Variability in the treatment of elderly patients with stage IIIA (N2) non-small-cell lung cancer

Characteristics of the clinical pharmacist interventions at the National Center for Cancer Care and Research Hospital in Qatar

INTRODUCTION

Drug-related problems (DRPs) affect the health outcomes of patients during hospitalization. We sought to analyze the clinical pharmacist-documented interventions among hospitalized patients in the cancer hospital in Qatar.

METHODS

A retrospective analysis of electronically reported clinical pharmacist interventions of patients admitted to cancer units at Hamad Medical Corporation, Qatar was conducted. Extracted data was based on an overall 3-month follow-up period; March 1-31, 2018, July 15-August 15, 2018 and January 1-31, 2019. Categorical variables were expressed as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation (SD).

RESULTS

A total of 281 cancer patients with 1354 interventions were included. The average age of the study participants was 47 years (SD ± 17.36). The majority of the study population was females (n = 154, 54.80%). The prevailing pharmacist intervention was the addition of a drug therapy (n = 305, 22.53%), followed by medication discontinuation (n = 288, 21.27%) and the addition of a prophylactic agent (n = 174, 12.85%). This pattern was similar across all subgroups (i.e., gender, age, ward), except for the urgent care unit, where an increase in medication dose was the third highest frequently identified intervention (n = 3, 0.22%). The two medication groups associated with the majority of interventions were the anti-infective and fluid/electrolyte agents. Most of the interventions documented were in the oncology ward (73.19%), while the urgent care unit had the least documented interventions (1.62%).

CONCLUSIONS

Our analysis showed that clinical pharmacists can effectively identify and prevent DRPs among hospitalized cancer patients.

The Impact of Immunotherapy Use in Stage IIIA (T1-2N2) NSCLC: A Nationwide Analysis

Introduction

Multiple clinical trials have revealed the benefit of immunotherapy (IO) for NSCLC, including unresectable stage III disease. Our aim was to investigate the impact of IO use on treatment and outcomes of potentially resectable stage IIIA NSCLC in a broader nationwide patient cohort.

Methods

We queried the National Cancer Database (2004-2019) for patients with stage IIIA (T1-2N2) NSCLC. Treatment and survival were evaluated with descriptive statistics, logistic regression, Kaplan-Meier analysis, and Cox proportional hazards modeling.

Results

Overall, 5.5% (3777 of 68,335) of patients received IO. IO use was uncommon until 2017, but by 2019, it was given to 40.1% (1544 of 2308) of stage IIIA patients. The increased use of IO after 2017 was associated with increased definitive chemoradiation treatment (54.2% [6800 of 12,535] from years 2017 to 2019 versus 46.9% [26,251 of 55,914] from 2004 to 2016, p < 0.001) and less use of surgery (18.1% [2266 of 12,535] from years 2017 to 2019 versus 22.0% [12,300 of 55,914] from 2004 to 2016, p < 0.001). IO treatment was associated with significantly better 5-year survival in the entire cohort (36.9% versus 23.4%, p < 0.001) and the subsets of patients treated with chemoradiation (37.2% versus 22.7%, p < 0.001) and surgery (48.6% versus 44.3%, p < 0.001). Pneumonectomy use decreased with increased IO treatment (5.1% of surgical patients [116 of 2266] from years 2017 to 2019 versus 9.2% [1127 of 12,300] from 2004 to 2016, p < 0.001).

Conclusions

Increased use of IO was associated with a change in treatment patterns and improved survival for patients with stage IIIA(N2) NSCLC.

Treatment and mortality risk of older adults with non-small cell cancer in Taiwan: A population-based cohort study

BACKGROUND

Older patients tend to have decreased physical functions and more comorbidities than younger patients. At present, the best management for very elderly patients with lung cancer is not known. In this study, we aimed to investigate treatment and mortality risk of older adults with non-small cell cancer (NSCLC) in Taiwan.

METHODS

This study analyzed data from the Taiwan Cancer Registry database. Patients aged ≥80 years with newly diagnosed NSCLC between 2010 and 2017 were included. Treatment options were categorized as curative, palliative, and no treatment. Patients were followed up until death or December 31, 2020. Univariable and multivariable Cox proportional hazards models were used to estimate mortality risk, and Kaplan-Meier survival curves were drawn.

RESULTS

A total of 11 941 patients, aged ≥80 years, with newly diagnosed NSCLC between 2010 and 2017 were identified from the Taiwan Cancer Registry and followed up until 2020. The mean age was 84.4 ± 3.7 years old, and 7468 (62.54%) were men. The Kaplan-Meier survival curves showed significant differences across the three treatment options (log-rank p < 0.001). Results from multivariate Cox regression demonstrated that patients on palliative treatment (adjusted HR: 0.52, 95% CI: 0.48-0.56, p < 0.001) and curative treatment (adjusted HR: 0.45, 95% CI: 0.42-0.48, p < 0.001) had a significantly lower mortality risk than those with no treatment. The subgroup analyses stratified by cancer stages also showed consistent findings.

CONCLUSION

Elderly patients with NSCLC had significantly decreased mortality risk when receiving curative or palliative treatment compared with those without treatment. In the future, further studies are warranted to investigate complications and quality of life of elderly patients with NSCLC during palliative or curative treatment.

