Chemotherapy and survival benefit in elderly patients with advanced non-small-cell lung cancer

Estimating oncologist variability in prescribing systemic cancer therapies to patients in the last 30 days of life

INTRODUCTION

Clinical guidelines and quality improvement initiatives have identified reducing the use of end-of-life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation.

RESULTS

Patients' median age at the time of death was 74 years (interquartile range, 69-79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end-of-life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end-of-life cancer therapy (OR, 4.42; 95% CI, 4.00-4.89).

CONCLUSIONS

Oncologists show substantial variation in end-of-life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision-making can reduce overuse of end-of-life cancer therapies.

Identifying Patient Populations in Texts Describing Drug Approvals Through Deep Learning-Based Information Extraction: Development of a Natural Language Processing Algorithm

BACKGROUND

New drug treatments are regularly approved, and it is challenging to remain up-to-date in this rapidly changing environment. Fast and accurate visualization is important to allow a global understanding of the drug market. Automation of this information extraction provides a helpful starting point for the subject matter expert, helps to mitigate human errors, and saves time.

OBJECTIVE

We aimed to semiautomate disease population extraction from the free text of oncology drug approval descriptions from the BioMedTracker database for 6 selected drug targets. More specifically, we intended to extract (1) line of therapy, (2) stage of cancer of the patient population described in the approval, and (3) the clinical trials that provide evidence for the approval. We aimed to use these results in downstream applications, aiding the searchability of relevant content against related drug project sources.

METHODS

We fine-tuned a state-of-the-art deep learning model, Bidirectional Encoder Representations from Transformers, for each of the 3 desired outputs. We independently applied rule-based text mining approaches. We compared the performances of deep learning and rule-based approaches and selected the best method, which was then applied to new entries. The results were manually curated by a subject matter expert and then used to train new models.

RESULTS

The training data set is currently small (433 entries) and will enlarge over time when new approval descriptions become available or if a choice is made to take another drug target into account. The deep learning models achieved 61% and 56% 5-fold cross-validated accuracies for line of therapy and stage of cancer, respectively, which were treated as classification tasks. Trial identification is treated as a named entity recognition task, and the 5-fold cross-validated F₁-score is currently 87%. Although the scores of the classification tasks could seem low, the models comprise 5 classes each, and such scores are a marked improvement when compared to random classification. Moreover, we expect improved performance as the input data set grows, since deep learning models need to be trained on a large enough amount of data to be able to learn the task they are taught. The rule-based approach achieved 60% and 74% 5-fold cross-validated accuracies for line of therapy and stage of cancer, respectively. No attempt was made to define a rule-based approach for trial identification.

CONCLUSIONS

We developed a natural language processing algorithm that is currently assisting subject matter experts in disease population extraction, which supports health authority approvals. This algorithm achieves semiautomation, enabling subject matter experts to leverage the results for deeper analysis and to accelerate information retrieval in a crowded clinical environment such as oncology.

Real-world treatment patterns of metastatic non-small cell lung cancer patients receiving epidermal growth factor receptor tyrosine kinase inhibitors

BACKGROUND

Several epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKI) have been approved for first-line (1L) treatment of EGFR-mutated metastatic non-small cell lung cancer (mNSCLC) in the United States (US). Real-world analyses of 1L treatment patterns with EGFR TKIs, including the third-generation EGFR TKI osimertinib which was most recently approved in 2018, are still sparse.

METHODS

This retrospective observational study used data from IQVIA's prescription claims (LRx) and medical claims (Dx) databases. mNSCLC patients newly treated with any EGFR TKI in the 1L setting were identified from January 1, 2015 to April 30, 2020; the first date of EGFR TKI (third-generation osimertinib, first-generation [erlotinib, gefitinib], or second-generation [afatinib, dacomitinib]) was the index date. Treatment patterns were reported in the cohorts stratified by 1L EGFR TKI.

RESULTS

A total of 2505 patients were included in the study (982 osimertinib, 1060 first-generation, and 463 second-generation EGFR TKI). Beginning in 2018, osimertinib became the most common 1L EGFR TKI (66.7%) and in early 2020, it accounted for 90.6% of 1L EGFR TKIs. Nearly all patients (>97%) were treated with 1L EGFR TKI monotherapy. Patients with 1L osimertinib had longer treatment duration compared to patients with 1L first- or second-generation EGFR TKI (median months: 17.8 vs. 8.7 vs. 10.5, respectively; log-rank test for comparisons with osimertinib p < 0.0001) over median follow-up times of 9.8, 20.5, and 19.3 months. 32.5% and 36.3% of the first- and second-generation EGFR TKI cohorts, respectively, had evidence of 2L treatment. Osimertinib monotherapy accounted for the majority of 2L treatments (58.3%/60.7%) and 11.3%/8.9% had 2L chemotherapy or immuno-oncology therapy following 1L first- or second-generation EGFR TKI.

