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Stares M, Doyle E, Chapple S, Raynes G, MacDonald J, Barrie C, Laird B, MacKean M, Philips I. Prognostic value of the Scottish Inflammatory prognostic Score in patients with NSCLC expressing PD-L1 ≥ 50 % progressing on first-line pembrolizumab. Lung Cancer 2024; 189:107497. [PMID: 38295631 DOI: 10.1016/j.lungcan.2024.107497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 01/17/2024] [Accepted: 01/27/2024] [Indexed: 03/04/2024]
Abstract
BACKGROUND Most patients with advanced non-small cell lung cancer (NSCLC) treated with first-line pembrolizumab monotherapy will experience progressive disease (PD). Only a minority will go on to receive subsequent systemic anticancer therapy for which outcomes are guarded. We investigated the prognostic significance of biomarkers of systemic inflammation following failure of first-line pembrolizumab for NSCLC to aid subsequent management decisions. METHODS Patients with radiological and/or clinical evidence of PD on first-line pembrolizumab for advanced NSCLC at a regional Scottish cancer centre were identified. Inflammatory biomarkers at the time of PD, including serum albumin, neutrophil count and the Scottish Inflammatory Prognostic Score (SIPS; combing albumin and neutrophils), and clinicopathological factors, including age, sex, histology, PDL1 expression and time to PD were recorded. The relationship between these and post-progression overall survival (ppOS) were examined. RESULTS Data were available for 211 patients. Median ppOS was 2.1 months. Only SIPS was predictive of ppOS on multivariate analysis (HR2.54 (95 %CI 1.81-3.56) (<0.001)), stratifying ppOS from 0.8 months (SIPS2), to 1.8 months (SIPS1), to 8.1 months (SIPS0) (p < 0.001). Thirty (14 %) patients received second-line systemic anticancer therapy with median ppOS 8.7 months. These patients had lower levels of systemic inflammation, as defined by albumin (p < 0.001), neutrophil count (p = 0.002), and SIPS (p = 0.004)), than all other patients. CONCLUSIONS SIPS, a simple biomarker of systemic inflammation, predicts ppOS after first-line pembrolizumab and may be useful alongside routine assessments of patient fitness to inform individualised discussions about subsequent treatment. We highlight poor outcomes in this patient group and a role for SIPS in signposting transition to best supportive care and early referral to palliative care. It may also help identify a small group of patients most likely to benefit from further lines of therapy.
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Affiliation(s)
- Mark Stares
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK; University of Edinburgh, Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK.
| | - Emma Doyle
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Sally Chapple
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - George Raynes
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - James MacDonald
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Colin Barrie
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Barry Laird
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK; University of Edinburgh, Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK
| | - Melanie MacKean
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK
| | - Iain Philips
- Edinburgh Cancer Centre, NHS Lothian, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK; University of Edinburgh, Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, Western General Hospital, Crewe Road South, Edinburgh EH4 2XR, UK
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Hall CC, Skipworth RJ, Blackwood H, Brown D, Cook J, Diernberger K, Dixon E, Gibson V, Graham C, Hall P, Haraldsdottir E, Hopkinson J, Lloyd A, Maddocks M, Norris L, Tuck S, Fallon MT, Laird BJ. A randomized, feasibility trial of an exercise and nutrition-based rehabilitation programme (ENeRgy) in people with cancer. J Cachexia Sarcopenia Muscle 2021; 12:2034-2044. [PMID: 34612012 PMCID: PMC8718057 DOI: 10.1002/jcsm.12806] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/03/2021] [Accepted: 08/23/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite rehabilitation being increasingly advocated for people living with incurable cancer, there is limited evidence supporting efficacy or component parts. The progressive decline in function and nutritional in this population would support an approach that targets these factors. This trial aimed to assess the feasibility of an exercise and nutrition based rehabilitation programme in people with incurable cancer. METHODS We randomized community dwelling adults with incurable cancer to either a personalized exercise and nutrition based programme (experimental arm) or standard care (control arm) for 8 weeks. Endpoints included feasibility, quality of life, physical activity (step count), and body weight. Qualitative and health economic analyses were also included. RESULTS Forty-five patients were recruited (23 experimental arm, 22 control arm). There were 26 men (58%), and the median age was 78 years (IQR 69-84). At baseline, the median BMI was 26 kg/m2 (IQR: 22-29), and median weight loss in the previous 6 months was 5% (IQR: -12% to 0%). Adherence to the experimental arm was >80% in 16/21 (76%) patients. There was no statistically significant difference in the following between trial arms: step count - median % change from baseline to endpoint, per trial arm (experimental -18.5% [IQR: -61 to 65], control 5% [IQR: -32 to 50], P = 0.548); weight - median % change from baseline to endpoint, per trial arm (experimental 1%[IQR: -3 to 3], control -0.5% [IQR: -3 to 1], P = 0.184); overall quality of life - median % change from baseline to endpoint, per trial arm (experimental 0% [IQR: -20 to 19], control 0% [IQR: -23 to 33], P = 0.846). Qualitative findings observed themes of capability, opportunity, and motivation amongst patients in the experimental arm. The mean incremental cost of the experimental arm versus control was £-319.51 [CI -7593.53 to 6581.91], suggesting the experimental arm was less costly. CONCLUSIONS An exercise and nutritional rehabilitation intervention is feasible and has potential benefits for people with incurable cancer. A larger trial is now warranted to test the efficacy of this approach.