Geriatric assessment and the variance of treatment recommendations in geriatric patients with gastrointestinal cancer-a study in AIO oncologists

BACKGROUND

Geriatric assessment (GA) is recommended to detect vulnerabilities for elderly cancer patients. To assess whether results of GA actually influence the treatment recommendations, we conducted a case vignette-based study in medical oncologists.

MATERIALS AND METHODS

Seventy oncologists gave their medical treatment recommendations for a maximum of 4 out of 10 gastrointestinal cancer patients in three steps: (i) based on tumor findings alone to simulate the guideline recommendation for a '50-year-old standard patient without comorbidities'; (ii) for the same situation in elderly patients (median age 77.5 years) according to the comorbidities, laboratory values and a short video simulating the clinical consultation; and (iii) after the results of a full GA including interpretation aid [Barthel Index, Cumulative Illness Rating Scale (CIRS), Geriatric 8 (G8), Geriatric Depression Scale (GDS), Mini Mental Status Examination (MMSE), Mini-Nutritional Assessment (MNA), Timed Get Up and Go (TGUG), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30), stair climb test].

RESULTS

Data on 164 treatment recommendations were analyzed. The recommendations had a significantly higher variance for elderly patients than for 'standard' patients (944 versus 602, P < 0.0001) indicating a lower agreement between oncologists. Knowledge on GA had marginal influence on the treatment recommendation or its variance (944 versus 940, P = 0.92). There was no statistically significant influence of the working place or the years of experience in oncology on the variance of recommendations. The geriatric tools were rated approximately two times higher as being 'meaningful' (53%) and 'useful for the presented cases' (49%) than they were 'used in clinical practice' (19%). The most commonly used geriatric tool in patient care was the MNA (30%).

CONCLUSIONS

The higher variance of treatment recommendations indicates that it is less likely for elderly patients to get the optimal recommendation. Although the proposed therapeutic regimen varied higher in elderly patients and the oncologists rated the GA results as 'useful', the GA results did not influence the individual recommendations or its variance. Continuing education on GA and research on implementation into clinical practice are needed.

Feasibility and oncological outcomes of video-assisted thoracic surgery versus thoracotomy for pathologic N2 disease in non-small cell lung cancer: A comprehensive systematic review and meta-analysis

This meta-analysis aimed to evaluate the feasibility and oncological outcomes between video-assisted thoracic surgery (VATS) and thoracotomy for non-small cell lung cancer (NSCLC) patients with pathologic N2 (pN2) disease. Data for analysis included short-term outcomes and long-term outcomes. We calculated the weighted mean differences (WMDs) for continuous data and the results of overall survival (OS) and disease free survival (DFS) were pooled using the hazard ratios (HRs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the Q-test and I² -test. Sensitivity analysis was performed to further examine the stability of pooled HRs and WMDs. In the pooled analyses of 10 eligible studies, results showed that VATS for NSCLC patients with pN2 disease yielded significantly less blood loss (WMD = -61.43; 95% confidence intervals [CI], [-87.69, -35.18]; p < 0.001), less post-operation hospital stay (WMD, -1.62; 95% CI, [-2.96, -0.28]; p = 0.02), and comparable operation time (WMD,  -8.32; 95% CI, [-23.88, 7.23]; p = 0.29), post-operation complication rate (risk ratio [RR], 0.95; 95% CI, [0.78, 1.15]; p = 0.59), chest tube duration to thoracotomy (WMD, -0.64; 95% CI, [-1.45, 0.17]; p = 0.12), extent of lymph node dissection (WMD, -1.46; 95% CI, [-3.87, 0.95]; p = 0.23) and 1-year OS (HR, 1.30; 95% CI, [0.96, 1.76]; p = 0.09) than thoracotomy. However, VATS may improve 3-year OS (HR, 1.26; 95% CI, [1.12, 1.42]; p = 0.0002) and yield comparable 1-year DFS (HR, 1.14; 95% CI, [0.89, 1.46]; p = 0.32) and 3-year DFS (HR, 1.03; 95% CI, [0.88, 1.22]; p = 0.70) for NSCLC patients with pN2 disease than thoracotomy. VATS could yield less surgical trauma and improve post-operative recovery than thoracotomy. Moreover, VATS may improve the oncological outcomes of those patients.

Diagnostic work-up and systemic treatment for advanced non-squamous non-small-cell lung cancer in four Southeast Asian countries

BACKGROUND

Lung cancer is the second most common cancer and leading cause of cancer mortality worldwide. Recent advances in molecular testing and targeted therapy have improved survival among patients with metastatic non-small-cell lung cancer (NSCLC). We sought to quantify and describe molecular testing among metastatic non-squamous NSCLC cases in selected Southeast Asian countries and describe first-line therapy chosen.

PATIENTS AND METHODS

A retrospective study was conducted based on incident lung cancer cases diagnosed between 2017 and 2019 in Lampang (Thailand), Penang (Malaysia), Singapore and Yogyakarta (Indonesia). Cases (n = 3413) were defined using the International Classification of Diseases for Oncology third edition. In Singapore, a clinical series obtained from the National Cancer Centre was used to identify patients, while corresponding population-based cancer registries were used elsewhere. Tumor and clinical information were abstracted by chart review according to a predefined study protocol. Molecular testing of epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK) gene rearrangement, ROS1 gene rearrangement and BRAF V600 mutation was recorded.

