of all-cause expenditures) with a huge variance according to initial treatment regimen [

SURGERY

€20,400, Chemotherapy/Radiotherapy: €26,300, No specific treatment: €4200]. Cost per year survived amounted to €15,500 (55% of all cause expenditures) [

SURGERY

€11,600, Chemotherapy/Radiotherapy: €20,200, No specific treatment: €7600].

CONCLUSION

Analyses of lung cancer-related expenditures need to take into account treatment strategies and survival. Our study is representative for a large share of the population and provides detailed, patient-level information on costs of care and their compilation. Results render estimates available for the cost of lung cancer e.g. for budget impact analyses, cost-effectiveness analyses of screening and prevention schemes, or prognostic models of life-time expenditures per lung cancer case.

Mindfulness-Based Stress Reduction for lung cancer patients and their partners: Results of a mixed methods pilot study

BACKGROUND

Lung cancer patients and partners show high rates of impaired quality of life and heightened distress levels. Mindfulness-Based Stress Reduction has proven to be effective in reducing psychological distress in cancer patients. However, studies barely included lung cancer patients.

AIM

We examined whether Mindfulness-Based Stress Reduction might be a feasible and effective intervention for patients with lung cancer and partners.

DESIGN

Mindfulness-Based Stress Reduction is a training in which mindfulness practices are combined with psycho-education to help participants cope with distress. In this mixed methods pilot study, questionnaires on psychological distress and quality of life were administered before, directly after and 3 months after the Mindfulness-Based Stress Reduction training, in combination with semi-structured interviews.

SETTING/PARTICIPANTS

Patients with lung cancer and partners were recruited at one tertiary care academic medical centre. A total of 19 lung cancer patients and 16 partners participated in the Mindfulness-Based Stress Reduction training.

RESULTS

Most patients were diagnosed with advanced stage lung cancer. Vast majority completed the training. Those receiving anti-cancer treatment did not miss more sessions than patients who were not currently treated. Patients and partners felt positive about participating in a peer group and with their partner. Among participants no significant changes were found in psychological distress. Caregiver burden in partners decreased significantly after following Mindfulness-Based Stress Reduction. The qualitative analysis showed that the training seemed to instigate a process of change in participants.

CONCLUSION

The Mindfulness-Based Stress Reduction training seemed to be feasible for patients with lung cancer and their partners. A randomized controlled trial is needed to examine the effectiveness of Mindfulness-Based Stress Reduction in reducing psychological distress in lung cancer patients and partners.

Local and systemic XAGE-1b-specific immunity in patients with lung adenocarcinoma

XAGE-1b is a cancer/testis antigen aberrantly expressed in pulmonary adenocarcinoma. Systemic antibody and T cell responses have been demonstrated in adenocarcinoma patients, but so far, local antigen-specific immunity has not been reported. In this study, XAGE-1b expression by tumor cells as well as the presence of systemic and/or local XAGE-1b-specific immunity was assessed in peripheral blood, tumor tissue and tumor-draining lymph nodes of Caucasian patients with pulmonary adenocarcinoma. XAGE-1b protein expression was detected in 43.6% (17 of 39) of patients when at least two different parts of a resected tumor were assessed. In 20 patients, analysis of T cells isolated and expanded from the primary tumor and its draining lymph node demonstrated XAGE-1b-specific responses in two patients. XAGE-1b-specific immunoglobulin G antibodies were found in 3 of 40 patients. These three antibody-positive patients had also mounted a systemic T cell response to XAGE-1b, measured by proliferation, cytokine production and expression of T cell activation markers on peripheral blood mononuclear cells. The population of XAGE-1b-specific T cells comprised both CD4+ and CD8+ T cells secreting both type I and II cytokines. Epitope mapping showed that T cells predominantly targeted the N-terminal part of the XAGE-1b protein, while the B cell response was directed against the C-terminal domain. Our study for the first time provides evidence for the presence of XAGE-1b-specific T cells within adenocarcinoma tissue, which supports the concept that XAGE-1b acts as a genuine tumor antigen and, therefore, might form an attractive target for a vaccine-based approach of immunotherapy.