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Affiliation(s)
- Charlie C. Hall
- St Columba's HospiceEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | | | | | | | | | - Katharina Diernberger
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
- Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
| | - Elizabeth Dixon
- Southampton Clinical Trials UnitUniversity of SouthamptonSouthamptonUK
| | | | - Catriona Graham
- Edinburgh Clinical Research FacilityUniversity of EdinburghEdinburghUK
| | - Peter Hall
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
- Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
| | | | | | | | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Kings CollegeLondonUK
| | - Lucy Norris
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Sharon Tuck
- Edinburgh Clinical Trials UnitUniversity of EdinburghEdinburghUK
| | - Marie T. Fallon
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Barry J.A. Laird
- St Columba's HospiceEdinburghUK
- Institute of Genetics and CancerUniversity of EdinburghEdinburghUK
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Stares M, Swan A, Cumming K, Ding TE, Leach J, Stratton C, Thomson F, Barrie C, MacLennan K, Campbell S, Evans T, Tufail A, Harrow S, MacKean M, Phillips I. Hypoalbuminaemia as a Prognostic Biomarker of First-Line Treatment Resistance in Metastatic Non-small Cell Lung Cancer. Front Nutr 2021; 8:734735. [PMID: 34660664 PMCID: PMC8517082 DOI: 10.3389/fnut.2021.734735] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction: Despite significant advances in systemic anticancer therapy (SACT) for non-small cell lung cancer (NSCLC), many patients still fail to respond to treatment or develop treatment resistance. Albumin, a biomarker of systemic inflammation and malnutrition, predicts survival in many cancers. We evaluated the prognostic significance of albumin in patients receiving first-line targeted therapy or immunotherapy-based SACT for metastatic NSCLC. Methods: All patients treated with first-line targeted therapy or immunotherapy-based SACT for metastatic NSCLC at a regional Scottish cancer centre were identified. Serum albumin at pre-treatment, after 12-weeks of treatment, and at the time of progressive disease were recorded. The relationship between albumin (≥ 35g/L v <35g/L) and overall survival (OS) was examined. Results: Data were available for 389 patients of both targeted therapy cohort (n = 159) and immunotherapy-based therapy cohort (n = 230). Pre-treatment albumin was predictive of OS in each cohort at HR1.82 (95%CI 1.23–2.7) (p =0.003) and HR2.55 (95%CI 1.78–3.65) (p < 0.001), respectively. Pre-treatment albumin <35 g/L was associated with a significantly higher relative risk of death within 12 weeks in each cohort at RR9.58 (95%CI 2.20–41.72, p = 0.003) and RR3.60 (95%CI 1.74–6.57, p < 0.001), respectively. The 12-week albumin was predictive of OS in each cohort at HR1.88 (95%CI 1.86–4.46) (p < 0.001) and HR2.67 (95%CI 1.74–4.08) (p < 0.001), respectively. 46 out of 133 (35%) evaluable patients treated with targeted therapy and 43 out of 169 (25%) treated with immunotherapy-based therapy crossed over albumin prognostic groups between pre-treatment and 12-week. The prognostic value of 12-week albumin was independent of pre-treatment albumin status. A majority of patients had albumin <35g/L at the time of progressive disease when it was also predictive of survival following progressive disease at HR2.48 (95%CI 1.61–3.82) (p < 0.001) and HR2.87 (95%CI 1.91–4.31) (p < 0.001) respectively). Conclusions: Albumin is a reliable prognostic factor in patients with metastatic NSCLC, predicting survival independent of the class of drug treatment at various time points during the patient journey. Tracking albumin concentrations during systemic therapy may indicate disease activity or treatment response over time.