RESULTS

Among 2962 cases with a specified pathological diagnosis (86.8%), most patients had non-squamous NSCLC (75.8%). For cases with staging information (92.1%), the majority presented with metastatic disease (71.3%). Overall, molecular testing rates in the 1528 patients with stage IV non-squamous NSCLC were 67.0% for EGFR, 42.3% for ALK, 39.1% for ROS1, 7.8% for BRAF and 36.1% for PD-L1. Among these patients, first-line systemic treatment included chemotherapy (25.9%), targeted therapy (35.6%) and immunotherapy (5.9%), with 31% of patients having no record of antitumor treatment. Molecular testing and the proportion of patients receiving treatment were highly heterogenous between the regions.

CONCLUSIONS

This first analysis of data from a clinically annotated registry for lung cancer from four settings in Southeast Asia has demonstrated the feasibility of integrating clinical data within population-based cancer registries. Our study results identify areas where further development could improve patient access to optimal treatment.

Select octogenarians with stage IIIa non–small cell lung cancer can benefit from trimodality therapy

Objectives

Currently, more than 36% of patients diagnosed with lung cancer are 75 years of age or older. Management of stage IIIA cancer is variable, especially for octogenarians who might not be offered surgery because of questionable benefit. In this study we investigated the outcomes of definitive chemoradiotherapy (CR) and trimodality therapy (TM) management (CR and surgery) for clinical stage IIIA non–small cell lung cancer (NSCLC) in patients 80 years of age or older.

Methods

The National Cancer Data Base was queried for stage IIIA NSCLC in patients 80 years of age or older between 2004 and 2015. Patients were divided according to treatment type: definitive CR and TM. Patient demographic characteristics, facility type, Charlson–Deyo score, final tumor pathology, and survival data were extracted. Univariate analysis was performed, followed by 3:1 propensity matching to analyze overall survival differences. Unadjusted and adjusted Kaplan–Meier survival analyses were performed.

Results

From the database, 6048 CR and 190 TM octogenarians were identified. Patients in the TM group were younger (82 years old [TM] vs 83 years old [CR]; P < .0001), more likely to be treated at an academic/research institution (36% [TM] vs 26% [CR]; P = .003), had greater proportion of adenocarcinoma (52% [TM] vs 34% [CR]; P < .001), and a smaller tumor size (38 mm [TM] vs 33 mm [CR]; P = .025). After 3:1 matching, the 5-year overall survival for the TM group was 29% (95% CI, 22%-38%) versus 15% (95% CI, 11%-20%) for the CR group.

Conclusions

Selected elderly patients with stage IIIa NSCLC can benefit from an aggressive TM approach.

Cancer and aging: A call to action

Background

The intersection of cancer and aging is an emerging public health challenge in developed countries because of the aging and expansion of the population.

Aims

We convened a panel of experts to share their insights on this topic at the inaugural University of Florida Health Cancer Center's (UFHCC's) Cancer and Aging Symposium, which was held virtually in February 2022.

Methods

We featured presentations from four leading scientists, whose research spans multiple disciplines including basic science, translational research, geriatric oncology, and population science.

Results

Each speaker offered their unique perspective and insight on the intersection between cancer and aging and discussed their current and ongoing research in this field. In addition to this panel of experts, scientists from the National Institutes of Health and the National Cancer Institute, as well as a UFHCC-affiliated citizen scientist, shared their perspectives on strategies to move the field forward. Some of the key open questions and opportunities for future research offered by these presenters in aging and cancer include but are not limited to infusing health disparities research into the field of cancer and aging, assessing the value of geriatric assessment in identifying early vulnerabilities that may affect response to emerging cancer therapies in older patients, and assessing biological age and other biomarkers (e.g., clonal hematopoiesis) in relation to clinical endpoints and the development of primary, secondary, and tertiary cancer prevention interventions.

Conclusion

Research is needed to accelerate knowledge regarding the dynamic interplay of cancer and aging and optimize care in diverse older adults to achieve equity in cancer outcomes.

Surgical under-treatment of older adult patients with cancer: A systematic review and meta-analysis

BACKGROUND

Older patients with cancer often have lower surgery rates and survival than younger patients, but this may reflect surgical contraindications of advanced disease, comorbidities, and frailty - and not necessarily under-treatment.

OBJECTIVES

This review aims to describe variations in surgery rates and observed or net survival among younger (<75) and older (≥75) patients with breast, lung and colorectal cancer, while taking account of pre-existing health factors, in order to understand how under-treatment is defined and estimated in the literature.

METHOD

MEDLINE, EMBASE, Web of Science and PubMed databases were searched for studies reporting surgery rates and observed or net survival among younger and older patients with breast, lung, and colorectal cancer. Study quality was assessed using the Newcastle Ottawa Scale, and random effects meta-analyses were used to combine study results. The I-squared statistic and subgroup analyses were used to assess heterogeneity.

