Incidence and survival of non-small cell lung cancer in Shanghai: a population-based cohort study

Time-dependent efficacy analysis of first-line immunotherapies for advanced non-small cell lung cancer

BACKGROUND

Many randomized controlled trials (RCTs) and network meta-analyses have demonstrated that the progression-free survival (PFS) and overall survival (OS) of advanced non-small cell lung cancer (NSCLC) patients can be improved through combination immunotherapy or monotherapies. However, time-dependent analysis of the treatment effect is currently lacking. Thus, we aimed to evaluate the efficacy of first-line immunotherapy, and establish a hazard ratio function to reflect the time-varying progression or mortality risk of patients with NSCLC.

METHODS

Seventeen clinical trials were selected based on search strategy. Baseline characteristics, including the age, sex, smoking status, geographical region, and Eastern Cooperative Oncology Group (ECOG) performance status of patients, were balanced, resulting in ten immunotherapies from nine appropriate clinical trials to conduct treatment effect comparison.

RESULTS

We found that nivolumab plus ipilimumab (nivo + ipi) improved the PFS and OS over time. The hazard ratio of nivo + ipi, relative to that of pembrolizumab, decreased from 1.11 to 0.36 for PFS, and from 0.93 to 0.49 for OS over a 10-year period. In terms of the response to immunotherapy in patients with different PD-L1 expression levels, patients with PD-L1 > = 50% experienced lower rates of progression and a reduced mortality risk over time. The hazard ratio of patients with PD-L1 > = 50% relative to all of the patients decreased from 0.73 to 0.69 for PFS, and from 0.78 to 0.67 for OS.

CONCLUSIONS

Based on the fact that time-dependent progression and mortality risk existed during the treatment duration, physicians should select a suitable treatment regimen for patients based on the hazard ratio.

First-line penpulimab combined with paclitaxel and carboplatin for metastatic squamous non-small-cell lung cancer in China (AK105-302): a multicentre, randomised, double-blind, placebo-controlled phase 3 clinical trial

BACKGROUND

Penpulimab is a novel programmed death (PD)-1 inhibitor. This study aimed to establish the efficacy and safety of first line penpulimab plus chemotherapy for advanced squamous non-small-cell lung cancer.

METHODS

This multicentre, randomised, double-blind, placebo-controlled, phase 3 clinical trial enrolled patients with locally advanced or metastatic squamous non-small-cell lung cancer from 74 hospitals in China. Eligible participants were aged 18-75 years, had histologically or cytologically confirmed locally advanced (stage IIIb or IIIc) or metastatic (stage IV) squamous non-small-cell lung cancer, were ineligible to complete surgical resection and concurrent or sequential chemoradiotherapy, had an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1, did not have previous systemic chemotherapy for locally advanced or metastatic non-small-cell lung cancer, and had one or more measurable lesions according to RECIST (version 1.1). Participants were randomly assigned (1:1) to receive intravenous penpulimab 200 mg or placebo (excipient of penpulimab injection), plus paclitaxel 175 mg/m2 and carboplatin AUC of 5 intravenously on day 1 every 3 weeks for four cycles, followed by penpulimab or placebo as maintenance therapy. Stratification was done according to the PD-L1 tumour proportion score (<1% vs 1-49% vs ≥50%) and sex (male vs female). The participants, investigators, and other research staff were masked to group assignment. The primary outcome was progression-free survival assessed by the masked Independent Radiology Review Committee in the intention-to-treat population and patients with a PD-L1 tumour proportion score of 1% or more (PD-L1-positive subgroup). The primary analysis was based on the intention-to-treat analysis set (ie, all randomly assigned participants) and the PD-L1-positive subgroup. The safety analysis included all participants who received at least one dose of study drug after enrolment. This trial was registered with ClinicalTrials.gov (NCT03866993).

FINDINGS

Between Dec 20, 2018, and Oct 10, 2020, 485 patients were screened, and 350 participants were randomly assigned (175 in the penpulimab group and 175 in the placebo group). Of 350 participants, 324 (93%) were male and 26 (7%) were female, and 347 (99%) were of Han ethnicity. In the final analysis (June 1, 2022; median follow-up, 24·7 months [IQR 0-41·4]), the penpulimab group showed an improved progression-free survival compared with the placebo group, both in the intention-to-treat population (median 7·6 months, 95% CI 6·8--9·6 vs 4·2 months, 95% CI 4·2-4·3; HR 0·43, 95% CI 0·33-0·56; p<0·0001) and in the PD-L1-positive subgroup (8·1 months, 5·7-9·7 vs 4·2 months, 4·1-4·3; HR 0·37, 0·27-0·52, p<0·0001). Grade 3 or worse treatment-emergent adverse events occurred in 120 (69%) 173 patients in the penpulimab group and 119 (68%) of 175 in the placebo group.

INTERPRETATION

Penpulimab plus chemotherapy significantly improved progression-free survival in patients with advanced squamous non-small-cell lung cancer compared with chemotherapy alone. The treatment was safe and tolerable. Penpulimab combined with paclitaxel and carboplatin is a new option for first-line treatment in patients with this advanced disease.

FUNDING

The National Natural Science Foundation of China, Shanghai Municipal Health Commission, Chia Tai Tianqing Pharmaceutical, Akeso.

Evaluating the impact of PD-1 inhibitor treatment on key health outcomes for cancer patients in China

BACKGROUND

There is a lack of studies examining the influence of programmed cell death protein 1 (PD-1) inhibitors on the health outcomes of cancer patients in China.

AIM

This study aimed to evaluate prospective health outcomes associated with introducing PD-1 inhibitor treatment in China over five years.

METHOD

We constructed a partitioned survival model to assess disparities in health outcomes over a 5-year time frame between two scenarios: one involving the availability of PD-1 inhibitor class with standard of care and the other involving standard of care alone. The impact on various health outcomes were assessed, including life years (LYs) gained, quality-adjusted life years (QALYs) gained, progression-free survival (PFS) years gained, the reduction in the number of grade 3-5 adverse events (AEs), and the improvement in objective remission rates (ORR). A sensitivity analysis was conducted to assess the robustness and reliability of the model.

RESULTS

From 2023 to 2027, the incorporation of PD-1 inhibitor class treatments was anticipated to yield substantial improvements in health outcomes, with an estimated increase of 1,336,332 LYs (+ 24.7%), 1,065,359 QALYs (+ 30.3%), and 1,177,564 PFS years (+ 57.4%) compared to standard of care alone. Simultaneously, the number of grade 3-5 AEs decreased by 334,976 (- 13.0%), and the ORR saw a 19.1% increase (+ 105.6%) relative to standard of care treatment alone.

CONCLUSION

This study provides a analysis of the potential beneficial effects on health outcomes in the Chinese population after introducing PD-1 inhibitor class treatment. The findings suggest the PD-1 inhibitor class will significantly improve patient survival.

Adjuvant Osimertinib in Patients With Stage IB to IIIA EGFR Mutation-Positive NSCLC After Complete Tumor Resection: ADAURA China Subgroup Analysis

Introduction

In Chinese patients with NSCLC, prevalence of EGFR-mutated (EGFRm) disease is high. In the global phase 3 ADAURA study (NCT02511106), adjuvant osimertinib was found to have a statistically significant and clinically meaningful improvement in disease-free survival (DFS) versus placebo in resected stage IB to IIIA EGFRm NSCLC. We present efficacy and safety data from a subgroup analysis of 159 Chinese patients enrolled in the People's Republic of China from ADAURA.

Methods

In ADAURA, patients with completely resected stage IB to IIIA EGFRm (exon 19 deletion/exon 21 L858R) NSCLC were randomized 1:1 to receive osimertinib (80 mg once daily) or placebo for 3 years or until disease recurrence/discontinuation. Adjuvant chemotherapy was permitted before randomization, per physician/patient choice. Primary end point was investigator-assessed DFS in stage II to IIIA disease; secondary end points included DFS in stage IB to IIIA (overall population), overall survival, health-related quality of life (HRQoL), and safety.

Results

Of 682 patients enrolled globally, 159 patients in the People's Republic of China were included in this subgroup analysis (osimertinib n = 77; placebo n = 82). Baseline characteristics were balanced across the treatment arms. At data cutoff, stage II to IIIA DFS hazard ratio (HR) was 0.23 (95% confidence interval [CI]: 0.13-0.42; maturity 59%); stage IB to IIIA DFS HR was 0.29 (95% CI: 0.17-0.48; maturity 42%). At 13% maturity (21 deaths), HR for overall survival in the stage IB to IIIA population was 0.51 (95% CI: 0.21-1.20). HRQoL was maintained from baseline, and safety was consistent with the global population.

Conclusions

In this population of Chinese patients from ADAURA, adjuvant osimertinib was found to have a clinically meaningful improvement in DFS versus placebo, with maintained HRQoL and a safety profile consistent with the global study population.

Cost-effectiveness of first-line immunotherapy combinations with or without chemotherapy for advanced non-small cell lung cancer: a modelling approach

BACKGROUND

Many studies have explored the cost-effectiveness of immunotherapy versus chemotherapy alone. However, there is paucity of evidence on direct pharmacoeconomic studies related to immunotherapy combinations. Thus, we aimed at assessing the economic outcomes of first-line immunotherapy combinations in the treatment of advanced non-small cell lung cancer (NSCLC) from the Chinese health care perspective.

METHODS

The mutual hazard ratios (HRs) of ten immunotherapy combinations and one chemotherapy regimen for the overall survival (OS) and progression-free survival (PFS) were obtained from a network meta-analysis. Based on proportional hazard (PH) assumption, adjusted OS and PFS curves were established to make the effects comparable. With the parameters of cost and utility, and of scale and shape from the fit of adjusted OS and PFS curves obtained from previous studies, a partitioned survival model was designed to estimate the cost-effectiveness of immunotherapy combinations versus chemotherapy alone. Parameter uncertainty in model inputs was assessed using one-way deterministic and probabilistic sensitivity analyses.