CONCLUSION

In this real-world study of a US claims database, 1L treatment duration was longer with osimertinib compared with other EGFR TKIs. Future studies with longer follow-up are recommended to understand treatment patterns after progression on EGFR TKIs.

Real-world data of atezolizumab plus carboplatin and etoposide in elderly patients with extensive-disease small-cell lung cancer

PURPOSE

The aim of this study was to assess the effectiveness and tolerability of atezolizumab plus carboplatin and etoposide combination chemotherapy in elderly patients with extensive-disease (ED) small-cell lung cancer (SCLC).

METHODS

This retrospective study evaluated 65 SCLC patients who received atezolizumab, carboplatin, and etoposide for ED-SCLC in nine study institutions between August 2019 and September 2020. Clinical efficacy, assessed according to response rate and survival, and toxicity were compared between the elderly (n = 36 patients; median age: 74 years [range: 70-89 years]) and the non-elderly group (n = 29 patients; median age: 67 years [range: 43-69 years]).

RESULTS

The response rate was 73.8% (80.5% in the elderly group and 65.5% in the non-elderly group). There was no significant difference in both the median progression-free survival (5.5 months vs. 4.9 months, p = 0.18) and the median overall survival (15.4 months vs. 15.9 months, p = 0.24) between the elderly group and the non-elderly group. The frequencies of grade ≥3 hematological adverse events in the elderly patients were as follows: decreased white blood cells, 36.1%; decreased neutrophil count, 61.1%; decreased platelet count, 8.3%; and febrile neutropenia, 8.3%. One treatment-related death due to lung infection occurred in the elderly group.

CONCLUSION

Despite hematologic toxicities, especially decreased neutrophil count, atezolizumab, carboplatin, and etoposide combination chemotherapy demonstrates favorable effectiveness and acceptable toxicity in elderly patients. Thus, atezolizumab plus carboplatin and etoposide could be the preferred standard treatment modality for elderly patients with ED-SCLC.

Real-world outcomes with second-line therapy in advanced esophageal squamous cell carcinoma using SEER-Medicare data

Aim: To characterize real-world patterns of second-line treatment and outcomes in older patients with advanced/metastatic esophageal squamous cell carcinoma (ESCC). Patients and methods: Patients aged ≥66 years diagnosed with advanced/metastatic ESCC between 2010 and 2015 and followed through 2016 were included in this retrospective analysis using SEER-Medicare data. Results: Of 756 patients with advanced/metastatic ESCC, 104 (14%) received second-line therapy; median duration of treatment was 1.5 months. Median overall survival was 5.7 months for all patients receiving second-line treatment, and 4.5, 5.6 and 8.5 months, respectively, for patients receiving taxane monotherapy, taxane combination therapy and nontaxane therapy. Conclusion: A small proportion of patients with advanced/metastatic ESCC received second-line therapy, which was associated with short duration of treatment and poor overall survival.

Effectiveness and Safety of EGFR-TKI Rechallenge Treatment in Elderly Patients with Advanced Non-Small-Cell Lung Cancer Harboring Drug-Sensitive EGFR Mutations

Background and Objectives: Epidermal growth factor receptor–tyrosine kinase inhibitors (EGFR-TKIs) are effective first-line chemotherapeutic agents for patients with advanced non-small-cell lung cancer (NSCLC) harboring drug-sensitive EGFR mutations. However, the effectiveness of EGFR-TKI rechallenge after first-line EGFR-TKI treatment is not sufficient in elderly patients (over 75 years of age) harboring drug-sensitive EGFR mutations. Therefore, we investigated the effectiveness and safety of EGFR-TKI rechallenge after first-line EGFR-TKI treatment in elderly patients with advanced NSCLC harboring drug-sensitive EGFR mutations. Materials and Methods: Between April 2008 and December 2015, we analyzed 78 elderly patients with advanced NSCLC harboring drug-sensitive EGFR mutations with first-line EGFR-TKI treatment at four Japanese institutions. We retrospectively evaluated the clinical effectiveness and safety profiles of EGFR-TKI rechallenge after first-line EGFR-TKI treatment in elderly patients with advanced NSCLC harboring drug-sensitive EGFR mutations (exon 19 deletion/exon 21 L858R mutation). Results: Twenty-two patients in the cohort were rechallenged with EGFR-TKI. The median age was 79.5 years (range 75–87 years). Despite the fact that it was a retrospective analysis, even with EGFR-TKI rechallenge treatment the response rate was 23%, progression-free survival was 5.3 months, and overall survival was 14.4 months. Common adverse events included rash acneiform, paronychia, diarrhea, and anorexia. There were no treatment-related deaths. Due to the occurrence of adverse events of grade 2 or more, dose reduction was performed in 15 (68.2%) of 22 cases. Conclusions: EGFR-TKI rechallenge treatment after first-line EGFR-TKI treatment in elderly patients with advanced NSCLC harboring drug-sensitive EGFR mutations was one of the limited, safe and effective treatment options for elderly EGFR-positive lung cancer patients.