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Affiliation(s)
- Mark Stares
- Edinburgh Cancer Centre, Edinburgh, United Kingdom.,Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - Amanda Swan
- Edinburgh Cancer Centre, Edinburgh, United Kingdom
| | | | - Tze-En Ding
- Edinburgh Cancer Centre, Edinburgh, United Kingdom
| | - James Leach
- Edinburgh Cancer Centre, Edinburgh, United Kingdom
| | - Cory Stratton
- Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - Findlay Thomson
- Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
| | - Colin Barrie
- Edinburgh Cancer Centre, Edinburgh, United Kingdom
| | | | | | | | - Aisha Tufail
- Edinburgh Cancer Centre, Edinburgh, United Kingdom
| | | | | | - Iain Phillips
- Edinburgh Cancer Centre, Edinburgh, United Kingdom.,Edinburgh Cancer Research UK Centre, Edinburgh, United Kingdom
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The Relationship between ECOG-PS, mGPS, BMI/WL Grade and Body Composition and Physical Function in Patients with Advanced Cancer. Cancers (Basel) 2020; 12:cancers12051187. [PMID: 32397102 PMCID: PMC7281405 DOI: 10.3390/cancers12051187] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/28/2020] [Accepted: 05/04/2020] [Indexed: 12/31/2022] Open
Abstract
Cancer remains one of the leading causes of mortality worldwide and the associated reduction in physical function has a marked impact on both quality of life and survival. The aim of the present study was to examine the relationship between Eastern Cooperative Oncology Group-Performance status (ECOG-PS), modified Glasgow Prognostic Score (mGPS), Body Mass Index/ Weight Loss grade (BMI/WL grade), and Computerised Tomography (CT)-derived body composition measurement and physical function in patients with advanced cancer. Nine sites contributed prospective data on patient demographics, ECOG-PS, mGPS, physical function tests, and CT-derived body composition. Categorical variables were analysed using χ2 test for linear-by-linear association, or χ2 test for 2-by-2 tables. Associations were analysed using binary logistic regression. A total of 523 cancer patients (266 males, 257 females) were included in the final analysis and most had metastatic disease (83.2%). The median overall survival was 5.6 months. On multivariate binary logistic regression analysis, a high ECOG-PS remained independently associated with a low skeletal muscle index (p < 0.001), low skeletal muscle density (p < 0.05), and timed up and go test failure (p < 0.001). A high mGPS remained independently associated with a low skeletal muscle density (p < 0.05) and hand grip strength test failure (p < 0.01). A high BMI/WL grade remained independently associated with a low subcutaneous fat index (p < 0.05), low visceral obesity (p < 0.01), and low skeletal muscle density (p < 0.05). In conclusion, a high ECOG-PS and a high mGPS as outlined in the ECOG-PS/mGPS framework were consistently associated with poorer body composition and physical function in patients with advanced cancer.
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Harding Z, Hall C, Lloyd A. Rehabilitation in palliative care: a qualitative study of team professionals. BMJ Support Palliat Care 2019; 12:e28-e38. [PMID: 31888873 DOI: 10.1136/bmjspcare-2019-002008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/14/2019] [Accepted: 11/19/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES There has been a recent drive to embed rehabilitation within palliative care. The concept of rehabilitative palliative care has been advocated to help patients preserve function and independence, through greater patient enablement and self-management. Such an approach requires engagement from all members of the palliative care team. There is a lack of understanding of such viewpoints. The objective of this research was to explore hospice-based palliative care professionals' understanding and perceptions of rehabilitation. METHODS Qualitative semi-structured interviews were conducted. Eighteen hospice-based healthcare professionals were recruited from a hospice in central Scotland. Interviews were audio-recorded, transcribed and thematically analysed. RESULTS Overall, participants clearly articulated the underlying values and benefits of rehabilitative palliative care. Emphasis was placed on ensuring that rehabilitation was appropriately tailored to each individual patient. There was more ambiguity regarding the pragmatic implementation of rehabilitative palliative care, with a number of barriers and facilitators identified. CONCLUSIONS The findings suggest that hospice-based palliative care professionals would be receptive to further implementation of rehabilitative palliative care. A lack of conceptual clarity among palliative care professionals may be a barrier to the effective implementation of rehabilitative palliative care. At an organisational level, this would require clarification of the approach, and additional training involving all members of the multidisciplinary team.