RESULTS

The incremental cost of camrelizumab plus chemotherapy versus chemotherapy alone was $13,180.65, the lowest among all the other immunotherapy combinations. Furthermore, sintilimab plus chemotherapy (sint-chemo) provided the highest quality-adjusted life-year (QALY) benefit versus chemotherapy alone (incremental QALYs = 0.45). Sint-chemo yielded the best incremental cost-effectiveness ratio (ICER) versus chemotherapy alone (ICER = $34,912.09/QALY), at the current price. The cost-effectiveness probabilities were 32.01% and 93.91% for pembrolizumab plus chemotherapy, and atezolizumab plus bevacizumab plus chemotherapy, respectively (if the original price of the pembrolizumab, atezolizumab, and bevacizumab were decreased by 90%).

CONCLUSIONS

Based on the fact that there is fierce competition in the PD-1/PD-L1 market, pharmaceutical enterprises should strive for greater efficacy, and optimal pricing strategy for therapies.

An open label, safety study of Asian patients with advanced non-small-cell lung cancer receiving second-line nivolumab monotherapy (CheckMate 870)

BACKGROUND

Nivolumab has been approved in China as second-line treatment for advanced non-small-cell lung cancer (NSCLC) via weight-based infusion, based on the CheckMate 078 study. We investigated the safety and efficacy of 240 mg flat-dose nivolumab in patients with advanced NSCLC, including those with hepatitis B virus (HBV) and epidermal growth factor receptor (EGFR) mutation/ALK receptor tyrosine kinase (ALK) translocation due to high prevalence in China.

METHODS

CheckMate 870 was a single-arm, open-label, phase IIIb trial in Asian (primarily Chinese) patients with previously treated advanced NSCLC. Patients received flat-dose nivolumab 240 mg every 2 weeks (Q2W) for up to 2 years. The primary endpoint was the incidence and severity of treatment-related select adverse events (TRsAEs) in non-HBV patients; secondary and exploratory endpoints included severity of high-grade TRsAEs in HBV-infected patients, and safety, efficacy and patient-reported outcomes (PROs) in the whole population.

RESULTS

Out of 404 patients enrolled, 400 received treatment. Median (standard deviation) age was 60.5 (8.68) years and the majority were male (78.5%). At a median follow-up of 37.6 months, no Grade 5 TRsAEs were reported, and the frequency of Grade 3-4 TRsAEs was low (0.0-5.9%) in non-HBV and HBV NSCLC patients. Median overall survival (OS) and progression-free survival (PFS) in all treated patients were 14.7 (12.3-18.1) and 3.6 (2.3-3.8) months, respectively. Median OS was 14.2 (12.3-18.1) and 22.3 (10.0-NA) months for non-HBV and HBV-infected patients, 19.3 (11.2-31.7) and 13.7 (11.5-18.1) months for EGFR-positive and wild-type subgroups, and 19.3 (12.9-23.5) and 13.3 (10.9-17.7) months for those with programmed death-ligand 1 (PD-L1) expression ⩾1% and <1%, respectively. No notable changes from baseline were observed in PROs throughout the study.

CONCLUSION

Nivolumab 240 mg infusion Q2W was well tolerated, efficacious, and maintained health status and quality of life in Asian patients with previously treated advanced NSCLC regardless of HBV, EGFR, or PD-L1 status.

Inflammatory Microenvironment in Early Non-Small Cell Lung Cancer: Exploring the Predictive Value of Radiomics

Patient prognosis is a critical consideration in the treatment decision-making process. Conventionally, patient outcome is related to tumor characteristics, the cancer spread, and the patients’ conditions. However, unexplained differences in survival time are often observed, even among patients with similar clinical and molecular tumor traits. This study investigated how inflammatory radiomic features can correlate with evidence-based biological analyses to provide translated value in assessing clinical outcomes in patients with NSCLC. We analyzed a group of 15 patients with stage I NSCLC who showed extremely different OS outcomes despite apparently harboring the same tumor characteristics. We thus analyzed the inflammatory levels in their tumor microenvironment (TME) either biologically or radiologically, focusing our attention on the NLRP3 cancer-dependent inflammasome pathway. We determined an NLRP3-dependent peritumoral inflammatory status correlated with the outcome of NSCLC patients, with markedly increased OS in those patients with a low rate of NLRP3 activation. We consistently extracted specific radiomic signatures that perfectly discriminated patients’ inflammatory levels and, therefore, their clinical outcomes. We developed and validated a radiomic model unleashing quantitative inflammatory features from CT images with an excellent performance to predict the evolution pattern of NSCLC tumors for a personalized and accelerated patient management in a non-invasive way.

Treatment strategy, overall survival and associated risk factors among patients with unresectable stage IIIB/IV non-small cell lung cancer in China (2015-2017): A multicentre prospective study

BACKGROUND

There are limited studies on treatment and survival analysis among patients with unresectable Stage IIIB or IV non-small cell lung cancer (NSCLC) in routine practice in China. To address this gap, we conducted a prospective observational study in a cohort of patients treated at 11 hospitals in China.

METHODS

This was a multicentre, prospective cohort study including patients with newly diagnosed unresectable Stage IIIB or IV NSCLC from June 26th, 2015 to April 28th, 2017. Patient baseline characteristics, disease characteristics, and anti-cancer treatments were obtained by medical chart review. The overall survival (OS) from the initiation of first-line treatment was analysed by the Kaplan-Meier method. Factors associated with survival were analysed by univariate and multivariate Cox regression models.

FINDINGS

Among 1324 patients enrolled with median follow-up duration of 15·0 (range: 0·0-42·1) months, 83·5% (1105/1324) of them received first-line chemotherapy of which platinum-based compounds were the dominated agents. Overall, 30·9% (409/1324) of patients received targeted therapy as 1st-line treatment including 65·0% (266/409) EGFR-TKIs and 5·1% (21/409) ALK-TKIs. Of all eligible patients, gene testing rates were 44·0% (583/1324) for EGFR mutations, 17·0% (225/1324) for EML4-ALK gene fusions, and 8·3% (110/1324) for ROS1 gene fusions. The EGFR-TKIs were administered to 63·9% (179/280) of EGFR mutated patients as first-line treatment. The overall median OS was 23·2 (95%CI 19·5-25·5) months, and patients treated at tier 1 cities had better OS than that of tier 2 cities. Also, the OS in patients with EGFR mutation was longer than those with EGFR wild type. Multivariate Cox regression models suggested that male, education below high school, tier 2 cities, smoking history, and multiple metastases were associated with poor survival.

INTERPRETATION

The gene test coverage was relatively low among the studied population, and over half of EGFR mutated patients received EGFR-TKIs, suggesting that the result of genetic tests in real-world settings may not always indicate the selection of treatment. The OS benefit observed from patients treated in tier 1 cities and those with EGFR mutation may indicate a need for broader gene test coverage, providing NSCLC patients with personalized treatment according to the results of genetic tests.

FUNDING

Roche Holding AG.TRANSLATED ABSTRACT: This translation in Chinese was submitted by the authors and we reproduce it as supplied. It has not been peer reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as reference for this manuscript.:IIIBIV(NSCLC)., ,, 11.:,, 20156262017428IIIBIVNSCLC.,.Kaplan-Meier(OS), Cox.:1324, 15.0(:0.0-42.1), 83.5%(1105/1324), ., 30.9%(409/1324), 65.0%(266/409)EGFR-TKI5.1%(21/409)ALK-TKI., EGFR,EML4-ALKROS144.0%(583/1324),17.0%(225/1324)8.3%(110/1324).63.9%(179/280)EGFREGFR-TKI.23.2 (95% 19·5-25·5) , ., EGFREGFR.Cox, ,,,.:, EGFREGFR-TKI, , .EGFR, , NSCLC.

Tumor-Derived Exosomes Regulate Apoptosis of CD45+EpCAM+ Cells in Lung Cancer

Lung cancer has the highest mortality rate among human cancers, and the majority of deaths result from metastatic spread. The tumor microenvironment plays an important role in suppressing the immune surveillance and elimination of tumor cells. A few studies have reported the presence of CD45⁺EpCAM⁺ double-positive cells in cancer, but the underlying mechanism remains unclear with respect to how these cells originate and their function in cancer biology. In this study, we analyzed 25 lung tumor samples. We confirmed the presence of CD45⁺EpCAM⁺ cells in lung cancer, and these cells exhibited higher apoptosis than CD45⁺EpCAM⁻ cells. Using co-culture of lung cancer cell-derived exosomes with healthy donor peripheral blood mononuclear cells, we recapitulated CD45⁺EpCAM⁺ cell formation and increased apoptosis that occurs in patients with primary lung cancer. Further analysis suggested that microRNAs in lung cancer cell-derived exosomes may alter the gene expression profile of CD45⁺EpCAM⁺ cells, resulting in elevated TP53 expression and increased apoptosis. To our knowledge, this is the first report of cancer cell-derived exosomes that can inhibit the immune system by promoting immune cell apoptosis.

A Proposal to Modify the 8th IASLC System: Is it Suitable for T4N2M0 Lung Adenocarcinoma to Be Placed in Stage IIIB?

PURPOSE

The International Association for the Study of Lung Cancer (IASLC) of TNM staging system has been well accepted as a precise model. However, the latest American Joint Committee on Cancer (AJCC) staging system to solve the different survival and prognosis of lung adenocarcinoma in the same period is still controversial. Therefore, it is necessary to thoroughly explore the applicability between the new system and survival prediction in terms of lung adenocarcinoma.

METHODS

We recruited 52,517 patients with lung adenocarcinoma from the Surveillence, Epidemiology, and End Results database. Cox regression analysis was performed to determine survival related factors. The mortality rate per 1000 persons per year of the T4N2M0 lung adenocarcinoma stage and other stages were compared. Survival curves were obtained using the Kaplan-Meier analysis and log-rank test.

RESULTS

The results of Cox proportional hazards regression analysis showed that age at diagnosis, race, T stage, distant metastasis, extrathoracic extension, radiotherapy, chemotherapy, and surgery are independent factors related to cancer-specific survival (CSS) and all-cause survival. Furthermore, patients with stage IIIA disease (P<0.001) and IIIB disease (P<0.001) excluding stage at T4N2M0 had a significantly lower risk of CSS and all-cause survival than those staged with T4N2M0 disease. The mortality rates per 1000 person-years with patients staged at T4N2M0 lung adenocarcinoma had higher mortality than patients in the same period. The CSS curves of patients with stage T4N2M0 reflected an obvious decline compared with those of stages IIIA disease and IIIB excluding T4N2M0, and there is no significant difference between this curve and stage IIIC patients (P>0.05).