Lung cancer treatment patterns and factors relating to systemic therapy use in Australia

AIM

Systemic therapies for lung cancer are rapidly evolving. This study aimed to describe lung cancer treatment patterns in New South Wales, Australia, prior to the introduction of immunotherapy and latest-generation targeted therapies.

METHODS

Systemic therapy utilization and treatment-related factors were examined for participants in the New South Wales 45 and Up Study with incident lung cancer ascertained by record linkage to the New South Wales Cancer Registry (2006-2013). Systemic therapy receipt to June 2016 was determined using medical and pharmaceutical claims data from Services Australia, and in-patient hospital records. Factors related to treatment were identified using competing risks regressions.

RESULTS

A total of 1,116 lung cancer cases were identified with a mean age at diagnosis of 72 years and median survival of 10.6 months. Systemic therapy was received by 45% of cases. Among 400 cases with metastatic non-small cell lung cancer, 51% and 28% received first- and second-line systemic therapy, respectively. Among 112 diagnosed with small-cell lung cancer, 79% and 29% received first- and second-line systemic therapy. The incidence of systemic therapy was lower for participants with indicators of poor performance status, lower educational attainment, and those who lived in areas of socioeconomic disadvantage; and was higher for participants with small-cell lung cancer histology or higher body mass index.

CONCLUSION

This population-based Australian study identified patterns of systemic therapy use for lung cancer, particularly small-cell lung cancer. Despite a universal healthcare system, the analysis revealed socioeconomic disparities in health service utilization and relatively low utilization of systemic therapy overall.

Are clinical trial eligibility criteria representative of older patients with lung cancer? A population-based data linkage study

OBJECTIVES

Older adults constitute the majority of patients with lung cancer. However, they are under-represented in clinical trials as eligibility criteria often restrict enrolment based on comorbidities that are common with aging. We aimed to describe comorbidities relating to trial exclusion criteria in older adults with lung cancer, determine the proportion that would typically be excluded from trials, and examine the impact on treatment uptake.

MATERIALS AND METHODS

We conducted a population-based study of people aged ≥65 years diagnosed with metastatic lung cancer using linked data for clients of the Australian Government Department of Veterans' Affairs (2005-2015). We defined trial-typical patients based on the absence of comorbidities related to the following: inadequate organ (cardiac, renal, hepatic, marrow) function; cognitive dysfunction; poor performance status (PS); prior malignancy within 5 years. We report systemic therapy uptake within 3 months of diagnosis.

RESULTS

Our study included 677 patients (median age 84). Over half (53.4%) were not trial-typical, with the most common reasons being poor PS (37.5%), cardiac disease (19.2%), and prior cancer (12.9%). Eighty-two (12.1%) received systemic therapy. Patients with poor PS, cardiac disease, and dementia had lower treatment uptake rates. However, there was no significant difference in treatment uptake between trial-typical and non-trial-typical patients (13.4 vs 11.0%).

CONCLUSION

More than half of older adults with advanced lung cancer would be typically excluded from trial participation. Future clinical trials of older adults need to consider broader eligibility criteria to better reflect this population to gain the best evidence for their care.

Population-level changes in outcomes and Medicare cost following the introduction of new cancer therapies

OBJECTIVE

To examine the population-level impacts of the introduction of novel cancer therapies with high cost in the United States, using immunotherapies in advanced nonsmall cell lung cancer (NSCLC) as an example.

DATA SOURCES

Surveillance, Epidemiology, and End Results data in 2012-2015 linked to Medicare fee-for-service claims until 2016.

STUDY DESIGN

We examined population-level trends in treatment patterns, survival, and Medicare spending in patients diagnosed with advanced NSCLC, the leading cause of cancer death in the United States, between 2012 and 2015. We estimated the percentage of patients who received any antineoplastic therapy within two years of diagnosis, including novel immunotherapies. We compared the trends in overall survival and mean two-year Medicare spending per each patient before and after the introduction of immunotherapies in 2015.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

PRINCIPAL FINDINGS

The percentage of patients treated with any antineoplastic therapy remained the same at 46.7% in 2012 and 2015, whereas the use of immunotherapies increased from 0% to 15.2%. The two-year survival rate and median survival increased by 3.3 percentage points (95% CI: 2.0, 4.5) and 0.4 months (CI: 0.0, 0.9), respectively, during the same period. The mean two-year total Medicare spending and outpatient spending per patient increased by $5735 (CI: 3479, 8040) and $7661 (CI: 5902, 9311), respectively, which were largely attributable to the increases in immunotherapy spending by $5806 (CI: 5165, 6459).