RESULTS

Thirty relatively high-quality studies of patients with breast (230,200; 71.9%), lung (77,573; 24.2%), and colorectal (12,407; 3.9%) cancers were identified. Compared to younger patients, older patients were less likely to receive surgical treatment for 1) breast cancer after adjusting for comorbidity, performance status (PS), functional status and patient choice, 2) lung cancer after accounting for stage, comorbidity, PS, and 3) colorectal cancer after adjusting for stage, comorbidity, and gender. The pooled unadjusted analyses showed lower surgery receipt in older patients with breast (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.78), lung (OR 0.54, 95% CI 0.39-0.75), and colorectal (OR 0.59, 95% CI 0.51-0.68) cancer. In separate analyses, older patients with breast, lung and colorectal cancer had lower observed and net survival, compared to younger patients.

CONCLUSIONS

Lower surgery rates in older patients may contribute to their poorer survival compared to younger patients. Future research quantifying under-treatment should include necessary clinical factors, patient choice, patient's quality of life and a statistically-robust approach, which will demonstrate how much of the survival deficit in older patients is due to their receiving lower surgery rates.

Older adult participation in cancer clinical trials: A systematic review of barriers and interventions

Cancer is a disease of aging and, as the world's population ages, the number of older persons with cancer is increasing and will make up a growing share of the oncology population in virtually every country. Despite this, older patients remain vastly underrepresented in research that sets the standards for cancer treatments. Consequently, most of what we know about cancer therapeutics is based on clinical trials conducted in younger, healthier patients, and effective strategies to improve clinical trial participation of older adults with cancer remain sparse. For this systematic review, the authors evaluated published studies regarding barriers to participation and interventions to improve participation of older adults in cancer trials. The quality of the available evidence was low and, despite a literature describing multifaceted barriers, only one intervention study aimed to increase enrollment of older adults in trials. The findings starkly amplify the paucity of evidence-based, effective strategies to improve participation of this underrepresented population in cancer trials. Within these limitations, the authors provide their opinion on how the current cancer research infrastructure must be modified to accommodate the needs of older patients. Several underused solutions are offered to expand clinical trials to include older adults with cancer. However, as currently constructed, these recommendations alone will not solve the evidence gap in geriatric oncology, and efforts are needed to meet older and frail adults where they are by expanding clinical trials designed specifically for this population and leveraging real-world data.

Developing an electronic geriatric assessment to improve care of older adults with cancer receiving radiotherapy

Older adults make up a substantial proportion of patients diagnosed with cancer. Gaps in evidence of care for older adults with cancer leads to treatment heterogeneity and poor outcomes. Medical and Surgical Oncology clinics throughout the world are increasingly using Geriatric Assessment (GA) based approaches to treatment that are beginning to improve care through treatment decision-making communication, health-related quality of life outcomes, and reducing chemotherapy toxicities. Yet, GA based approaches are not often used in radiation oncology clinics. This manuscript aims to describe the ongoing development of an electronic patient-reported GA with real-time data interpretation and recommendation delivery to help increase the use of a personalized GA based approach to the care of older adults within radiation oncology clinics. Future studies demonstrating the utility and benefit of GA based approaches to help older adults undergoing radiotherapy for their cancers are still sorely needed.

Practical implications to contemplate when considering radical therapy for stage III non-small-cell lung cancer

The type of patients with stage III non-small-cell lung cancer (NSCLC) selected for concurrent chemoradiotherapy (cCRT) varies between and within countries, with higher-volume centres treating patients with more co-morbidities and higher-stage disease. However, in spite of these disease characteristics, these patients have improved overall survival, suggesting that there are additional approaches that should be optimised and potentially standardised. This paper aims to review the current knowledge and best practices surrounding treatment for patients eligible for cCRT. Initially, this includes timely acquisition of the full diagnostic workup for the multidisciplinary team to comprehensively assess a patient for treatment, as well as imaging scans, patient history, lung function and genetic tests. Such information can provide prognostic information on how a patient will tolerate their cCRT regimen, and to perhaps limit the use of additional supportive care, such as steroids, which could impact on further treatments, such as immunotherapy. Furthermore, knowledge of the safety profile of individual double-platinum chemotherapy regimens and the technological advances in radiotherapy could aid in optimising patients for cCRT treatment, improving its efficacy whilst minimising its toxicities. Finally, providing patients with preparatory and ongoing support with input from dieticians, palliative care professionals, respiratory and care-of-the-elderly physicians during treatment may also help in more effective treatment delivery, allowing patients to achieve the maximum potential from their treatments.

Video-assisted thoracoscopic surgery lobectomy might be a feasible alternative for surgically resectable pathological N2 non-small cell lung cancer patients

Background

The majority of previous studies of the clinical outcome of video‐assisted thoracoscopic surgery (VATS) versus open lobectomy for pathological N2 non‐small cell lung cancer (pN2 NSCLC) have been single‐center experiences with small patient numbers. The aim of this study was therefore to investigate these procedures but in a large cohort of Chinese patients with pathological N2 NSCLC in real‐world conditions.

Methods

Patients who underwent lobectomy for pN2 NSCLC by either VATS or thoracotomy were retrospectively reviewed from 10 tertiary hospitals between January 2014 and September 2017. Perioperative outcomes and overall survival of the patients were analyzed. Cox regression analysis was performed to identify potential prognostic factors. Propensity‐score analysis was performed to reduce cofounding biases and compare the clinical outcomes between both groups.