CONCLUSION

The survival rate of patients with T4N2M0 stage was significantly lower than that of patients with IIIA and IIIB stages excluding T4N2M0, there was no significant difference between T4N2M0 and IIIC. It was suggested that this group of patients with stage T4N2M0 were upgraded in the 8th IASLC system.

Cost-effectiveness of stereotactic body radiotherapy in the treatment of non-small-cell lung cancer (NSCLC): a systematic review

OBJECTIVES

This study aims to systematically review the studies on the cost-effectiveness of stereotactic body radiotherapy (SBRT) in the treatment of non-small-cell lung cancer (NSCLC).

METHODS

A systematic literature search was performed in databases from 2000 through April 2021. The search terms included 'economics,' 'cost,' 'cost effectiveness,' 'SBRT,' and all names for NSCLC. Two reviewers independently screened the titles, abstracts and full texts to determine the studies for the final sample. The quality of the included studies was assessed using the Quality of Health Economic Studies checklist.

RESULTS

Eleven studies were identified and included in our final review. SBRT was reported to be a cost-effective (5 of 5) option compared to conventional radiotherapy, radiofrequency ablation, and best supportive care for medically inoperable, early-stage NSCLC. However, the identified studies revealed that no single treatment was found to be more cost-effective than others between SBRT and surgical interventions. The key drivers of this cost-effectiveness were the cost of the treatment, utility value, and the rate of surgical mortality.

CONCLUSIONS

SBRT may be considered a more cost-effective strategy for medically inoperable, early-stage NSCLC. Considering the limited studies available, more related research should be conducted to further validate these results.

Evaluating the expression of tumorigenic long noncoding RNAs in circulating exosomes isolated from non-small-cell lung cancer patients

Aim: To evaluate the correlation of long noncoding RNAs (lncRNAs) expression in circulating exosomes and the cancerous and noncancerous tissues in patients with non-small-cell lung carcinoma. Methods: The relative expression of the four lncRNAs including LUADT1, MALAT1, NEAT1 and MIAT between tumor tissue, adjacent noncancerous tissues and circulating exosomes were evaluated by quantitative reverse transcription PCR. Results & conclusion: The relative expression of the lncRNAs, including LUADT1, MALAT1 and NEAT1, was upregulated and MIAT was downregulated in tumor tissue compared with noncancerous tissue samples. The expression of lncRNAs in circulating exosomes was not significantly different from cancerous tissue. Our results indicate that the studied exosomal lncRNAs have a good potential to be further evaluated as prognostic/diagnostic biomarkers in patients with non-small-cell lung cancer.

Real-world treatment patterns in resectable (stages I-III) non-small-cell lung cancer: a systematic literature review

Aim: The aim of this systematic literature review was to describe treatment patterns in non-metastatic non-small-cell lung cancer. Methods: A search was conducted in MEDLINE and EMBASE. Eligible studies were multicentered (>50 patients) and conducted after 2000 in North America, Europe and Asia. Results: Twenty studies met the eligibility criteria. Based on US and Canadian studies in the resectable population, the proportion of patients who received neoadjuvant chemotherapy/chemoradiotherapy and adjuvant chemotherapy/chemoradiotherapy increased with increasing stage (i.e., from <3% in stage I to about 40% in stage III and from 15% in stage I to 30% in stage III, respectively). Within the resectable population, the breakdown between bimodal and trimodal therapy was variable, suggesting that clinical practice is not uniform. Conclusion: Overall, studies were heterogeneous, precluding data extrapolation across regions. Despite heterogeneity and limited evidence, this review suggested an increase in neoadjuvant and adjuvant chemotherapy with increasing stage, generally in line with treatment guidelines.

Tumor-derived exosomes: Key players in non-small cell lung cancer metastasis and their implication for targeted therapy

Exosomes represent extracellular vesicles of endocytic origin ranging from 30 to 100 nm that are released by most of eukaryotic cells and can be found in body fluids. These vesicles in carrying DNA, RNA, microRNA (miRNA), Long noncoding RNA, proteins, and lipids serve as intercellular communicators. Due to their role in crosstalk between tumor cells and mesenchymal stroma cells, they are vital for tumor growth, progression, and anticancer drug resistance. Lung cancer is a global leading cause of cancer-related deaths with 5-year survival rates of about 7% in patients with distant metastasis. Although the implementation of targeted therapy has improved the clinical outcome of nonsmall cell lung cancer, drug resistance remains a major obstacle. Lung tumor-derived exosomes (TDEs) conveying molecular information from tumor cells to their neighbor cells or cells at distant sites of the body activate the tumor microenvironment (TME) and facilitate tumor metastasis. Exosomal miRNAs are also considered as noninvasive biomarkers for early diagnosis of lung cancer. This review summarizes the influence of lung TDEs on the TME and metastasis. Their involvement in targeted therapy resistance and potential clinical applications are discussed. Additionally, challenges encountered in the development of exosome-based therapeutic strategies are addressed.

Community-based lung cancer screening by low-dose computed tomography in China: First round results and a meta-analysis

OBJECTIVE

To evaluate the efficiency of low-dose computed tomography (LDCT) screening for lung cancer in China by analyzing the baseline results of a community-based screening study accompanied with a meta-analysis.

METHODS

A first round of community-based lung cancer screening with LDCT was conducted in Tianjin, China, and a systematic literature search was performed to identify LDCT screening and registry-based clinical studies for lung cancer in China. Baseline results in the community-based screening study were described by participant risk level and the lung cancer detection rate was compared with the pooled rate among the screening studies. The percentage of patients per stage was compared between the community-based study and screening and clinical studies.

RESULTS

In the community-based study, 5523 participants (43.6% men) underwent LDCT. The lung cancer detection rate was 0.5% (high-risk, 1.2%; low-risk, 0.4%), with stage I disease present in 70.0% (high-risk, 50.0%; low-risk, 83.3%), and the adenocarcinoma present in 84.4% (high-risk, 61.5%; low-risk, 100%). Among all screen-detected lung cancer, women accounted for 8.3% and 66.7% in the high- and low-risk group, respectively. In the screening studies from mainland China, the lung cancer detection rate 0.6% (95 %CI: 0.3%-0.9%) for high-risk populations. The proportions with carcinoma in situ and stage I disease in the screening and clinical studies were 76.4% (95 %CI: 66.3%-85.3%) and 15.2% (95 %CI: 11.8%-18.9%), respectively.

CONCLUSIONS

The stage shift of lung cancer due to screening suggests a potential effectiveness of LDCT screening in China. Nearly 70% of screen-detected lung cancers in low-risk populations are identified in women.

Downregulation of miR-487a-3p suppresses the progression of non-small cell lung cancer via targeting Smad7

Non-small cell lung cancer (NSCLC) is the most prevalent type of lung cancer; however, the treatment efficacy of advanced NSCLC remains poor. MicroRNAs (miRNAs) are closely associated with the pathogenesis of lung cancer, while the detailed function of miR-487a-3p in NSCLC remains unclear. Bioinformatic analysis was performed to identify differentially expressed miRNAs (DEmiRNAs) between NSCLC and normal tissues. The effects of miR-487a-3p antagomir on the proliferation and invasion of NSCLC cells were explored with CCK-8 and Transwell assays. A total of 48 overlapping miRNAs were identified, including 9 commonly downregulated and 39 commonly upregulated miRNAs. MiR-487a-3p was found to be associated with poor survival rate of patients with NSCLC. MiR-487a-3p level was notably upregulated in NSCLC cells compared with that in human bronchial epithelial cells. Downregulation of miR-487a-3p inhibited the proliferation of NCI-H1299 and A549 cells via inducing apoptosis. In addition, miR-487a-3p antagomir significantly decreased the migration and invasion ability of NCI-H1299 cells. The results of the dual-luciferase reporter assay and western blotting indicated that miR-487a-3p antagomir exerted antitumor effects via targeting Smad7. The findings of the present study revealed that downregulation of miR-487a-3p suppressed the progression of NSCLC via inhibiting the Smads pathway, and it may serve as a novel promising target for the treatment of NSCLC.

Association between Alzheimer's disease and risk of cancer: A retrospective cohort study in Shanghai, China

INTRODUCTION

We investigated the association between Alzheimer's disease (AD) and the risk of cancer in the Chinese population.

METHODS

In this retrospective cohort study, multivariate Cox proportional hazard regression analysis was used to determine the correlation between AD and the risk of various cancers, as shown by hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

Of 8097 AD patients, the HR for all subsequent cancers was 0.822 (95% CI, 0.728-0.928; P = .002). Among them, three specific cancers were associated with AD: lung cancer (HR, 0.656; 95% CI, 0.494- 0.871; P = .004), prostate and testicular cancer (HR, 0.414; 95% CI, 0.202-0.847; P = .016), and lymphoma (HR, 2.202; 95% CI, 1.005-4.826; P = .049).

CONCLUSION

Patients with AD might have a lower chance of developing several cancers, including lung cancer and prostate and testicular cancer. Meanwhile, a positive association between AD and a higher incident rate of lymphoma was observed.

Treatment and outcomes for early non-small-cell lung cancer: a retrospective analysis of a Portuguese hospital database

Aim:

This observational study evaluated treatment patterns and survival for patients with stage I–IIIA non-small-cell lung cancer (NSCLC).

Materials & methods:

Adults newly diagnosed with NSCLC in 2012–2016 at IPO-Porto hospital were included. Treatment data were available for patients diagnosed in 2015–2016.

Results:

495 patients were included (median age: 67 years). The most common treatments were surgery alone or with another therapy (stage I: 66%) and systemic anticancer therapy plus radiotherapy (stage II: 54%; stage IIIA: 59%). One-year OS (95% CI) for patients with stage I, II and IIIA NSCLC (diagnosed 2012–2016) were 92% (88–96), 71% (62–82) and 69% (63–75), respectively; one-year OS (95% CI) for treated patients with stage I–II or stage IIIA NSCLC (diagnosed 2015–2016) were 89% (81–97) and 86% (75–98) for non-squamous cell and 76% (60–95) and 49% (34–70) for squamous cell NSCLC.