CONCLUSIONS

The introduction of lung cancer immunotherapies was accompanied by improvements in survival and increases in spending between 2012 and 2015 in the Medicare population. As novel immunotherapies and other target therapies continue to change the clinical management of various cancers, further efforts are needed to ensure their effective and efficient use, and to understand their population-level impacts in the United States.

The effects of physical activity on overall survival among advanced cancer patients: a systematic review and meta-analysis

Background

The survival rates of advanced cancer patients remain low despite clinical therapy advancements. However, physical activity showed promising effects in improving cancer outcomes. This review aimed to systematically evaluate and synthesize the effects on overall mortality of post-diagnosis physical activity in advanced cancer patients.

Methods

A systematic search of six English databases (PubMed, EMBASE, CINAHL, PsycINFO, The Cochrane Central Register of Controlled Trials, and SPORTDiscus) was conducted from their inception up to 3 February 2021. The association of physical activity with survival was evaluated by combining study-specific hazard ratios with random-effects meta-analysis models.

Results

Eleven studies were identified. Compared with the reference group, higher-level physical activity was not significantly associated with a lower risk of earlier mortality in advanced cancer patients (InHR = − 0.18, 95% CI, − 0.36 to 0.01). When separated by study type, a higher level of physical activity in non-randomised trials was significantly associated with reduced mortality risk (InHR = − 0.25, 95% CI: − 0.44, − 0.06). However, in randomised trials, engaging in exercise was not significantly associated with a lower mortality risk compared with the control group (InHR = 0.08, 95%CI: − 0.17, 0.32).

Conclusions

Discrepancies were uncovered in the effect of physical activity on overall survival in randomised and non-randomised trials. In non-randomised trials, a higher level of physical activity was significantly associated with a lower risk of mortality, whereas no significant effect on survival was observed during exercise interventions compared to the control in randomised trials. Considering the wider benefits of physical activity, exercise can still be recommended to improve outcomes for advanced cancer patients. Nevertheless, it might be too late for advanced cancer patients to start exercising for survival improvements, based on findings from randomised controlled trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-07988-1.

Evaluation of the prognostic utility of bone marrow biopsy in diffuse large B-Cell lymphoma in the SEER-Medicare dataset

Positron emission tomography-computed tomography (PET-CT) has become the primary modality for staging in diffuse large B-cell lymphoma (DLBCL), whereas the role of staging bone marrow biopsy (BMB) has become less clear. In this analysis, we included 7,005 DLBCL patients in SEER-Medicare who received either PET-CT without BMB (PET-CT w/o BMB), CT with BMB (CT w/ BMB), or both PET-CT and BMB (PET-CT w/ BMB). The proportion of patients undergoing PET-CT increased across years of diagnosis, while the proportion undergoing CT or BMB decreased. In a fully adjusted Cox proportional hazards model, PET-CT w/ BMB was associated with a marginally superior OS compared to PET-CT w/o BMB. Notably, the association between PET-CT w/ BMB and OS was strongest in patients ≤70 years, but was not present when looking at individual stage of diagnosis. Overall, these data do not provide sufficient support to eliminate staging BMB in patients who undergo PET-CT.

The role for chemotherapy in 80 years and older patients with metastatic non-small cell lung cancer: A National cancer database analysis

BACKGROUND

There are limited data on the role for chemotherapy in patients > 80 years old with advanced stage non-small cell lung carcinoma (NSCLC). We used the National Cancer Database (NCDB) to evaluate treatment patterns and outcomes for patients ≥80 years old with advanced NSCLC.

METHODS

We identified patients diagnosed with metastatic NSCLC between 2004 and 2014. We divided them into two groups: < 80 years old (n = 218,365) and ≥ 80 years old (n = 33,352). Patient characteristics including median age at diagnosis, gender, ethnicity, histology, chemotherapy status, tumor grade, treatment center, insurance status, income, education, and Charlson-Deyo co-morbidity index were collected. Continuous variables were compared using t-test and categorical variables were compared using chi-square or Fisher's exact test. Multivariable (MV) and propensity matched analyses were performed to analyze the impact of chemotherapy on overall survival.

RESULTS

We identified 33,352 patients > 80 years old diagnosed with advanced NSCLC. Only 29 % received chemotherapy, those who received chemotherapy had improved median overall survival of 8 months compared to 2 months in patients not receiving chemotherapy; adjusted hazards ratio (HR) 0.46; confidence interval (CI) 0.45-0.47; p < .001. MV analysis showed benefit of chemotherapy in all age subgroups (80-84 years, 85-89 years and 90+ years; p < .0001) and it was confirmed by propensity matched analysis. Patients receiving multiagent chemotherapy had improved 1-year survival of 35.5 % compared to 32.8 % with single agent chemotherapy (adjusted HR 0.92; CI 0.88-0.96; p < .001). Despite benefit from chemotherapy, the proportion of patients age ≥ 80 years receiving chemotherapy did not change over time.