Results

Among 2144 pN2 NSCLC, 1244 patients were managed by VATS and 900 by open procedure. A total of 305 (24.5%) and 344 patients died during VATS and the thoracotomy group during a median follow‐up of 16.7 and 15.6 months, respectively. VATS lobectomy patients had better overall survival when compared with those undergoing the open procedure (P < 0.0001). Multivariate COX regression analysis showed VATS lobectomy independently favored overall survival (HR = 0.75, 95% CI: 0.621–0.896, P = 0.0017). Better perioperative outcomes, including less blood loss, shorter drainage time and hospital stay, were also observed in patients undergoing VATS lobectomy (P < 0.05). After propensity‐score matching, 169 patients in each group were analyzed, and no survival difference were found between the two groups. Less blood loss was observed in the VATS group, but there was a longer operation time.

Conclusions

VATS lobectomy might be a feasible alternative to conventional open surgery for resectable pN2 NSCLC.

Key points

Significant findings of the study: VATS lobectomy has comparative OS in pN2 NSCLC versus open procedure in resectable patients.

What this study adds: VATS lobectomy might be feasible for pN2 NSCLC.

Association Between Treatment Facility Volume, Therapy Types, and Overall Survival in Patients With Stage IIIA Non-Small Cell Lung Cancer

BACKGROUND

There is significant heterogeneity in the treatment of stage IIIA non-small cell lung cancer (NSCLC). This study evaluated the therapeutic and survival disparities in patients with stage IIIA NSCLC based on the facility volume using the National Cancer Database.

METHODS

Patients with stage IIIA NSCLC diagnosed from 2004 through 2015 were included. Facilities were classified by tertiles based on mean patients treated per year, with low-volume facilities treating ≤8 patients, intermediate-volume treating 9 to 14 patients, and high-volume treating ≥15 patients. Cox multivariate analysis was used to determine the volume-outcome relationship.

RESULTS

Analysis included 83,673 patients treated at 1,319 facilities. Compared with patients treated at low-volume facilities, those treated at high-volume centers were more likely to be treated with surgical (25% vs 18%) and trimodality (12% vs 9%) therapies. In multivariate analysis, facility volume was independently associated with all-cause mortality (P<.0001). Median overall survival by facility volume was 15, 16, and 19 months for low-, intermediate-, and high-volume facilities, respectively (P<.001). Compared with patients treated at high-volume facilities, those treated at intermediate- and low-volume facilities had a significantly higher risk of death (hazard ratio, 1.09 [95% CI, 1.07-1.11] and 1.11 [95% CI, 1.09-1.13], respectively).

CONCLUSIONS

Patients treated for stage IIIA NSCLC at high-volume facilities were more likely to receive surgical and trimodality therapies and had a significant improvement in survival.

Community Oncologists' Decision-Making for Treatment of Older Patients With Cancer

Background: This study's objectives were to describe community oncologists' beliefs about and confidence with geriatric care and to determine whether geriatric-relevant information influences cancer treatment decisions. Methods: Community oncologists were recruited to participate in 2 multisite geriatric oncology trials. Participants shared their beliefs about and confidence in caring for older adults. They were also asked to make a first-line chemotherapy recommendation (combination vs single-agent vs no chemotherapy) for a hypothetical vignette of an older patient with advanced pancreatic cancer. Each oncologist received one randomly chosen vignette that varied on 3 variables: age (72/84 years), impaired function (yes/no), and cognitive impairment (yes/no). Other patient characteristics were held constant. Logistic regression models were used to identify associations between oncologist/vignette-patient characteristics and treatment decisions. Results: Oncologist response rate was 61% (n=305/498). Most oncologists agreed that "the care of older adults with cancer needs to be improved" (89%) and that "geriatrics training is essential" (72%). However, <25% were "very confident" in recognizing dementia or conducting a fall risk or functional assessment, and only 23% reported using the geriatric assessment in clinic. Each randomly varied patient characteristic was independently associated with the decision to treat: younger age (adjusted odds ratio [aOR], 5.01; 95% CI, 2.73-9.20), normal cognition (aOR, 5.42; 95% CI, 3.01-9.76), and being functionally intact (aOR, 3.85; 95% CI, 2.12-7.00). Accounting for all vignettes across all scenarios, 161 oncologists (52%) said they would offer chemotherapy. All variables were independently associated with prescribing single-agent over combination chemotherapy (older age: aOR, 3.22; 95% CI 1.43-7.25, impaired cognition: aOR, 3.13; 95% CI, 1.36-7.20, impaired function: aOR, 2.48; 95% CI, 1.12-5.72). Oncologists' characteristics were not associated with decisions about providing chemotherapy. Conclusion: Geriatric-relevant information, when available, strongly influences community oncologists' treatment decisions.

Real-world treatment patterns among patients with unresected stage III non-small-cell lung cancer

Aim: Little is known about recent treatment patterns among patients with unresected stage III NSCLC in the real world. This retrospective study used medical records from USA community oncology practices to address this knowledge gap. Materials & methods: Eligible patients were stage III NSCLC adults diagnosed between 1 January 2011 and 1 March 2016 without surgical resection. Treatment patterns were assessed across three progression intervals, from stage III diagnosis through third progression. Results: The most common regimen in interval 1 was platinum doublet chemotherapy + radiation therapy, in interval 2 was chemotherapy only, and in interval 3 was non-platinum chemotherapy monotherapy. Conclusion: Most patients were treated following national guidelines, but important unmet needs remain.