Conclusion:

Treatment advances are strongly needed for stage I–IIIA NSCLC, especially for patients with squamous cell histology.

Lower Airway Dysbiosis Affects Lung Cancer Progression

In lung cancer, enrichment of the lower airway microbiota with oral commensals commonly occurs, and ex vivo models support that some of these bacteria can trigger host transcriptomic signatures associated with carcinogenesis. Here, we show that this lower airway dysbiotic signature was more prevalent in the stage IIIB-IV tumor-node-metastasis lung cancer group and is associated with poor prognosis, as shown by decreased survival among subjects with early-stage disease (I-IIIA) and worse tumor progression as measured by RECIST scores among subjects with stage IIIB-IV disease. In addition, this lower airway microbiota signature was associated with upregulation of the IL17, PI3K, MAPK, and ERK pathways in airway transcriptome, and we identified Veillonella parvula as the most abundant taxon driving this association. In a KP lung cancer model, lower airway dysbiosis with V. parvula led to decreased survival, increased tumor burden, IL17 inflammatory phenotype, and activation of checkpoint inhibitor markers. SIGNIFICANCE: Multiple lines of investigation have shown that the gut microbiota affects host immune response to immunotherapy in cancer. Here, we support that the local airway microbiota modulates the host immune tone in lung cancer, affecting tumor progression and prognosis.See related commentary by Zitvogel and Kroemer, p. 224.This article is highlighted in the In This Issue feature, p. 211.

A novel circular RNA hsa_circRNA_103809/miR-377-3p/GOT1 pathway regulates cisplatin-resistance in non-small cell lung cancer (NSCLC)

Background

Cisplatin is the first-line chemotherapeutic drug for non-small cell lung cancer (NSCLC), and emerging evidences suggests that targeting circular RNAs (circRNAs) is an effective strategy to increase cisplatin-sensitivity in NSCLC, but the detailed mechanisms are still not fully delineated.

Methods

Cell proliferation, viability and apoptosis were examined by using the cell counting kit-8 (CCK-8) assay, trypan blue staining assay and Annexin V-FITC/PI double staining assay, respectively. The expression levels of cancer associated genes were measured by using the Real-Time qPCR and Western Blot analysis at transcriptional and translated levels. Dual-luciferase reporter gene system assay was conducted to validated the targeting sites among hsa_circRNA_103809, miR-377-3p and 3′ untranslated region (3’UTR) of GOT1 mRNA. The expression status, including expression levels and localization, were determined by immunohistochemistry (IHC) assay in mice tumor tissues.

Results

Here we identified a novel hsa_circRNA_103809/miR-377-3p/GOT1 signaling cascade which contributes to cisplatin-resistance in NSCLC in vitro and in vivo. Mechanistically, parental cisplatin-sensitive NSCLC (CS-NSCLC) cells were subjected to continuous low-dose cisplatin treatment to generate cisplatin-resistant NSCLC (CR-NSCLC) cells, and we found that hsa_circRNA_103809 and GOT1 were upregulated, while miR-377-3p was downregulated in CR-NSCLC cells but not in CS-NSCLC cells. In addition, hsa_circRNA_103809 sponged miR-337-3p to upregulate GOT1 in CS-NSCLC cells, and knock-down of hsa_circRNA_103809 enhanced the inhibiting effects of cisplatin on cell proliferation and viability, and induced cell apoptosis in CR-NSCLC cells, which were reversed by downregulating miR-377-3p and overexpressing GOT1. Consistently, overexpression of hsa_circRNA_103809 increased cisplatin-resistance in CS-NSCLC cells by regulating the miR-377-3p/GOT1 axis. Finally, silencing of hsa_circRNA_103809 aggravated the inhibiting effects of cisplatin treatment on NSCLC cell growth in vivo.

Conclusions

Analysis of data suggested that targeting the hsa_circRNA_103809/miR-377-3p/GOT1 pathway increased susceptibility of CR-NSCLC cells to cisplatin, and this study provided novel targets to improve the therapeutic efficacy of cisplatin for NSCLC treatment in clinic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07680-w.

Treatment patterns, clinical outcomes, and healthcare resource use associated with advanced/metastatic lung cancer in China: protocol for a retrospective observational study

Background

Lung cancer (LC) is the most common cancer worldwide. The prevalence of LC and rate of associated mortality are high and increasing faster in China than in Western countries. Non-small cell lung cancer (NSCLC) accounts for most LCs. This study aims to be the first large, multi-center, non-interventional retrospective study of treatment patterns (type/duration, number of lines, completion rate), real-world outcomes, and medical costs among Chinese patients with advanced/metastatic NSCLC (IIIb/IV) or extensive-stage small cell LC (ES-SCLC).

Methods

This study will enroll 8,800 patients (≥18 years, with a diagnosis of advanced/metastatic NSCLC made between 1 December 2013 to 30 November 2014) from 35 to 50 Chinese sites. Hospital information systems (HIS) and electronic medical records will be retrospectively reviewed, in adherence with regulatory and ethical requirements. Early-stage treatment (starting from 1 December 2010) of patients with recurrent disease or early disease progression will be examined. Data will be collected at baseline (diagnosis) and 6 and 12 months after this. Observation will end after 3 years or death. Data will be stratified by histology, staging, age, region, health insurance, and epidermal growth factor receptor (EGFR)/anaplastic lymphoma kinase (ALK) mutation status. Treatment duration and overall survival will be estimated using Kaplan-Meier curves. Descriptive statistics will be used for disease characteristics and patient demographics. Cox-proportional hazards models will be used to examine the impact of demographics/treatment on survival. Treatment patterns and outcome predictors will be explored using multivariate logistic regression.

Discussion

This protocol describes the methodology for collecting real-world data to guide evidence-based clinical practice and inform unmet needs in NSCLC treatment, with potential to identify gaps between guidelines and current practice.

Trial registration

NCT03505515; data registered on ClinicalTrials.gov: 12h Apr., 2018.

Investigation on the potential of circulating tumor DNA methylation patterns as prognostic biomarkers for lung squamous cell carcinoma

Background

Aberrant epigenetic modifications play a key role in lung tumorigenesis. In our study, we aimed to explore the clinical implications of baseline circulating tumor DNA (ctDNA) somatic and methylation profiles in patients with lung squamous cell carcinoma (LUSC).

Methods

A total of 26 patients with LUSC of various stages were included in this study. Somatic mutations and methylation levels were profiled from the plasma-derived ctDNA obtained at the time of diagnosis using unique molecular identifier (UMI)-based targeted sequencing and bisulfite sequencing, respectively. The correlation between baseline ctDNA mutation and methylation profile, and overall survival (OS), were analyzed.

Results

Somatic mutations were detected in 80.8% (20/26) of the patients. Patients harboring somatic mutations with maximum allelic fraction (maxAF) of >5% had significantly shorter OS compared to those with maxAF ≤5% (7.1 vs. 54.6 months; P=0.020). ctDNA methylation level was found to be strongly correlated with maxAF (Pearson correlation =0.934; P<0.001). Consistent with maxAF, higher methylation levels were also associated with poorer OS (hazard ratio =2.377; 95% CI: 1.283–4.405; P=0.006). Moreover, a total of 1,956 ctDNA methylation blocks were differentially methylated in patients with maxAF >0 (P<0.05). Least absolute shrinkage and selection operator (LASSO) regression analysis revealed a significant correlation between methylation signatures from 5 methylation blocks and OS (hazard ratio =183.20, 95% CI: 2.74–12,243.32; P=0.015). These 5 methylation blocks could serve as an alternative to maxAF and can be explored as prognostic biomarkers.

Conclusions

Our study identified several ctDNA methylation blocks that can potentially predict the prognosis of LUSC at the time of diagnosis.

The effect of anti-cancer and anti-tuberculosis treatments in lung cancer patients with active tuberculosis: a retrospective analysis

BACKGROUND

Lung tuberculosis (TB) and lung cancer have a complex relationship. Data concerning TB treatment in lung cancer patients are still incomplete. The aim of this study was to investigate the effects of anti-cancer and anti-tuberculosis treatments in lung cancer patients with active lung TB.

METHODS

In a retrospective cohort study, lung cancer patients with active lung TB were identified between January 2013 and December 2016. Age- and sex-matched lung cancer patients without tuberculosis were selected as control subjects. Anti-cancer and anti-tuberculosis treatments were administered according to the national guidelines. The clinical courses and responses of lung cancer patients with and without active lung TB were examined and compared.

RESULTS

A total of 31 consecutive lung cancer patients were diagnosed with active lung TB. Fifty-one lung cancer patients without TB were enrolled as control subjects. Most patients in the two groups were elderly, had advanced non-small cell lung cancer and had tumor burdens. The anti-cancer treatment completion rate and response rate were not different between two group (87.1% in TB treatment patients vs. 92.2% in lung cancer patients, 77.4% in TB treatment patients vs. 88.2% in lung cancer patients, respectively). The anti-tuberculosis treatment completion rate and success rate was 87.1 and 80.7%. The median survival times were not different between two groups (52 weeks in TB treatment patients vs. 57 weeks in lung cancer patients). The change in Karnofsky performance score was also not different between two groups. The most common side effect in TB treatment patients was liver injury (61.3%). The most serious side effect in TB treatment patients was leukocyte deficiency (9.7% in Grade 3). Both of side effects mentioned above were not different between two groups.

CONCLUSION

Both anti-cancer and anti-tuberculosis treatments can be safely and effectively administered in lung cancer patients with active lung TB. Attention should be paid to the risk of tuberculosis in lung cancer patients in TB high-burden countries.

Genetic Variants in DNA Mismatch Repair Pathway predict prognosis of Lung Cancer patients with receiving Platinum-Based Chemotherapy

Objective: To investigate the relationships between genetic variants in DNA mismatch repair pathway genes and the prognosis of platinum-based chemotherapy in lung cancer patients.

Methods: 346 lung cancer patients who received at least two cycles of platinum-based chemotherapy were recruited in this study. A total of 35 single nucleotide polymorphisms in 7 DNA mismatch repair genes were genotyped to investigate their associations with platinum-based chemotherapy prognosis.