Variation in causes of death in patients with non-small cell lung cancer according to stage and time since diagnosis

BACKGROUND

Many patients with non-small cell lung cancer (NSCLC) die within the first few years of diagnosis, and considerable excess mortality remains even after 5 years. We investigated the death rate and the distribution of causes of death for NSCLC patients by age and stage at diagnosis during long-term follow-up.

PATIENTS AND METHODS

All 72 021 patients aged 45-89 years diagnosed with stage I-III NSCLC between 1989 and 2008 in the Netherlands and who died up till 2011 were derived from the Netherlands Cancer Registry and linked with the database of Statistics Netherlands for underlying causes of death. Mortality ratios and proportional distribution of causes of death were calculated during 5 time periods after diagnosis of NSCLC (up to 15 years).

RESULTS

Median follow-up was 9.6 years (range: 0-23 years). Lung cancer was the predominant cause of death in the first 6 years after diagnosis (being 80%-85% and ∼90% up to 3 years for localized and locally advanced disease, respectively, and ∼60%-75% and ∼75%-85% during years 4-6 for both stage groups, respectively). Thereafter, lung cancer as cause of death proportionally decreased with time since diagnosis, but remained over 30%. Hence, cardiovascular diseases and chronic obstructive pulmonary diseases (COPD) became more important causes of death, especially for patients aged >60 years at diagnosis (up to 34% for cardiovascular diseases and up to 19% for COPD).

CONCLUSIONS

With time, the relative contribution of cardiovascular and COPD causes of death increased, although the absolute contribution of lung cancer remained high in non-metastatic NSCLC. Therefore, managing morbidity of these diseases remains relevant.

Trends in cancer prognosis in a population-based cohort survey: can recent advances in cancer therapy affect the prognosis?

BACKGROUND

The aim of the study was to investigate trends in cancer prognosis by examining the relationship between period of diagnosis and probability of death from cancer in a population-based cohort.

METHODS

Within a cohort of Japanese men and women aged 40-69 years and free of prior diagnosis of cancer and cardiovascular disease at baseline, data from 4403 patients diagnosed with cancer between 1990 and 2006 and followed up until 2012 were analyzed using survival regression models to assess the presence of an effect of the period of diagnosis (before 1998 versus after 1998) on the risk of dying from cancer.

RESULTS

We noted a significant decrease in risk of dying from cancer among individuals diagnosed after 1998 with lung cancer (hazard ratio [HR]=0.676 [0.571-0.800]) or colorectal cancer (HR=0.801 [0.661-0.970]). A decrease in the estimated five-year probability of death from cancer was also noted between the first (before 1998) and the second (after 1998) period of diagnosis for lung and colorectal cancers (e.g., 85.4% vs. 73.3% for lung cancer and 44.6% vs. 37.7% for colorectal cancer, respectively, for stage III in men aged 60 at diagnosis).

CONCLUSIONS

This study presented the first scientific evidence of improvement in prognosis for lung and colorectal cancer patients in a population-based cohort in Japan. Our results suggest that recent advances in cancer treatment could have influenced cancer survival differently among lung, colorectal and gastric cancers.

Incidental receipt of cardiac medications and survival outcomes among patients with stage III non-small-cell lung cancer after definitive radiotherapy

BACKGROUND

Preclinical and epidemiologic studies suggest that receipt of some cardiac medications such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-blockers, or aspirin may have antiproliferative effects in several types of cancer. The aim of this study was to estimate survival outcomes in patients receiving incidental cardiac medications during treatment for lung cancer, and to compare outcomes with those patients not receiving these medications.

PATIENTS AND METHODS

We retrospectively reviewed 673 patients who had received definitive radiotherapy for stage III non-small-cell lung cancer (NSCLC). Cox proportional hazard models were used to assess associations between receipt of ACEIs, ARBs, β-blockers, or aspirin and locoregional progression-free survival (LRPFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS).