"Age matters"-German claims data indicate disparities in lung cancer care between elderly and young patients

Background

Although lung cancer is most commonly diagnosed in elderly patients, evidence about tumor-directed therapy in elderly patients is sparse, and it is unclear to what extent this affects treatment and care. Our study aimed to discover potential disparities in care between elderly patients and those under 65 years of age.

Methods

We studied claims from 13 283 German patients diagnosed with lung cancer in 2009 who survived for at least 90 days after diagnosis. We classified patients as “non-elderly” (≤ 65), “young-old” (65–74), “middle-old” (75–84), and “old-old” (≥ 85). We compared receipt of tumor-directed therapy (6 months after diagnosis), palliative care, opioids, antidepressants, and pathologic diagnosis confirmation via logistic regression. We used generalized linear regression (gamma distribution) to compare group-specific costs of care for 3 months after diagnosis. We adjusted all models by age, nursing home residency, nursing care need, comorbidity burden, and area of residence (urban, rural). The age group “non-elderly” served as reference group.

Results

Compared with the reference group “non-elderly”, the likelihood of receiving any tumor-directed treatment was significantly lower in all age groups with a decreasing gradient with advancing age. Elderly lung cancer patients received significantly fewer resections and radiotherapy than non-elderly patients. In particular, treatment with antineoplastic therapy declined with increasing age (“young-old” (OR = 0.76, CI = [0.70,0.83]), “middle-old” (OR = 0.45, CI = [0.36,0.50]), and “old-old” (OR = 0.13, CI = [0.10,0.17])). Patients in all age groups were less likely to receive structured palliative care than “non-elderly” (“young-old” (OR = 0.84, CI = [0.76,0.92]), “middle-old” (OR = 0.71, CI = [0.63,0.79]), and “old-old” (OR = 0.57, CI = [0.44,0.73])). Moreover, increased age was significantly associated with reduced quotas for outpatient treatment with opioids and antidepressants. Costs of care decreased significantly with increasing age.

Conclusion

This study suggests the existence of age-dependent care disparities in lung cancer patients, where elderly patients are at risk of potential undertreatment. To support equal access to care, adjustments to public health policies seem to be urgently required.

Optimising Clinical Trial Design in Older Cancer Patients

Cancer is predominantly a disease of older patients, with over half of those aged over 65 years of age being diagnosed with cancer at some stage. Despite comprising a significant proportion of the patients that we see in clinical practice, there is a lack of representation of older patients in cancer clinical trials. This is mainly due to restrictive trial inclusion criteria that prevent older patients from participating. Also, trial endpoints, such as overall survival, may not represent the most important and most meaningful endpoints for older patients. The latter may place more significance on quality of life and other outcomes such as functional independence. Baseline assessment using Comprehensive Geriatric Assessment, may provide a better framework for quantifying patient outcomes for varying degrees of fitness or frailty. This short communication makes the case for more age appropriate endpoints, such as quality of life, toxicity and functional independence, and that novel trial designs are necessary to inform evidence-based care of older cancer patients.

New horizons in systemic anti-cancer therapy in older people

Cancer is a disease associated with ageing. Increased life expectancy means that cancer in older adults is becoming an increasingly common problem. There are unique issues to consider when making decisions about cancer treatment in older populations. Unfortunately, however, this group is still under-represented in clinical trials for new cancer therapies meaning there are less evidence-based data to guide management. This article aims to look at how we can optimise the cancer treatment for older patients with a focus on systemic anti-cancer therapy and addressing particular issues around patient selection, improving treatment tolerance and use of newer agents with different toxicity profiles.

Feasibility of stereotactic body radiotherapy for locally-advanced non-small cell lung cancer

SBRT was feasible for approximately half of the locally-advanced NSCLC patients we assessed and for these patients has the potential to reduce a 30 fraction course to 12 fractions. Using SBRT in this setting requires compromises in techniques and further compromises may allow SBRT in a greater proportion of patients.

Improving the Evidence Base for Treating Older Adults With Cancer: American Society of Clinical Oncology Statement

The American Society of Clinical Oncology (ASCO) convened a subcommittee to develop recommendations on improving the evidence base for treating older adults with cancer in response to a critical need identified by the Institute of Medicine. Older adults experience the majority of cancer diagnoses and deaths and make up the majority of cancer survivors. Older adults are also the fastest growing segment of the US population. However, the evidence base for treating this population is sparse, because older adults are underrepresented in clinical trials, and trials designed specifically for older adults are rare. The result is that clinicians have less evidence on how to treat older adults, who represent the majority of patients with cancer. Clinicians and patients are forced to extrapolate from trials conducted in younger, healthier populations when developing treatment plans. This has created a dearth of knowledge regarding the risk of toxicity in the average older patient and about key end points of importance to older adults. ASCO makes five recommendations to improve evidence generation in this population: (1) Use clinical trials to improve the evidence base for treating older adults with cancer, (2) leverage research designs and infrastructure for generating evidence on older adults with cancer, (3) increase US Food and Drug Administration authority to incentivize and require research involving older adults with cancer, (4) increase clinicians' recruitment of older adults with cancer to clinical trials, and (5) use journal policies to improve researchers' reporting on the age distribution and health risk profiles of research participants.