Result: The results revealed that patients carried MSH2 rs4608577 TT genotype had a significantly shorter progression free survival than patients with GG or GT genotypes (Additive model: P=0.003, OR =0.94, 95% CI =0.33-1.57). Patients with SAPCD1 rs707937 TT genotype had a significantly longer overall survival than patients with GG or GT genotypes (Additive model: P=0.0003, OR=0.75, 95% CI =0.35-1.14). Eight SNPs and fourteen SNPs were related to progression free survival and overall survival in subgroup analyses, respectively.

Conclusion: Our findings suggest that the MSH2 rs4608577 and SAPCD1 rs707937 may be potential clinical biomarkers for predicting platinum-based chemotherapy prognosis in lung cancer patients.

Effects of tyrosine kinase inhibitor therapy on skin toxicity and skin-related quality of life in patients with lung cancer: An observational study

Epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) therapy is the primary treatment option for patients with non-small cell lung cancer (NSCLC). However, one of the major adverse effects associated with this therapy is skin toxicity, which impacts the patient's quality of life. This study aimed to describe the severities and locations of skin toxicity, and to analyze their association with the quality of life in patients with advanced NSCLC who received EGFR-TKI therapy as first-line treatment.This cross-sectional and correlation study was conducted at a tertiary medical center in northern Taiwan between July 2015 and March 2016. Skin toxicity was assessed and graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.03). The Skindex-16 scale was used to measure the skin disease-related quality of life.A total of 146 NSCLC patients who received EGFR-TKI therapy within the first 3 months of diagnosis were included in this study; 93.2% of these patients experienced skin toxicities. Approximately 70% of the patients developed xerosis and pruritus, while 50% had papulopustular eruptions and paronychia. The mean skin symptom impact score was 5.38 (standard deviation = 2.65). The skin-related quality of life varied widely among the participants but remained acceptable (mean score = 13.96, standard deviation = 16.55). Skin symptoms correlated significantly with poor quality of life (r = 0.50, P < .001). Younger patients and those treated with afatinib were the most affected, reporting the poorest quality of life. Patients who required EGFR-TKI dose reduction had experienced more severe skin symptoms than had patients who did not require it (7.35 vs 5.01, P < .001).Skin toxicity related to EGFR-TKI treatment impacts the quality of life in patients with NSCLC. During the treatment period, skin assessment and tailored management should be incorporated into the daily care plan.

Evaluation of expression of vitamin D receptor related lncRNAs in lung cancer

Lung cancer as the most common cancer in the world is associated with high rate of mortality. Previous studies have detected expression of vitamin D receptor (VDR) in lung cancer tissues and reported significant of this gene in determination of patients' survival. Methods: In the current study, we assessed expression of VDR and five long non-coding RNAs (lncRNAs) which have been associated with VDR (MALAT1, SNHG16, SNHG6, LINC00346, LINC00511) in 32 pairs of lung cancer tissues and adjacent non-cancerous tissues (ANCTs) using real time PCR method. Expression of VDR was significantly decreased in tumor tissues obtained from male patients compared with their matched ANCTs (ER = 0.31, P value = 0.02). However, this pattern was not detected in female subjects (ER = 0.93, P value = 0.94). Expression of LINC00346 was significantly decreased in tumoral tissues compared with ANCTs (Expression ratio (ER) = 0.38, P value = 0.03). When evaluating expression of this lncRNA based on the sex of patients, differences in its expression was only significant among males (ER = 0.3, P value = 0.04). VDR expression was significantly associated with sex of patients in a way that most male patients exhibited down-regulation of this gene in their tumor tissue samples compared with the paired ANCTs (P = 0.03). Expression levels of LINC00346 could discriminate lung cancer tissues from ANCTs with sensitivity of 83.3% and specificity of 52.4%. Correlations between expressions of SNHG6 and other genes were all significant in tumoral tissues but insignificant in ANCTs. The current investigation potentiates VDR and LINC00346 as possible participants in the pathogenesis of lung cancer.

Postoperative Elevations of Neutrophil-to-lymphocyte and Platelet-to-lymphocyte Ratios Predict Postoperative Pulmonary Complications in Non-small Cell Lung Cancer Patients: A Retrospective Cohort Study

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are found to increase in patients who develop postoperative complications (PCs). The aim of the present study was to explore the association of the perioperative changes of NLR (ΔNLR) and PLR (ΔPLR) with PCs in non-small cell lung cancer (NSCLC). Clinical data of 509 patients, who were diagnosed with NSCLC and underwent thoracoscopic radical resection between January 1, 2014 and July 31, 2016 at the Department of Thoracic Surgery, West China Hospital, were reviewed. Patients were divided into PC and non-PC groups, and clinical characteristics including ΔNLR and ΔPLR were compared between them. The optimal cut-off values of ΔNLR and ΔPLR were determined by receiver operating characteristics (ROC) curves and patients were assigned to high ΔNLR/ΔPLR and low ΔNLR/ΔPLR groups in terms of the cut-off values. Clinicopathologic characteristics and the incidence of different PCs were compared between the dichotomized groups. Univariate and multivariate logistic regression analyses were performed to identify the independent risk factors for PCs. The results showed that the ΔNLR and ΔPLR in the PC group were signifcantly higher than those in the non-PC group (P<0.001 for both). The optimal cutoff values of ΔNLR and ΔPLR were 6.6 and 49, respectively. Patients with ΔNLR>6.6 or ΔPLR>49 were more likely to experience postoperative pulmonary complications (PPCs) (P<0.001 for both). Multivariate logistic regression analysis demonstrated that smoking [odds ratio (OR): 2.450, 95% confdence interval (95% CI): 1.084-5.535, P=0.031)], tumor size (OR: 1.225, 95% CI: 1.047-1.433, P=0.011), ΔNLR>6.6 (OR: 2.453, 95% CI: 1.224-4.914, P=0.011) and ΔPLR>49 (OR: 2.231, 95% CI: 1.182-4.212, P=0.013) were predictive of PPCs. In conclusion, the ΔNLR and ΔPLR may act as novel predictors for PPCs in NSCLC patients undergoing thoracoscopic radical lung resection, and patients with ΔNLR>6.6 or ΔPLR>49 should be treated more actively to prevent or reduce PPCs.

Physician preferences for chemotherapy in the treatment of non-small cell lung cancer in China: evidence from multicentre discrete choice experiments

OBJECTIVE

To evaluate physician risk-benefit preferences and trade-offs when making chemotherapy decisions for patients with non-small cell lung cancer (NSCLC).

DESIGN

A discrete choice experiment (DCE).

SETTINGS

Tertiary hospitals in Beijing, Shanghai, Guangzhou and Chengdu of China.

PARTICIPANTS

The participants were 184 physicians (mean age of 37 years) with more than 1 year of NSCLC chemotherapy practice.

OUTCOMES

The DCE survey was constructed by six attributes: progression-free survival (PFS), disease control rate (DCR), risk of moderate side effects, risk of severe side effects, mode of administration and out-of-pocket costs. Physicians' relative preferences and trade-offs in patient out-of-pocket costs for each attribute level were estimated using a mixed logit model, and interaction terms were added to the model to assess preferences variation among physicians with different sociodemographic factors.

RESULTS

Physicians had the strongest preferences for improvements in PFS, followed by reducing the risk of severe side effects. The DCR, risk of moderate side effects and mode of administration were ranked in decreasing order of importance. There was little variation in preferences among physicians with different sociodemographic characteristics. Physicians were willing to trade $4814 (95% CI $4149 to $5480) of patient out-of-pocket costs per month for a chemotherapy that guaranteed 11 months of PFS, followed by $1908 (95% CI $1227 to $2539) for reducing the risk of severe side effects to 2%.

CONCLUSIONS

With regard to chemotherapy for patients with NSCLC, prolonging PFS, reducing severe and moderate side effects were primary considerations for physicians in China. The mode of administration and treatment costs significantly influenced physicians' therapeutic decision. The current findings could add some evidence to inform NSCLC chemotherapy implementation and promote shared decision-making.

[Comparison of Effectiveness of Gefitinib, Erlotinib, and Afatinib in Advanced Non-small Cell Lung Cancer Patients with EGFR Mutation Positive in Indonesian Population]

Background and objective

EGFR-tyrosine kinase inhibitors (EGFR-TKIs) were used to treat non-small cell lung cancer (NSCLC) patients with EGFR mutation positive. This study aims to compare the effectiveness of first line TKIs; gefitinib, erlotinib, and afatinib in the treatment of advanced stage NSCLC patients with EGFR mutation positive in the Indonesian population.

Methods

A retrospective cohort study of 88 NSCLC patients with EGFR mutation positive treated with gefitinib (n=59), erlotinib (n=22), and afatinib (n=7) was performed in national cancer hospital in Indonesia.Inclusion criteria were stage Ⅲb or Ⅳ NSCLC with adenocarcinoma subtype. Subjects less than 18 years or with a history of other malignancy were excluded. Outcomes were treatment response, progression-free survival (PFS), and mortality rate.

Results

Complete response, partial response, and stable disease were shown in 1.1%, 35.2%, and 31.8% of subjects, respectively. There were 31.8% of subjects developed progressive disease during treatment. Regarding EGFR mutation positive profile, a total of 56.8% subjects had deletion in exon 19, 42% subjects had mutation in exon 21, and rare mutation in exon 18 was found in 3.4% of total subjects. Demography and clinical characteristics had no significant association with the risk of progressive disease. The median PFS of subjects was 11 months (95%CI: 6.8-15.2 months). There was no statistical difference of PFS between treatment groups.

Conclusion

Gefitinib, erlotinib, and afatinib have similar effectiveness in advanced stage NSCLC with EGFR mutation positive. Afatinib tends to be associated with longer PFS but further investigation is required.

Lung cancer and end-of-life care: a systematic review and thematic synthesis of aggressive inpatient care

OBJECTIVES

Despite recent advances in thoracic oncology, most patients with metastatic lung cancer die within months of diagnosis. Aggressiveness of their end-of-life (EOL) care has been the subject of numerous studies. This study was undertaken to evaluate the literature on aggressive inpatient EOL care for lung cancer and analyse the evolution of its aggressiveness over time.