RESULTS

Multivariate analyses showed that ACEI receipt was associated with poorer LRPFS but had no effect on DMFS, DFS, or OS. Aspirin receipt was associated only with improved DMFS, and β-blocker receipt was associated with improved DMFS, DFS, and OS.

CONCLUSION

Incidental receipt of ACEIs was associated with a higher prevalence of local failure, whereas receipt of either β-blockers or aspirin had protective effects on survival outcomes in this large group of patients with lung cancer. This finding warrants further clinical and preclinical exploration, as it may have important implications for treating patients with lung cancer who are also receiving cardiac medications.

Management of elderly patients with NSCLC; updated expert's opinion paper: EORTC Elderly Task Force, Lung Cancer Group and International Society for Geriatric Oncology

Non-small-cell lung cancer (NSCLC) is a very common disease in the elderly population and its incidence in this particular population is expected to increase further, because of the ageing of the Western population. Despite this, limited data are available for the treatment of these patients and, therefore, the development of evidence-based treatment recommendations is challenging. In 2010, European Organization for Research and Treatment of Cancer (EORTC) took an initiative in collaboration with International Society of Geriatric Oncology (SIOG) and created an experts panel that provided an experts' opinion consensus paper for the management of elderly NSCLC patients. Since this publication, important new data are available and EORTC and SIOG recommended to update the 2010 recommendations. Besides recommendations for surgery, adjuvant chemotherapy and radiotherapy, treatment of locally advanced and metastatic disease, recommendations were expanded, to include data on patient preferences and geriatric assessment.

Novel treatment options in stage I non-small-cell lung cancer

In the last 5 years, the current management of stage I non-small-cell lung cancer has been challenged due to novel surgical approaches and advances in radiation technology. The outcome after a sublobar resection is promising, especially for tumors less than 2 cm. Other treatment opportunities are available for high risk patients with comorbidity and impaired pulmonary function. Stereotactic ablative body radiotherapy is a good alternative treatment to surgery, especially in elderly and comorbid patients. However, randomized evidence comparing sublobar resection and stereotactic radiotherapy is presently lacking. The most recent development in radiotherapy is hadron therapy with a presumed reduced toxicity because of its peculiar physical and biological effects. Promising thermal and microwave ablative techniques are in development and have specific niche indications.

Changes in non-surgical management of stage III non-small cell lung cancer at a single institution between 2003 and 2010

BACKGROUND

Concurrent chemo-radiotherapy (CON-CRT) is recommended for selected patients with stage III non-small cell lung cancer (NSCLC), but utilization varies. We assessed the response to national guidelines introduced in 2004 and the impact on outcomes.

MATERIAL AND METHODS

Retrospective study of stage III NSCLC patients treated with radical intent non-surgical treatment during 2003-2010 in a university medical center characterized by multidisciplinary assessment, routine use of four-dimensional computed tomography for radiotherapy planning, and rapid implementation of radiotherapy advances.

RESULTS

Between 2003 and 2010, 319/435 (73%) patients with stage III NSCLC received (chemo) radiotherapy. The number receiving CON-CRT in successive two-year periods increased from 13/48 (27%) - 40/80 (50%) - 63/90 (70%), to 74/101 (73%). Median overall survival (OS) from start of radiotherapy was 18.6 months for CON-CRT (190/319) and 17.4 months for sequential (SEQ), typically hypofractionated, CRT (90/319) (p = 0.78). Eleven months OS with radiotherapy alone (39/319) was significantly shorter (p = 0.006). OS did not differ between the four periods (p = 0.87). CON-CRT was not over-represented in the 16% of patients dying within five months of starting radiotherapy.

CONCLUSIONS

Between 2003 and 2010, CON-CRT for stage III NSCLC was rapidly and safely increased. However, OS did not increase and, as practiced, did not differ between CON- or SEQ-CRT.