Sublobar Resection for Clinical Stage IA Non-small-cell Lung Cancer in the United States

BACKGROUND

This study evaluated the use of lobectomy and sublobar resection for clinical stage IA non-small-cell lung cancer (NSCLC) in the National Cancer Data Base (NCDB).

METHODS

The NCDB from 2003 to 2011 was analyzed to determine factors associated with the use of a sublobar resection versus a lobectomy for the treatment of clinical stage IA NSCLC. Overall survival was assessed using the Kaplan-Meier method and Cox proportional hazard modeling.

RESULTS

Among 39,403 patients included for analysis, 29,736 (75.5%) received a lobectomy and 9667 (24.5%) received a sublobar resection: 84.7% wedge resection (n = 8192) and 15.3% segmental resection (n = 1475). Lymph node evaluation was not performed in 2788 (28.8%) of sublobar resection patients, and 7298 (75.5%) of sublobar resections were for tumors ≤ 2 cm. After multivariable logistic regression, older age, higher Charlson-Deyo comorbidity scores, smaller tumor size, and treatment at lower-volume institutions were associated with sublobar resection (all P < .001). Overall, lobectomy was associated with significantly improved 5-year survival compared to sublobar resection (66.2% vs. 51.2%; P < .001, adjusted hazard ratio 0.66; P < .001). However among sublobar resection patients, nodal sampling was associated with significantly better 5-year survival (58.2% vs. 46.4%; P < .001).

CONCLUSION

Despite adjustment for patient and tumor related characteristics, a sublobar resection is associated with significantly reduced long-term survival compared to a formal surgical lobectomy among patients with NSCLC, even for stage 1A tumors. For patients who cannot tolerate lobectomy and who are treated with sublobar resection, lymph node evaluation is essential to help guide further treatment.

2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines of treatment in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on locally advanced disease.

Adding radiation to induction chemotherapy does not improve survival of patients with operable clinical N2 non-small cell lung cancer

OBJECTIVE

Radiotherapy is commonly used in induction regimens for patients with non-small cell lung cancer with operable mediastinal nodal disease, although evidence has not shown a benefit over induction chemotherapy alone. We compared outcomes between induction chemotherapy and induction chemoradiation using the National Cancer Data Base.

METHODS

Induction radiation use and survival of patients who underwent lobectomy or pneumonectomy after induction chemotherapy for clinical T1-3N2M0 non-small cell lung cancer in the National Cancer Data Base from 2003 to 2006 were assessed using logistic regression, general linear regression, Kaplan-Meier, and Cox proportional hazard analysis.

RESULTS

Of 1362 patients who met study criteria, 834 (61%) underwent induction chemoradiation and 528 (39%) underwent induction chemotherapy. Lobectomy was performed in 82% of patients (n = 1111), and pneumonectomy was performed in 18% of patients (n = 251). Pneumonectomy was performed more often after induction chemoradiation than after induction chemotherapy (20% vs 16%, P = .04). Downstaging from N2 to N0/N1 was more common with induction chemoradiation compared with induction chemotherapy (58% vs 46%, P < .01), but 5-year survival of patients receiving induction chemoradiation and patients receiving induction chemotherapy was similar in unadjusted analysis (41% vs 41%, P = .41). In multivariable analysis, the addition of radiation to induction chemotherapy also was not associated with a survival benefit (hazard ratio, 1.03; 95% confidence interval, 0.89-1.18; P = .73).

CONCLUSIONS

Induction chemoradiation is used in the majority of patients with non-small cell lung cancer with N2 disease who undergo induction therapy before surgical resection, but it is not associated with improved survival compared with induction chemotherapy.

Causal effects of time-dependent treatments in older patients with non-small cell lung cancer

Background

Treatment selection for elderly patients with lung cancer must balance the benefits of curative/life-prolonging therapy and the risks of increased mortality due to comorbidities. Lung cancer trials generally exclude patients with comorbidities and current treatment guidelines do not specifically consider comorbidities, so treatment decisions are usually made on subjective individual-case basis.

Methods

Impacts of surgery, radiation, and chemotherapy mono-treatment as well as combined chemo/radiation on one-year overall survival (compared to no-treatment) are studied for stage-specific lung cancer in 65+ y.o. patients. Methods of causal inference such as propensity score with inverse probability weighting (IPW) for time-independent and marginal structural model (MSM) for time-dependent treatments are applied to SEER-Medicare data considering the presence of comorbid diseases.

Results

122,822 patients with stage I (26.8%), II (4.5%), IIIa (11.5%), IIIb (19.9%), and IV (37.4%) lung cancer were selected. Younger age, smaller tumor size, and fewer baseline comorbidities predict better survival. Impacts of radio- and chemotherapy increased and impact of surgery decreased with more advanced cancer stages. The effects of all therapies became weaker after adjustment for selection bias, however, the changes in the effects were minor likely due to the weak selection bias or incompleteness of the list of predictors that impacted treatment choice. MSM provides more realistic estimates of treatment effects than the IPW approach for time-independent treatment.