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Affiliation(s)
- Zoe Harding
- School of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Charlie Hall
- School of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.,Education and Research, St Columba's Hospice, Edinburgh, UK
| | - Anna Lloyd
- Education and Research, St Columba's Hospice, Edinburgh, UK
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Naito T. Emerging Treatment Options For Cancer-Associated Cachexia: A Literature Review. Ther Clin Risk Manag 2019; 15:1253-1266. [PMID: 31754304 PMCID: PMC6825473 DOI: 10.2147/tcrm.s196802] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022] Open
Abstract
Cachexia is a disease that has been recognized since antiquity; however, research in this area has recently increased. Promising new agents, including anamorelin hydrochloride, have been tested in large randomized controlled studies, and multidrug as well as multimodal approaches have been proposed as having the potential to improve outcomes in patients with cancer cachexia. However, standard treatment remains elusive. This review summarizes the current literature on treatment of cancer-associated cachexia, showing that there are challenges associated with conducting clinical trials in such patients. First, poor recruitment, retention, and compliance among cachectic patients cause research delays. Second, the lack of consensus regarding clinically meaningful endpoints impedes standardization of study designs and results. Further consideration is needed to identify the most suitable study design and endpoints, which can lead to the development of pharmacological and nonpharmacological interventions that improve patients’ prognosis and outcomes. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/0yiCRNGZyXk
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Affiliation(s)
- Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
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Hall CC, Cook J, Maddocks M, Skipworth RJE, Fallon M, Laird BJ. Combined exercise and nutritional rehabilitation in outpatients with incurable cancer: a systematic review. Support Care Cancer 2019; 27:2371-2384. [PMID: 30944994 PMCID: PMC6541700 DOI: 10.1007/s00520-019-04749-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 03/15/2019] [Indexed: 01/06/2023]
Abstract
PURPOSE The optimal components for rehabilitation in patients with incurable cancer are unclear. However, principles of exercise and nutrition-based interventions used in cancer cachexia may be applied usefully to this population of cancer patients. This systematic review examines current evidence for rehabilitation combining exercise and nutritional support in patients with incurable cancer. METHODS MEDLINE, EMBASE and Cochrane databases were searched. Eligible studies included patients with incurable cancer and rehabilitation programmes combining exercise and nutritional interventions. Studies of cancer survivors, curative treatments, reviews, case note reviews, protocols and abstracts were excluded. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied to patient-important outcomes. RESULTS Of the 2424 search results, 67 abstracts were reviewed and 24 full texts examined. Eight studies (n = 685) were included comprising two randomised control trials, three prospective, one exploratory and two secondary analyses. All examined multi-modal outpatient programmes. GRADE analysis revealed moderate evidence (B) for improvements in depression and physical endurance, low-quality evidence (C) for quality of life and fatigue and very low-quality evidence (D) for overall function and nutritional status. CONCLUSION There are limited data for multi-modal rehabilitation programmes combining exercise and nutritional interventions in patients with incurable cancer. However, studies to date report improvements in multiple domains, most notably physical endurance and depression scores. This supports the concept that multi-modal rehabilitation incorporating principles of cachexia management may be appropriate for the wider group of patients with incurable cancer. Further, high-quality studies are needed to define the optimal approach and outcome measures.
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Affiliation(s)
- Charlie C Hall
- St Columba's Hospice, 15 Boswall Road, Edinburgh, EH5 3RW, UK. .,Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
| | - Jane Cook
- St Columba's Hospice, 15 Boswall Road, Edinburgh, EH5 3RW, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Kings College London, London, UK
| | | | - Marie Fallon
- St Columba's Hospice, 15 Boswall Road, Edinburgh, EH5 3RW, UK.,Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Barry J Laird
- St Columba's Hospice, 15 Boswall Road, Edinburgh, EH5 3RW, UK.,Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
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