[Impact of induction therapies on pathology and outcome after surgical resection of non-small lung cancer: a 30-year experience of 859 patients]

The management of localized non-small cell lung cancer (NSCLC) has been modified over the last decades, with induction therapies being increasingly recommended as a prerequisite to surgical resection. However, the relative impact of chemo- and chemoradiotherapy on tumours' pathology and patients' survival is still discussed.

METHODS

We set a retrospective study including every patient who underwent surgical resection for NSCLC in 2 French centres from 1980 to 2009. We then compared the tumours' pathology and patients' survival according to the use of induction chemotherapy (group 1) or induction chemoradiotherapy (group 2).

RESULTS

There were 733 patients in group 1 and 126 patients in group 2. In group 1, 669 patients (91%) had platinum-based chemotherapy, for 2 to 3 cycles in 564 cases (77%). In group 2, chemoradiotheray was concomitant in 68 patients (54%), and sequential in 58 patients (46%). As compared with group 1, group 2 was characterized by younger age (mean 59.8±9.5 vs 56.4±9.6, respectively, P<.001), a higher rate of tumours deemed unresectable before induction treatment (25% vs 44%, P<.001), and a higher proportion of T4 (25% vs 44%, P<.001) or N2 diseases (56% vs 69%, P=.005). The type of resection, postoperative complications, and postoperative mortality were not significantly different between groups. On final pathologic report, as compared with group 1, there were more N0 and N1 disease in group 2 (N0: 43% vs 58%, P=.002; N1: 22% vs 10%, P=.002) while the rate of N2 disease was comparable (34% vs 32%, P=ns). The median, 5-, and 10-year survivals were 28 months, 35%, and 21% for group 1, and 29 months, 36%, and 23% for group 2, respectively (P=ns).

CONCLUSION

As compared with induction chemotherapy, induction chemoradiotherapy was performed in more advanced NSCLC, and resulted in better downstaging, similar postoperative course, and comparable long-term outcome after surgical resection.

Estimates of cancer burden in Liguria

Aims and background

The regional health care system of Liguria caters for a resident population which is among the oldest in Europe. One population-based cancer registry is present in the region, providing incidence and survival data for the Genoa province (covering 55% of the regional population). This paper will estimate the incidence, prevalence and mortality in the Liguria region for cancers of the lung, breast, prostate, colon-rectum, stomach and uterine cervix and melanoma of the skin in 1970—2015.

Methods

The estimated figures were obtained by applying the MIAMOD method. Starting from mortality and survival data, incidence and prevalence were derived using a statistical back-calculation approach. Survival was modeled on the basis of published data from the Italian cancer registries. The MIAMOD method was applied also to estimate the colorectal cancer incidence, mortality and prevalence rates in the Ligurian provinces in the period 1988—2015.

Results

In 2012 about 1,500 new cases of breast cancer were expected in Ligurian women. The estimates for the other cancer sites were considerably lower, ranging from 839 (colon-rectum) to 54 (cervix). In men about 1,400 new cases were estimated for prostate cancer, while the incidence for the other sites ranged from 1,118 (colon-rectum) to 208 (skin melanoma). The breast cancer prevalence rate was more than 10 times the incidence rate in women, and the lung cancer prevalence rate was more than double the incidence rate in both sexes. Mortality rates were highest for lung cancer in men and breast cancer in women; the lowest rates were estimated for melanoma and cancer of the uterine cervix.

Conclusion

In Liguria a large portion of the health expenditure has been devoted to diagnostic and therapeutic resources. This may have contributed to the reduction of mortality rates and to the improvement of cancer survival. This phenomenon, added to population aging, will inflate the cancer prevalence. One of the major challenges for the Liguria region is to face the increasing demand for oncology services.