Conclusions

Causal inference methods provide substantive results on treatment choice and survival of older lung cancer patients with realistic expectations of potential benefits of specific treatments. Applications of these models to specific subsets of patients can aid in the development of practical guidelines that help optimize lung cancer treatment based on individual patient characteristics.

Cardiovascular comorbidities and survival of lung cancer patients: Medicare data based analysis

OBJECTIVES

To evaluate the role of cardiovascular disease (CVD) comorbidity in survival of patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

The impact of seven CVDs (at the time of NSCLC diagnosis and during subsequent follow-up) on overall survival was studied for NSCLC patients aged 65+ years using the Surveillance, Epidemiology, and End Results data linked to the U.S. Medicare data, cancer stage- and treatment-specific. Cox regression was applied to evaluate death hazard ratios of CVDs in univariable and multivariable analyses (controlling by age, TNM statuses, and 78 non-CVD comorbidities) and to investigate the effects of 128 different combinations of CVDs on patients' survival.

RESULTS

Overall, 95,167 patients with stage I (n=29,836, 31.4%), II (n=5133, 5.4%), IIIA (n=11,884, 12.5%), IIIB (n=18,020, 18.9%), and IV (n=30,294, 31.8%) NSCLC were selected. Most CVDs increased the risk of death for stages I-IIIB patients, but did not significantly impact survival of stage IV patients. The worse survival of patients was associated with comorbid heart failure, myocardial infarction, and cardiac arrhythmias that occurred during a period of follow-up: HRs up to 1.85 (p<0.001), 1.96 (p<0.05), and 1.67 (p<0.001), respectively, varying by stage and treatment. The presence of hyperlipidemia at baseline (HR down to 0.71, p<0.05) was associated with better prognosis. Having multiple co-existing CVDs significantly increased mortality for all treatments, especially for stages I and II patients treated with surgery (HRs up to 2.89, p<0.05) and stages I-IIIB patients treated with chemotherapy (HRs up to 2.59, p<0.001) and chemotherapy and radiotherapy (HRs up to 2.20, p<0.001).

CONCLUSION

CVDs impact the survival of NSCLC patients, particularly when multiple co-existing CVDs are present; the impacts vary by stage and treatment. This data should be considered in improving cancer treatment selection process for such potentially challenging patients as the elderly NSCLC patients with CVD comorbidities.

Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations

A majority of cancer diagnoses and deaths occur in patients age ≥ 65 years. With the aging of the US population, the number of older adults with cancer will grow. Although the coming wave of older patients with cancer was anticipated in the early 1980s, when the need for more research on the cancer-aging interface was recognized, many knowledge gaps remain when it comes to treating older and/or frailer patients with cancer. Relatively little is known about the best way to balance the risks and benefits of existing cancer therapies in older patients; however, these patients continue to be underrepresented in clinical trials. Furthermore, the available clinical trials often do not include end points pertinent to the older adult population, such as preservation of function, cognition, and independence. As part of its ongoing effort to advance research in the field of geriatric oncology, the Cancer and Aging Research Group held a conference in November 2012 in collaboration with the National Cancer Institute, the National Institute on Aging, and the Alliance for Clinical Trials in Oncology. The goal was to develop recommendations and establish research guidelines for the design and implementation of therapeutic clinical trials for older and/or frail adults. The conference sought to identify knowledge gaps in cancer clinical trials for older adults and propose clinical trial designs to fill these gaps. The ultimate goal of this conference series is to develop research that will lead to evidence-based care for older and/or frail adults with cancer.

Benefit of adjuvant chemotherapy after resection of stage II (T1-2N1M0) non-small cell lung cancer in elderly patients

BACKGROUND

We evaluated the use and efficacy of adjuvant chemotherapy after resection of T1-2N1M0 non-small cell lung cancer (NSCLC) in elderly patients.

METHODS

Factors associated with the use of adjuvant chemotherapy in patients older than 65 years of age who underwent surgical resection of T1-2N1M0 NSCLC without induction chemotherapy or radiation in the Surveillance, Epidemiology, and End Results-Medicare database from 1992 to 2006 were assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census tract characteristics. Overall survival (OS) was analyzed using the Kaplan-Meier approach and inverse probability weight-adjusted Cox proportional hazard models.

RESULTS

Overall, 2,781 patients who underwent surgical resection as the initial treatment for T1-2N1M0 NSCLC and survived at least 31 days after surgery were identified, with adjuvant chemotherapy given to 784 patients (28.2 %). Factors that predicted adjuvant chemotherapy use were younger age and higher T status. The 5-year OS was significantly better for patients who received adjuvant chemotherapy compared with patients not given adjuvant chemotherapy: 35.8 % (95 % confidence interval [CI] 31.9-39.6) vs. 28.0 % (95 % CI 25.9-30.0) (p = 0.008). In the inverse probability weight-adjusted Cox proportional hazard regression model, adjuvant chemotherapy use predicted significantly improved survival (hazard ratio 0.84; 95 % CI 0.76-0.92; p = 0.0002).

CONCLUSIONS

Adjuvant chemotherapy after resection of T1-2N1M0 NSCLC is associated with significantly improved survival in patients older than 65 years. These data can be used to provide elderly patients with realistic expectations of the potential benefits when considering adjuvant chemotherapy in this setting.