METHODS

A systematic international literature search restricted to English-language publications used terms associated with aggressiveness of care, EOL and their synonyms. Two independent researchers screened for eligibility and extracted all data and another a random 10% sample of the abstracts. Electronic Medline and Embase databases were searched (2000-20 September 2018). EOL-care aggressiveness was defined as follows: 1) chemotherapy administered during the last 14 days of life (DOL) or new chemotherapy regimen during the last 30 DOL; 2) >2 emergency department visits; 3) >1 hospitalisation during the last 30 DOL; 4) ICU admission during the last 30 DOL and 5) palliative care started <3 days before death.

RESULTS

Among the 150 articles identified, 42 were retained for review: 1 clinical trial, 3 observational cohorts, 21 retrospective analyses and 17 administrative data-based studies. The percentage of patients subjected to aggressive therapy seems to have increased over time. Early management by palliative care teams seems to limit aggressive care.

CONCLUSIONS

Our analysis indicated very frequent aggressive EOL care for patients with lung cancer, regardless of the definition used. The extent of that aggressiveness and its impact on healthcare costs warrant further studies.

A Proposal to Reflect Survival Difference and Modify the Staging System for Lung Adenocarcinoma and Squamous Cell Carcinoma: Based on the Machine Learning

Objective: To propose modifications to refine prognostication over anatomic extent of the current tumor, node, and metastasis (TNM) staging system of non-small cell lung cancer (NSCLC) for a better distinction, and reflect survival differences of lung adenocarcinoma and squamous cell carcinoma. Study Design: Three large cohorts were included in this study. The training cohort consisted of 124,788 patients in the Surveillance, Epidemiology, and End Results (SEER) database (2006-2015). The validation cohort consisted of 4,247 patients from the Zhongshan Hospital, Fudan University (FDZSH; 2005-2014), and People's Hospital, Peking University (PKUPH; 2000-2017). The algorithm generated a hierarchical clustering model based on the unsupervised learning for survival data using Kaplan-Meier curves and log-rank test statistics for recursive partitioning and selection of the principal groupings. Results: In the modified staging system, adenocarcinoma cases are usually at a lower stage than the squamous cell carcinoma cases of the same TNM, reflecting a better outcome of adenocarcinoma than that of squamous cell carcinoma. The C-index of the modified staging system was significantly superior to that of the staging system [SEER cohort: 0.722, 95% CI, (0.721-0.723) vs. 0.643, 95% CI, (0.640-0.647); FDZSH cohort: 0.720, 95% CI, (0.709-0.731) vs. 0.519, 95% CI, (0.450-0.586); and PKUPH cohort: 0.730, 95% CI, (0.705-0.735) vs. 0.728, 95% CI, (0.703-0.753)]. Conclusion: Survival differences between lung adenocarcinoma and squamous cell carcinoma have been reflected accurately and reliably in the modified staging system based on the machine learning. It may refine prognostication over anatomic extent.

Association between single nucleotide polymorphisms of NOTCH signaling pathway-related genes and the prognosis of NSCLC

Objective

In this study, we analyzed the association between genetic variants of genes in the NOTCH signaling pathway and the prognosis of non-small-cell lung cancer (NSCLC) in the Chinese population. We also explored the interaction between genetic and epidemiological factors for the test group.

Methods

We performed genotyping of 987 NSCLC patients. Then, we used Cox proportional hazard models to analyze the associations between single-nucleotide polymorphisms (SNPs) and the prognosis of NSCLC. We employed Stata software to test the heterogeneity of associations between subgroups, and we analyzed the additive and multiplicative interactions between SNPs and epidemiologic factors.

Results

This work revealed the important prognostic and predictive value of rs915894 in the NOTCH4 gene, which may be regarded as a promising prognosis biomarker of NSCLC. Cox regression analysis indicated that the C allele of rs915894 is associated with longer survival and decreased risk of death in NSCLC (codominant model: adjusted HR =0.83, 95% CI =0.70-0.99; dominant model: adjusted HR =0.83, 95% CI =0.71-0.98). Additional stepwise regression analysis suggested that this SNP is an independently favorable factor for the prognosis of NSCLC (dominant model: adjusted HR =0.85, 95% CI =0.72-0.99). This protective effect is more pronounced for patients who are not smokers, have a history of other lung diseases, or have a family history of cancer. We also detected statistically significant additive and multiplicative interactions between rs915894 and smoking, rs915894 and history of lung diseases, and rs915894 and family history of cancer, which all affect NSCLC survival.

Conclusion

This study demonstrated that rs915894 in NOTCH 4 may be a genetic marker for NSCLC prognosis in the Chinese population and that rs915894 may have an interactive relationship with epidemiologic factors.

Silencing of RAD51AP1 suppresses epithelial-mesenchymal transition and metastasis in non-small cell lung cancer

Background

Non‐small cell lung cancer (NSCLC) is a major cause of cancer‐related mortality and is frequently accompanied by metastasis. The crucial roles of genes in lung cancer have attracted attention. Thus, this study aimed to investigate the effects of RAD51AP1 on the epithelial–mesenchymal transition (EMT) and metastasis of NSCLC.

Methods

The positive expression rate of the RAD51AP1 protein was examined. NSCLC cells were transfected with a series of plasmids to alter the expression of RAD51AP1 to clarify the influence of RAD51AP1 on EMT and metastasis in NSCLC, as well as NSCLC cell migration, invasion, apoptosis, proliferation, and cloning. An in vivo experiment was conducted to determine the oncogenicity of human NSCLC cells in nude mice.

Results

RAD51AP1 was highly expressed in NSCLC tissues. Furthermore, we found promotion of N‐cadherin, vimentin, fibronectin, MMP‐2, OPN, CD62, and TMP‐2, but inhibition of E‐cadherin, occludin, cytokeratin in the context of elevated RAD51AP1 expression. An in vivo experiment also confirmed that silencing of RAD51AP1 could inhibit NSCLC tumor formation and growth.

Conclusion

Our results revealed that RAD51AP1 silencing suppressed the EMT and metastasis of NSCLC, thereby highlighting its potential as a promising novel target for NSCLC treatment.

Prognostic value of a novel scoring system using inflammatory response biomarkers in non-small cell lung cancer: A retrospective study

Background

The neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and lymphocyte‐to‐monocyte ratio (LMR) are reported to show a strong correlation with prognosis in patients with non‐small cell lung cancer (NSCLC). We aimed to describe a novel scoring system combining these ratios, termed the inflammatory response biomarker (IRB) score, and test its prognostic value in NSCLC.

Methods

The data of 261 NSCLC patients who underwent thoracoscopic radical resection in a single center were retrospectively reviewed. The IRB score was defined as follows: a high NLR (> 2.12), a high PLR (92.9), and a low LMR (< 4.57) were each scored as 1; the opposite values were scored as 0. The individual scores were added to produce the IRB score (range: 0–3).

Results

Multivariate analyses indicated that high tumor node metastasis (TNM) stage (hazard ratio [HR] 2.721, 95% confidence interval [CI] 1.597–4.989; P < 0.001) and an IRB score ≥ 2 (HR 2.696, 95% CI 1.506–4.826; P = 0.001) were independent prognostic factors for poor overall survival. Furthermore, smoking history (HR 2.953, 95% CI 1.086–8.026; P = 0.034), high TNM stage (HR 3.108, 95% CI 1.911–5.056; P < 0.001), and IRB score ≥ 2 (HR = 2.316, 95% CI: 1.389–3.861; P = 0.001) were demonstrated to be independent prognostic factors for poor disease‐free survival.

Conclusion

The novel scoring system combining NLR, PLR, and LMR was an independent prognostic factor in NSCLC patients undergoing thoracoscopic radical resection and was superior to these ratios alone for predicting prognosis.

Clinical characteristics and prognostic analysis of multiple primary malignant neoplasms in patients with lung cancer

Retrospective analysis of data from 14,528 lung cancer patients with multiple primary malignant neoplasm (MPMN) revealed that 2.5% (364/14,528) were MPMN cases and 96.2% (350/364) were diagnosed with two primary malignancies, 3.6% (13/364) with three primary malignancies, and 0.3% (1/364) with four primary malignancies. Among 350 lung cancer patients diagnosed with two primary malignancies, 26.6% (93/350) had lung cancer diagnosed first (LCF) and 73.4% (257/350) had other cancers diagnosed initially (OCF), whereas synchronous MPMN (SMPMN) accounted for 21.1% (74/350) and metachronous MPMN (MMPMN) accounted for 78.9% (276/350) of the cases. Detection of first primary neoplasms were at an early stage for LCF patients and the age of the first lung cancer diagnosis was 59.3 years vs. 55.4 years in the OCF group (P = 0.008), whereas the onset age of second primary neoplasm diagnosis was similar in both groups (62.5 and 61.6 years, P = 0.544). Median survival times of MMPMN and SMPMN patients in the LCF group were 6.83 and 2.42 years and in the OCF group 8.67 years and 2.25 years, respectively. Multivariate analysis showed that SMPMN, LCF and the age of the primary cancer diagnosed first ( ≥ 60 years) and NSCL staging  > II were significant independent factors for inferior prognosis of patients.

Prognostic significance of combined preoperative platelet-to-lymphocyte ratio and lymphocyte-to-monocyte ratio in patients undergoing surgery with stage IB non-small-cell lung cancer

Background

Research indicates that the presence of a systemic inflammatory response plays an important role in predicting survival in patients with cancer. The aim of this study was to investigate the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), prognostic nutritional index, and the combination of preoperative LMR and PLR (LMR-PLR) in predicting the survival of patients with stage IB non-small-cell lung cancer (NSCLC).

Materials and methods

We retrospectively analyzed clinical data of 577 patients with stage IB NSCLC who underwent pneumonectomy from January 1999 to December 2009. Univariate and multivariate Cox survival analyses were used to evaluate the prognostic indicators, including LMR-PLR. The cutoff values for LMR and PLR were defined by the receiver operating characteristic (ROC) curve analysis. According to the ROC curve, the recommended cutoff values of LMR and PLR were 3.16 and 81.07, respectively. We divided the patients into three groups according to their LMR and PLR status and defined them with different scores. Patients with both high LMR (>3.16) and low PLR (≤81.07) were given a score of 2, whereas those with one or neither were scored 1 or 0, respectively. Survival curves were plotted using the Kaplan–Meier method and compared with the log-rank test. Cox proportional hazards analyses were used to identify the factors associated with overall survival (OS).