CONCLUSIONS

Chemotherapy improved overall survival in ≥80 years old patients with advanced stage NSCLC. Despite improved survival and an increase in the proportion of ≥80 years old patients diagnosed with advanced NSCLC, less than one-third receive chemotherapy.

Survival Outcomes with Photodynamic Therapy, Chemotherapy and Radiation in Patients with Stage III or Stage IV Non-Small Cell Lung Cancer

Simple Summary

The association between photodynamic therapy (PDT) and mortality in lung cancer patients remains unclear. We studied the association between PDT and mortality in patients with stage III/IV non-small cell lung cancer (NSCLC) using the National Cancer Database (NCDB) between 2004 and 2016. From the NCDB, we identified patients whose treatment code was ablation (including PDT). From Medicare and Medicaid data between 2000 and 2013, we identified NSCLC patients receiving PDT and used these to confirm PDT treatment. We assessed the association between PDT and mortality. Study groups consisted of 147 patients with PDT + radiation + chemotherapy, 227,629 with radiation + chemotherapy, 106,667 with radiation therapy alone and 122,193 with chemotherapy alone. Compared to the radiation alone group, the PDT group and radiation with chemotherapy group had lower risk of mortality (50% and 53% lower, respectively). Among the NSCLC patients with stage III or stage IV disease not eligible for surgery, the addition of PDT to chemotherapy and radiation therapy offers survival benefit over radiation therapy alone.

Abstract

Data regarding the association between photodynamic therapy (PDT) and mortality in lung cancer patients are limited. We analyzed the association between PDT and mortality in patients with stage III or IV non-small cell lung cancer (NSCLC) using data from the National Cancer Database (NCDB) between 2004 and 2016. From the NCDB, we identified patients receiving laser ablation/cryosurgery or local tumor destruction/excision (which includes PDT). From Medicare and Medicaid claims between 2000 and 2013, we identified NSCLC patients receiving PDT and those receiving bronchoscopy, then used these to confirm the PDT treatment. From NCDB, we extracted NSCLC patients who received radiation with chemotherapy, radiation alone or chemotherapy alone. We used survival analysis to determine the association between PDT and mortality. Between 2004 and 2016, 457,556 NSCLC patients with stage III or stage IV were identified, of which 147 received PDT with radiation and chemotherapy, 227,629 received radiation with chemotherapy, 106,667 had radiation therapy alone and 122,193 received chemotherapy alone. Compared to the radiation alone group, the PDT group and radiation with chemotherapy group had lower hazard of mortality (50% and 53% lower, respectively). Among the NSCLC patients with stage III or stage IV disease, the addition of PDT to radiation therapy offers survival benefit over radiation therapy alone.

Neoadjuvant immunotherapy for elderly patients with non-small-cell lung cancer: a case report and literature review

Although neoadjuvant immunotherapy has achieved remarkable results in the treatment of lung cancer, it is still infrequently applied in geriatric patients. We report on a 76-year-old male patient with a long-term history of heavy smoking presenting with cough and hemolysis. There was no related underlying disease or positive findings on physical examination. On July 23, 2019, his chest computed tomography (CT) showed small nodules in the upper lobe of the right lung and multiple enlarged lymph nodes in the mediastinum. Fiberoptic bronchoscopy showed a neoplasm in a subsegment of the upper lobe of the right lung. Following biopsy the patient was diagnosed with squamous cell carcinoma of the right upper lung, with lymph node metastasis in the mediastinum (CT1N2M0, IIIA). Between late July and mid-August of 2019, he received chemotherapy (TP regimen) combined immunotherapy for 2 cycles of preoperative neoadjuvant therapy. Three weeks later he underwent chest CT re-examination which revealed his focus was significantly shrunken in size, and multiple lymph nodes in the mediastinum and right hilum were smaller in comparison to the first examination. The patient then underwent thoracoscopic radical resection of the right upper lung cancer under general anesthesia and recovered uneventfully after surgery. The postoperative pathology examination showed complete response and no signs of recurrence were discovered on the 6 months follow up during which time the patient received immunotherapy on a monthly basis. We report on a case of immunotherapy in a geriatric patient with literature review which supports new treatment strategies for the treatment of elderly patients with lung cancer.