Developments in early-stage NSCLC: advances in radiotherapy

An increase in the number of predominantly elderly patients with early-stage non-small-cell lung cancer is anticipated in many Western populations. Patients often have major co-morbidities and are at increased risk for surgical morbidity and mortality. In the past decade, the use of stereotactic ablative radiotherapy (SABR) has achieved excellent results, with only mild toxicity in such vulnerable patient groups, leading to SABR becoming accepted as a standard of care for unfit patients in several countries. The planning and delivery of SABR has rapidly improved in recent years, particularly with the use of 'on-board' imaging at treatment units, and shortened treatment delivery times. Increasingly, more central tumors are being treated using lower doses per fraction (so-called risk-adapted schemes). It is also becoming clear that long-term follow-up should take place at specialist centers in order to distinguish the evolving fibrosis that is frequently observed from the relatively infrequent local recurrences. Given the high local control rates and limited toxicity, increasing attention is being paid to the use of SABR in the subgroup of so-called borderline operable patients, and clinical trials comparing surgery and SABR in these patients are ongoing.

Unexpected extensions of non-small-cell lung cancer diagnosed during surgery: revisiting exploratory thoracotomies and incomplete resections

OBJECTIVES

Only patients with a complete resection of non-small-cell lung cancer (NSCLC) may expect long-term survival. Despite the recent progress in imaging and induction therapy, a thoracotomy may remain exploratory or with incomplete resection (R2). Our purpose was to revisit these situations.

METHODS

A total of 5305 patients who underwent surgery for NSCLC between 1980 and 2009 were reviewed. We compared the epidemiology, pathology, causes and prognosis characteristics of exploratory thoracotomy (ET) and R2 resections.

RESULTS

ET and R2 resections were observed in 223 (4%) and 197 (4%) patients, respectively. The frequency of ET decreased with time, while the frequency of R2 resection remained almost stable. The indications for ET and R2 resections were not significantly different. In comparison with ET, R2 resections were characterized by a significantly higher frequency of induction therapy (22 vs 17%, P < 10(-3)), adenocarcinomas (49 vs 15%, P < 10(-6)), T1-T2 (53 vs 29%, P < 10(-6)) and N0-N1 extension (67 vs 42%, P = 10(-6)). R2 resections were also characterized by a higher rate of postoperative complications (19.1 vs 9.9%, P = 0.014), with no significant difference in postoperative mortality (6.9 vs 4.9%, P = non significant). R2 resections resulted in a higher 5-year survival compared with ET (11.1 vs 1.2%, P = 10(-3)). There was no long-term survivor after ET, except during the last decade.

CONCLUSIONS

ET and R2 remain unavoidable. In comparison with ET, R2 resection is associated with a higher rate of postoperative complications, but a higher long-term survival.

Radical treatment of non-small cell lung cancer during the last 5 years

The management of non-small cell lung cancer (NSCLC) has continued to improve over the last 5 years due to advances in surgery, radiological staging, combined modality therapies and advances in radiation technology. We have an updated staging classification (7th Edition American Joint Committee on Cancer staging) and now in 2011, a new histology classification introducing the concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma. This classification has profound surgical implications as the role of limited resection is reconsidered for early stage lesions. Surgery is curative in early stage disease. The role of surgery in locally advanced NSCLC remains controversial. The principal aim is a complete resection as this will determine long-term prognosis. Intraoperative staging of lung cancer is extremely important to determine the extent of resection according to the tumour and nodal status. Systematic nodal dissection is generally advocated to obtain accurate intraoperative staging and to help decide on adjuvant therapy. Radiotherapy currently plays a major role in the management of lung cancer as most patients are not surgical candidates due to disease stage, fitness and co-morbidities. In the last 5 years we have seen continuing optimisation of chemo-radiotherapy combinations and technological advances including the development of image guided radiotherapy (IGRT), stereotactic ablative body radiotherapy (SABR) and intensity modulated radiotherapy (IMRT). Quality of life evaluation is becoming increasingly important and should be considered when deciding on a specific treatment, especially in a multimodality setting.