Results

The median follow-up time was 93.77 months. The allocation of the LMR-PLR score was as follows: LMR-PLR = 0, 193 (33.4%) patients; LMR-PLR = 1, 308 (53.4%) patients; and LMR-PLR = 2, 76 (13.2%) patients. After multivariate analysis, our results showed that LMR-PLR was an independent prognostic indicator for OS (P=0.001). The 10-year OS rates were 70.0%, 60.4%, and 49.5% for LMR-PLR =2, LMR-PLR =1, and LMR-PLR =0, respectively (P<0.001).

Conclusion

This study demonstrated that preoperative LMR and PLR are simple, readily available, and low-cost biomarkers. Preoperative LMR-PLR score can be used as a valuable prognostic marker for long-term survival in stage IB NSCLC patients who underwent surgery.

Quantitative profiling of cortisol metabolites in human urine by high-resolution accurate-mass MS

Aim, materials & methods: Urinary cortisol profile has the potential as a diagnostic biomarker. We therefore developed a stable-isotope dilution ultraperformance chromatography multistage MS-based method to quantify cortisol and 16 metabolites in human urines. Results & conclusion: The LOD for cortisol and its metabolites ranges from 0.02 to 5.81 pg/μl urine. The inter- and intraday variations were 3.7-12.9% and 3.5-15.6%, respectively. Among the metabolites analyzed, significant person-to-person heterogeneity was observed, demonstrating the need for comprehensive metabolite profiling in diagnosis. Nevertheless, the glucuronides of dihydrocortisol, dihydrocortisone, tetrahydrocortisol, allo-tetrahydrocortisol and tetrahydrocortisone are the major ones. The sum of the glucuronidated and free forms constitute >93% of the metabolites analyzed, which is termed as total cortisol equivalent. Total cortisol equivalent may serve as a surrogate of cortisol secretion. Clinical trial registration number: NCT02500472.

Lung cancer with bone metastases in the United States: an analysis from the Surveillance, Epidemiologic, and End Results database

The present study used the Surveillance, Epidemiology and End Results (SEER) database to identify demographic and prognostic characteristics of lung cancer with bone metastases in the United States from 2010 to 2014. 30,364 patients with metastatic lung cancer to bones were identified in the SEER database. Their information on the basic characteristics and the histological signatures of the cancer was extracted and analyzed. Joinpoint analysis was used to test the trends in annual percentage change (APC) of the incidence. 1-year survival rate among patients with metastatic lung cancer to bones was only 20.2%, and median survival time was about 3.0 months for those patients. Young age, female sex, race other than white and black, tumor in lobes, smaller tumor, adenocarcinoma, and surgery for primary site were associated with a significant survival benefit. APC of the incidence almost increased steadily on the whole and reached the level of statistical significance among the patients older than age 60. Although there are some signatures associated with better prognosis, the overall outcome remains very poor in patients with metastatic lung cancer to bones. In addition, the incidence of lung cancer with bone metastases is increasing in certain subgroups in the United States.

The roles of tumor-derived exosomes in non-small cell lung cancer and their clinical implications

Non-small cell lung cancer (NSCLC) accounts for approximately 85% of lung cancer cases, and it is one of the leading causes of cancer death in both men and women worldwide due to diagnosis in the advanced stage, rapid metastasis, and recurrence. At present, precision molecular targeted therapeutics directed toward NSCLC driven genes has made great progress and significantly improved the overall survival of patients with NSCLC, but can easily lead to acquired drug resistance. New methods are needed to develop real-time monitoring of drug efficacy and drug resistance, such as new molecular markers for more effective early detection and prediction of prognosis. Exosomes are nano-sized extracellular vesicles, containing proteins, nucleic acids and lipids, which are secreted by various cells, and they play an important role in the development of lung cancer by controlling a wide range of pathways. Tumor-derived exosomes are of great significance for guiding the targeted therapy of NSCLC and exosomes themselves can be a target for treatment. In this review, we describe the potential roles of tumor-derived exosomes and their clinical significance in NSCLC.

Prevalence of and risk factors for presenting initial respiratory symptoms in patients undergoing surgery for lung cancer

Background: Patients with early stage lung cancer seldom present initial respiratory symptoms, causing a delayed diagnosis and missed opportunity to receive operation. This study aimed to investigate the prevalence of initial respiratory symptoms and identity what factors would predispose lung cancer patients to present initial respiratory symptoms in patients undergoing lung cancer surgery. Methods: A retrospective chart review was conducted on 3,203 patients undergoing surgery for primary lung cancer. The prevalence of initial respiratory symptoms was investigated and the comparisons of clinicopathological parameters were performed between patients with and without initial respiratory symptoms or between patients with single and multiple initial respiratory symptoms. Independent risk factors for presenting initial respiratory symptoms or multiple initial respiratory symptoms were identified using a logistic regression. Results: A total of 1,474 (46.0%) patients with lung cancer were admitted to hospital due to present initial respiratory symptoms. Symptom clusters of cough or sputum (33.1%) and bloody sputum or hemoptysis (16.7%) presented as the two major chief complaints for medical consultation while chest pain (6.9%) and chest distress or dyspnea (5.6%) remained relatively unusual. Multiple analyses found that coexisting chronic obstructive pulmonary disease (OR=1.70, 95% CI=1.41-2.05), tumor size >3 cm (OR=2.27, 95% CI=1.93-2.67), squamous cell carcinoma (OR=2.22, 95% CI=1.86-2.65), tumor located in left lower lung (OR=1.39, 95% CI=1.10-1.74) and advanced tumor stage (OR=1.27, 95% CI=1.06-1.52) were independent risk factors for presenting initial respiratory symptoms. Furthermore, current smoking (OR=1.36, 95% CI=1.07-1.73), tumor size >3 cm (OR=1.53, 95% CI=1.21-1.93) and squamous cell carcinoma (OR=1.68, 95% CI=1.32-2.15) were demonstrated to be independent risk factors for presenting multiple initial respiratory symptoms. Conclusions: Presenting initial respiratory symptoms was the common cause for medical consultation in patients undergoing lung cancer surgery. Patients with lung cancer in larger tumor size or squamous cell carcinoma more likely presented initial and even multiple initial respiratory symptoms.

Influence of different drug delivery methods for Endostar combined with a gemcitabine/cisplatin regimen in locally advanced or metastatic lung squamous cell carcinoma: A retrospective observational study

Continuous endovenous administration of Endostar (CE) gradually replaced drip intravenous administration of Endostar (DE) in lung squamous cell carcinoma (SCC) treatment presently, but the efficacy and safety of CE and DE which is better in advanced lung SCC are yet unclear. To evaluate the feasibility of CE as an alternative to DE with gemcitabine/cisplatin (GP) chemotherapy. Data were collected from patients admitted with locally advanced or metastatic lung SCC from January 2011 to April 2015, including the patients' characteristics, the therapeutic regimen, the treatment effectiveness, and toxicity. There are 71 patients with pathologically confirmed lung SCC retrospectively assigned to a treatment (CE) group of 48 patients and a control (DE) group of 23 patients. The response of each tumor to the therapy was assessed every 2 cycles by a chest and upper abdomen computed tomography for the comparison of curative effects and adverse reactions. Compared with the DE group, the response rate and disease control rate were noninferior in the CE group. The median progression-free survival and overall survival in the CE and DE groups were no significantly difference (5.5 vs 5.5 months, P = .141; 22.9 vs 14.3 months, P = .053). Increased progression-free survival (PFS) for patients in CE group was observed across 3 subgroups analyzed. There was a 35.7% reduction in the total dose of Endostar per cycle in the CE group compared with that in the DE group. Thus, in combination with GP chemotherapy, CE could be a suitable alternative to DE in locally advanced or metastatic SCC patients, resulting in less hemoptysis, less treatment time, and lower costs.

A stable isotope dilution tandem mass spectrometry method of major kavalactones and its applications

Kava is regaining its popularity with detailed characterizations warranted. We developed an ultraperformance liquid chromatography high-resolution tandem mass spectrometry (UPLC-MS/MS) method for major kavalactones (kavain, dihydrokavain, methysticin, dihydromethysticin and desmethoxyyangonin) with excellent selectivity and specificity. The method has been validated for different matrices following the Food and Drug Administration guidance of analytical procedures and methods validation. The scope of this method has been demonstrated by quantifying these kavalactones in two kava products, characterizing their tissue distribution and pharmacokinetics in mice, and detecting their presence in human urines and plasmas upon kava intake. As expected, the abundances of these kavalactones differed significantly in kava products. All of them exhibited a large volume of distribution with extensive tissue affinity and adequate mean residence time (MRT) in mice. This method also successfully quantified these kavalactones in human body fluids upon kava consumption at the recommended human dose. This UPLC-MS/MS method therefore can be used to characterize kava products and its pharmacokinetics in animals and in humans.

Health state utilities in patients with advanced non-small-cell lung cancer in China

AIM

Non-small-cell lung cancer (NSCLC) is a leading global health threat that impairs patient health outcomes. Health state utilities are fundamental values in economic evaluation and significantly vary across countries. Given the scarce data on the Chinese population, the current study measured utility values in the Chinese patients with NSCLC.

METHODS

This study was conducted as a cross-sectional survey of patients with advanced NSCLC at the Shanghai Chest Hospital. Utility values were assessed using the EuroQol five-dimension (EQ-5D) instrument and scored based on the Chinese-specific value algorithm. Predictors of utility values were examined using a subgroup analysis and a multiple regression model.

RESULTS

The mean EQ-5D utility value of recruited patients was 0.814. The regression analysis revealed that tumor stage, treatment regimen and line of therapy were the potential predictors of utility values.

CONCLUSION

This study provides the Chinese-specific health utility data for advanced NSCLC using the EQ-5D.

Evaluating the Time to Palliative Care Referrals in Patients With Small-Cell Lung Cancer: A Single-Centre Retrospective Review

INTRODUCTION

Lung cancer is a leading cause of morbidity and mortality worldwide. Patients with lung cancer may experience a plethora of symptoms, which can be debilitating and affect their quality of life. Palliative care input to manage their physical and psychological well-being is a crucial component of their oncological care. The benefit of early palliative care input has been shown in patients with non-small cell lung cancer; however, data pertaining to patients with small-cell lung cancer are scarce. Nevertheless, early palliative care input is recommended by several national and international guidelines. Thus, we aimed to assess the time to palliative care referrals in patients diagnosed with small-cell lung cancer in an Irish tertiary hospital and to determine what impact this had on overall survival.