Personalised treatment for older adults with cancer: The role of frailty assessment

It is widely accepted in clinical practice that chronological age is a poor predictor of treatment tolerance and outcomes in older adults with cancer. Intrinsic vulnerability is more a function of underlying frailty, rather than chronological age. Frailty is a state of increased vulnerability to stressors, such as cancer and its treatment, which can lead to adverse health outcomes for patients. Capturing this heterogeneity in reserve capacity is the cornerstone of management in geriatricmedicine, but remains poorly understood or adopted in radiation oncology. A two-step approach, using a shorter screening tool, followed by full assessment for those who need it, is the mostresourceful way of implementing frailty assessment in radiotherapy departments. It is important for radiation oncology professionals to identify frailty and to use this information in multidisciplinary decision making in order to develop a personalised radiotherapy approach for the older person. There are many ways we can effectively use this information, such as considering treatment fractionation schedules that would limit the burden of travel for those with social frailty, or reviewing the range of modalities at our disposal, which might limit toxicity in the older person at high risk of deterioration during treatment. Frailty assessment is not carried out in many radiotherapy departments presently, but there are many international models to use as exemplars as to how it may be implemented in clinical practice. There are many opportunities for further research and role development in this field at the current time.

Platinum-Based Chemotherapy in Older Patients with Non-Small Cell Lung Cancer: What to Expect in the Real World

BACKGROUND

The role of platinum-based chemotherapy (PBC) for the treatment of older patients with non-small cell lung cancer (NSCLC) is still a matter of debate, despite the advent of immunotherapy.

OBJECTIVE

The aim of the study was to identify factors associated with first-line PBC prescription and, secondly, to evaluate the impact of first-line PBC on survival, treatment intensity, risk of hospitalization, and subsequent treatments.

PATIENTS AND METHODS

We reviewed a consecutive series of 474 older patients (age ≥ 70 years) diagnosed with stage IIIB-IV NSCLC at the Department of Oncology, University Hospital of Udine, Italy from January 2009 to March 2017.

RESULTS

Overall, 198 patients were deemed eligible, and 65.2% received a PBC. At multivariate analysis, older age was the only factor associated with PBC prescription. In the whole cohort, 46 patients (23.2%) were hospitalized for chemotherapy-related toxicity. Both PBC prescription (odds ratio [OR] 2.23, 95% confidence interval [CI] 1.02-4.87, p = 0.04) and tumor burden (OR 2.39, 95% CI 1.07-5.32, p = 0.03) emerged as independent risk factors for hospitalization. Moving to significant predictors of patterns of care, Eastern Cooperative Oncology Group (ECOG) performance status > 0 was associated with greater risk of first-line failure (OR 2.20, 95% CI 1.15-4.20, p = 0.02), while bone metastases (OR 0.29, 95% CI 0.12-0.69, p = 0.005) and a Charlson Comorbidity Index score ≥ 3 (OR 0.40, 95% CI 0.19-0.84, p = 0.016) independently predicted lower probability of receiving second-line therapy. Remarkably, PBC did not significantly impact overall survival (hazard ratio [HR] 0.83, 95% CI 0.61-1.14, p = 0.24) and progression-free survival (HR 0.95, 95% CI 0.70-1.28, p = 0.73) compared to single-agent chemotherapy (SAC). However, according to an exploratory landmark analysis, patients who received four cycles of treatment or maintenance therapy experienced prolonged overall survival, regardless of PBC use.

CONCLUSIONS

This study evaluated the real-world use of PBC in older patients with NSCLC, offering an insight into the determinants of its prescription and the pattern of care of these patients. Of note, PBC use was associated with a higher likelihood of hospitalization for chemotherapy-related toxicity, with no benefit on survival compared to SAC.

Active Treatment Improves Overall Survival in Extremely Older Non-Small Cell Lung Cancer Patients: A Multicenter Retrospective Cohort Study

PURPOSE

As the aging of society progresses, the proportion of extremely older lung cancer patients has also increased; However, studies of these patients with non-small cell lung cancer are limited. Therefore, we investigated the initial treatment modalities and survival outcomes for patients aged 80 years or over.

Materials and Methods

We included a multicenter retrospective cohort from the Korean Association for Lung Cancer Registry, which surveys 10% of the newly diagnosed lung cancer patients across 52 hospitals in Korea. We analyzed and compared the 2014-2016 data of the non-small cell lung cancer patients aged ≥ 80 years and those aged < 80 years.

RESULTS

Of the 6,576 patients reviewed, 780 patients were aged ≥ 80 years, and 5,796 patients were aged < 80 years. In the patients aged ≥ 80 years, surgery and radiation therapy resulted in longer patient survival among those with a resectable tumor (stage I-II) than the best supportive care (median survival, not reached [surgery] vs. 32.2 months [radiation therapy] vs. 11.43 months [best supportive care]). The duration of survival in patients with advanced-stage (IV) lung cancers was higher after chemotherapy than after the best supportive care (median survival, 8.63 months vs. 2.5 months). Patients with stage IV adenocarcinoma who received targeted therapy had better survival than those who did not (median survival, 9.0 months vs. 4.3 months).

CONCLUSION

Even in extremely older patients, active treatments, such as surgery, radiation therapy, and chemotherapy, can result in better survival outcomes than the best supportive care.

Paclitaxel and betulonic acid synergistically enhance antitumor efficacy by forming co-assembled nanoparticles

The side effects and low bioavailability of paclitaxel (PTX) limit its clinical application. The formation of self-assembled nanomedicines without structural modification is attractive for biomedical applications. Here, we constructed a supramolecular co-assembled nanoparticles (NPs), which is formed by betulonic acid (BTA) and PTX mainly through hydrogen bond interaction and hydrophobic interaction. It not only has the characteristics of NPs but also the activity of natural small molecules (NSMs). The results of in vitro and in vivo experiments showed that BTA-PTX NPs showed excellent synergistic enhancement of anti-tumor efficacy, because BTA and PTX have different anti-tumor mechanisms. What's more, BTA-PTX NPs showed excellent biosafety and low toxicity, because BTA has impressive biological activity and biosafety. This work provides an effective and simple method to construct high efficiency and minimize side effects of NPs, which provides more possibilities for the application of NSMs in drug delivery.

Real-world systemic therapy utilization in Medicare patients with locally advanced or metastatic urothelial carcinoma diagnosed between 2008 and 2012

PURPOSE

Treatment of advanced urothelial carcinoma (UC) remains a challenging clinical entity occurring predominantly in older patients with limited treatment options. However, real-world treatment patterns, differential cancer center access, and association with outcomes is lacking in nationally representative clinical practice and will provide context for emerging therapies.

MATERIALS AND METHODS

We used SEER-Medicare data to identify patients with locally advanced or metastatic UC of the bladder or upper urinary tract diagnosed between 2008 and 2012. We characterized utilization systemic therapy, including first- and second-line chemotherapy. Patients receiving neoadjuvant chemotherapy were excluded; results were stratified by academic versus non-academic setting.

RESULTS

3569 patients met study criteria; 48% received some form of chemotherapy within 2 years of diagnosis. Of these, one-third subsequently received second-line chemotherapy. The majority received a regimen including ≥2 agents. Gemcitabine alone or in combination with platinum was the most common first- and second-line treatment. Similar patterns of first- and second-line chemotherapy were observed between patients treated in academic and non-academic centers. Sensitivity analyses of trial-similar patients demonstrated increased utilization (69%). Receipt of platinum doublet as 1st line therapy was less likely in older patients and those with renal disease, and more likely for grade IV disease.

CONCLUSIONS

Roughly half of all Medicare patients with locally advanced/metastatic UC receive systemic therapy regardless of access to academic cancer centers and despite poor oncologic outcomes. Cytotoxic, gemcitabine-based doublet chemotherapy remains the most common treatment. A substantial population of older patients exists for whom alternative, non-cytotoxic, treatment options may be of benefit.

Long non-coding RNA colon cancer-associated transcript-1 regulates tumor cell proliferation and invasion of non-small-cell lung cancer through suppressing miR-152

AIM

Lung cancer serves as one of the most common cancers in the world, and approximately 50% of non-small-cell lung cancer (NSCLC) patients are found to be aged >70 when diagnosed. In this study, we aimed to explore the effect of long non-coding RNAs colon cancer-associated transcript-1 (CCAT1) in NSCLC.

METHODS

A total of 72 clinical samples from older NSCLC patients were collected for analysis. The relative mRNA level of CCAT1 was detected through real-time polymerase chain reaction. Overall survival of NSCLC patients was detected through Kaplan-Meier survival analysis. MTT assays were used to detect cell proliferation. Cell invasion was determined by transwell assay. Protein levels were detected through western blot.

RESULTS

CCAT1 expression levels significantly increased in NSCLC tumor tissues and were associated with poor overall survival of NSCLC patients. CCAT1 promotes cell proliferation, cell invasion and epithelial-mesenchymal transition of NSCLC cell lines. CCAT1 binds with miR-152, and the effect of si-CCAT1 in NSCLC cell proliferation, cell invasion and epithelial-mesenchymal transition was partially reversed by anti-miR-152.

CONCLUSIONS

Long non-coding RNA CCAT1 regulates tumor cell proliferation and invasion in NSCLC through suppressing miR-152. Geriatr Gerontol Int 2020; ••: ••-••.

Predictors of chemoradiotherapy versus single modality therapy and overall survival among patients with unresectable, stage III non-small cell lung cancer

Introduction

Concurrent chemoradiotherapy (cCRT) was the standard of care for patients with unresectable stage III non-small cell lung cancer (NSCLC) prior to the PACIFIC trial, however, patients also received single modality therapy. This study identified predictors of therapy and differences in overall survival (OS).