METHODS

We performed a retrospective, single-center audit of all patients diagnosed with extensive stage small-cell lung cancer over a 6-year period in an Irish tertiary hospital.

RESULTS

Overall, 91 patients were identified. Median age at diagnosis was 66 years (range: 38-83 years). The median Eastern Cooperative Oncology Group Performance Status at diagnosis was 1 (range: 0-3); 24 (26%) patients had multiple sites of distant metastasis at diagnosis; 45 (49.5%) patients were alive at 6 months, and 15 (16.5%) patients were alive at 12 months. One hundred percent of patients received palliative care input in our center over the course of their care. In the patients alive at 6 months after diagnosis, there was no survival advantage in those receiving palliative care within 1 month ( P = .002, odd ratio: 0.23, 95% confidence interval: 0.09-0.59).

CONCLUSION

Palliative care treatment is a critical aspect in the oncological treatment of all patients diagnosed with advanced cancer, and this study highlights good compliance with existing national guidelines. Further research focusing on quality-of-life issues with the use of questionnaires to assess physical and psychological symptoms should be performed to further understand the impact of palliative care in these patients.

Gender and outcomes in non-small cell lung cancer: an old prognostic variable comes back for targeted therapy and immunotherapy?

Background

There are well-known differences in gender outcome in non-small cell lung cancer (NSCLC) and other cancers. In this work, we evaluated several randomised clinical trials to explore the gender influence in the outcome of patients with NSCLC treated with targeted therapy and immunotherapy.

Methods

We performed a series of meta-analysis to compare the gender outcome in the routine setting for overall survival and progression-free survival (PFS) in phase III randomised clinical trials comparing EGFR inhibitors versus chemotherapy (OPTIMAL, LUX-lung 3, LUX-lung 6, EURTAC, ENSURE and WTJOG); ALK inhibitors versus chemotherapy (ASCEND 4, ASCEND 5, PROFILE 1014 and NCT009323893) and anti-PD1 checkpoint inhibitors versus chemotherapy (CheckMate 017, CheckMate 026, CheckMate 057, KEYNOTE 010 and KEYNOTE 024).

Results

Female patients with NSCLC have a reduced risk of death compared with men (HR=0.73; 95% CI 0.67 to 0.79; p<0.00001). Women had a better benefit from EGFR inhibitors than men (HR=0.34; 95% CI 0.28 to 0.40; p<0.00001 vs HR=0.44; 95% CI 0.34 to 0.56; p<0.00001, respectively). The benefit from ALK inhibitors was similar for both genders (HR=0.51; 95% CI 0.42 to 0.61; p<0.00001 vs HR=0.48; 95% CI 0.39 to 0.59; p<0.00001, for women and men, respectively). Anti-PD1 inhibitors significantly improved the PFS in male patients when compared with chemotherapy (HR=0.76; 95% CI 0.68 to 0.86; p<0.00001); in contrast, women showed no benefit in 5/5 randomised trials (HR=1.03; 95% CI 0.89 to 1.20; p=0.69).

Conclusions

In this exploratory study, some targeted treatments were influenced by gender. Despite differences in outcomes that could be attributed to different histology, EGFR and smoking status, gender should be evaluated more deeply as prognostic variable in patients with NSCLC.

Preoperative platelet to lymphocyte and neutrophil to lymphocyte ratios are independent prognostic factors for patients undergoing lung cancer radical surgery: A single institutional cohort study

BACKGROUND

The aim of this study was to assess the prognostic value for NSCLC patients who were scheduled to receive lung cancer radical resection.

METHODS

In this cohort study (Dec.2014-Feb.2016), patients with non-small cell lung cancer (NSCLC) who underwent radical lung cancer thoracotomy were enrolled and accessed at postoperative complications, one-year overall survival (OS) and relapse-free survival (RFS). The preoperative PLR and NLR of all patients were calculated based on preoperative complete blood counts. Univariate and multivariate Cox regression analyses were performed to determine the associations of PLR and NLR with OS and RFS.

RESULTS

A total of 174 NSCLC patients were studied. The results indicated that both high PLR (>148.6) and NLR (>2.9) were related to a high rate of postoperative pulmonary complications significantly (49.3%vs.29.1%, P = 0.007; 50.7% vs. 28.6%, P = 0.003). Moreover, NSCLC patients with a high PLR level (> 148.6) was significantly associated with a lower one-year OS (90.3% vs. 77.5%, P = 0.034).

CONCLUSIONS

Preoperative PLR and NLR were good prognostic factors for postoperative pulmonary complications and OS in NSCLC patients undergoing radical lung cancer surgery. Thus, blood PLR and NLR would be helpful as a prognostic tool before radical lung cancer surgery.

High circulating miR-18a, miR-20a, and miR-92a expression correlates with poor prognosis in patients with non-small cell lung cancer

The purpose of this study was to assess the predictive value of angiogenic miRNAs for disease-free survival (DFS) and overall survival (OS) of patients with non-small cell lung cancer (NSCLC). In total, 196 patients with NSCLC (tumor lymph nodes metastasis (TNM) stage I-III) were enrolled and peripheral blood samples were collected. Total RNA was extracted from blood samples, and the relative expression levels of candidate miRNAs were evaluated by real time-polymerase chain reaction (RT-PCR). The median follow-up period was 56.7 months, and the final follow-up date was in August 2016. The median DFS of all patients was 30.0 (14.0-49.0) months, whereas the median OS was 41.5 (23.0-58.0) months. Furthermore, the 5-year DFS and OS rates were 11.3% and 32.3%, respectively. Kaplan-Meier (K-M) curves showed that high plasma miR-18a (P < 0.001), miR-20a (P < 0.001), miR-92a (P < 0.001), miR-126 (P < 0.001), miR-210 (P = 0.003), and miR-19a (P = 0.027) expressions levels correlated with a worse DFS. Moreover, patients with high plasma miR-18a, miR-20a, miR-92a, miR-210, and miR-126 expression levels had a shorter OS than patients with low expression levels of these miRNAs (all P <= 0.001). Furthermore, multivariate Cox regression analyses revealed that high plasma expression levels of miR-18a, miR-20a, and miR-92a as well as lymphatic node metastasis (all P < 0.001) were independent risk factors for both DFS and OS in patients with NSCLC. Thus, the circulating miR-18a, miR-20a, and miR-92a levels may serve as novel and promising prognostic biomarkers in patients with NSCLC.

Development and validation of two prognostic nomograms for predicting survival in patients with non-small cell and small cell lung cancer

Purpose

This study aimed to construct two prognostic nomograms to predict survival in patients with non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC) using a novel set of clinical parameters.

Patients and Methods

Two nomograms were developed, using a retrospective analysis of 5384 NSCLC and 647 SCLC patients seen during a 10-year period at Xiang Ya Affiliated Cancer Hospital (Changsha, China). The patients were randomly divided into training and validation cohorts. Univariate and multivariate analyses were used to identify the prognostic factors needed to establish nomograms for the training cohort. The model was internally validated via bootstrap resampling and externally certified using the validation cohort. Predictive accuracy and discriminatory capability were estimated using concordance index (C-index), calibration curves, and risk group stratification.

Results

The largest contributor to overall survival (OS) prognosis in the NSCLC nomogram was the therapeutic regimen and diagnostic method parameters, and in the SCLC nomogram was the therapeutic regimen and health insurance plan parameters. Calibration curves for the nomogram prediction and the actual observation were in optimal agreement for the 3-year OS and acceptable agreement for the 5-year OS in both training datasets. The C-index was higher for the NSCLC cohort nomogram than for the TNM staging system (0.67 vs. 0.64, P = 0.01) and higher for the SCLC nomogram than for the clinical staging system (limited vs. extensive) (0.60 vs. 0.53, P = 0.12).

Conclusion

Treatment regimen parameter made the largest contribution to OS prognosis in both nomograms, and these nomograms might provide clinicians and patients a simple tool that improves their ability to accurately estimate survival based on individual patient parameters rather than using an averaged predefined treatment regimen.

Mortality outcomes of low-dose computed tomography screening for lung cancer in urban China: a decision analysis and implications for practice

BACKGROUND

Mortality outcomes in trials of low-dose computed tomography (CT) screening for lung cancer are inconsistent. This study aimed to evaluate whether CT screening in urban areas of China could reduce lung cancer mortality and to investigate the factors that associate with the screening effect.

METHODS

A decision tree model with three scenarios (low-dose CT screening, chest X-ray screening, and no screening) was developed to compare screening results in a simulated Chinese urban cohort (100,000 smokers aged 45-80 years). Data of participant characteristics were obtained from national registries and epidemiological surveys for estimating lung cancer prevalence. The selection of other tree variables such as sensitivities and specificities of low-dose CT and chest X-ray screening were based on literature research. Differences in lung cancer mortality (primary outcome), false diagnoses, and deaths due to false diagnosis were calculated. Sensitivity analyses were performed to identify the factors that associate with the screening results and to ascertain worst and optimal screening effects considering possible ranges of the variables.

RESULTS

Among the 100,000 subjects, there were 448, 541, and 591 lung cancer deaths in the low-dose CT, chest X-ray, and no screening scenarios, respectively (17.2% reduction in low-dose CT screening over chest X-ray screening and 24.2% over no screening). The costs of the two screening scenarios were 9387 and 2497 false diagnoses and 7 and 2 deaths due to false diagnosis among the 100,000 persons, respectively. The factors that most influenced death reduction with low-dose CT screening over no screening were lung cancer prevalence in the screened cohort, low-dose CT sensitivity, and proportion of early-stage cancers among low-dose CT detected lung cancers. Considering all possibilities, reduction in deaths (relative numbers) with low-dose CT screening in the worst and optimal cases were 16 (5.4%) and 288 (40.2%) over no screening, respectively.

CONCLUSIONS

In terms of mortality outcomes, our findings favor conducting low-dose CT screening in urban China. However, approaches to reducing false diagnoses and optimizing important screening conditions such as enrollment criteria for screening are highly needed.