Methods

This retrospective study included stage III NSCLC patients aged ≥65 years, with ≥1 claim for systemic therapy (ST) or radiotherapy (RT) within 90 days of diagnosis, identified in SEER-Medicare data (2009–2014). Patients who had overlapping claims for chemotherapy and RT ≤90 days from start of therapy were classified as having received cCRT. Patients who received sequential CRT or surgical resection of tumor were excluded. Predictors of cCRT were analyzed using logistic regression. OS was compared between therapies using adjusted Cox proportional hazards models.

Results

Of 3,799 patients identified, 21.7% received ST; 26.3% received RT; and 52.0% received cCRT. cCRT patients tended to be younger (p <0.001), White (p = 0.002), and have a good predicted performance status (p<0.001). Patients who saw all three specialist types (medical oncologist, radiation oncologist, and surgeon) had increased odds of receiving cCRT (p<0.001). ST and RT patients had higher mortality risk versus cCRT patients (hazard ratio [95% CI]: ST: 1.38 [1.26–1.51]; RT: 1.75 [1.61, 1.91]); p<0.001).

Conclusions

Several factors contributed to treatment selection, including patient age and health status, and whether the patient received multidisciplinary care. Given the survival benefit of receiving cCRT over single-modality therapy, physicians should discuss treatment within a multidisciplinary team, and be encouraged to pursue cCRT for patients with unresectable stage III NSCLC.

Outcomes of primary endocrine therapy in elderly women with stage I-III breast cancer: a SEER database analysis

BACKGROUND

Frail elderly women with nonmetastatic hormone receptor-positive breast cancer often receive primary endocrine therapy. Limited data are available on the outcomes associated with this population and treatment approach.

METHODS

We selected patients with an initial primary diagnosis of stage I-III ER-positive breast cancer from 2001 to 2015 in Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Patients were excluded if they received surgery, radiation, chemotherapy, or other targeted drug treatment including anti-HER2 agents. Two Cox proportional-hazards models were constructed to determine the predictors of breast cancer-specific survival and overall survival after a cancer diagnosis.

RESULTS

A total of 552 patients were identified, with 82.1% of the patients being 80 years or older and 81.7% of patients being non-Hispanic White. PR positive (OR 1.77; 95% CI 1.09-2.85; p = 0.025) and tumor size larger than 50 mm (OR 1.99; 95% CI 1.05-3.75; p = 0.035) were associated with higher adherence to endocrine therapy. In the multivariable Cox analyses, patients who were adherent of endocrine therapy had significantly worse survival (HR 1.40; 95% CI 1.17-1.69; p < 0.001). The other two factors associated with worse survival were larger tumor size and more comorbidities. The competing risk model demonstrated no statistically significant difference between patients who were adherent to endocrine therapy and those who were not in terms of risk of dying from breast cancer.

CONCLUSION

In elderly women with localized ER-positive breast cancer, there were no statistically significant differences in breast cancer-specific or overall mortality between those who were adherent to endocrine therapy and those who were not.

SOX2 mediates cisplatin resistance in small-cell lung cancer with downregulated expression of hsa-miR-340-5p

Background

This study is aimed to unravel the genetic factors associated with microRNA (miRNA) expression in regulating sex‐determining region Y‐box 2 (SOX2)‐mediated cisplatin resistance in small‐cell lung cancer (SCLC).

Methods

The relevance of SOX2 expression in SCLC was analyzed in a panel of SCLC cells by quantitative real‐time PCR (qPCR) and western blot (WB). We selected DMS114 cell line, in which SOX2 was amplified via lentiviral vector‐mediated transfection of the SOX2 genes and tested for the half‐maximal inhibitory concentration (IC₅₀) by MTS assay. High‐throughput sequencing and screening of differentially expressed miRNAs between SOX2‐overexpressing and normal control cells were performed. Finally, miRanda software was used to verify the miRNAs bound with SOX2 and qPCR was used to identify the expression of miRNAs which were binding with SOX2.

Results

Cisplatin‐resistant SOX2‐overexpressing DMS114 cell lines were successfully developed, showing a statistically significant increase in SOX2 expression by qPCR and WB. Our results showed a typically higher IC₅₀ value in SOX2‐overexpressing cells compared with the negative controls. The high‐throughput sequencing analysis revealed that 68 miRNAs were upregulated and 24 miRNAs were downregulated in the SOX2‐overexpressing cells. The 24 downregulated miRNAs were further verified. Of them, a cancer‐related miRNA, hsa‐miR‐340‐5p, showed a higher binding affinity with SOX2 in network regulation mapping, which was also found to be markedly downregulated under qPCR analysis.

Conclusion

We demonstrated that downregulated expression of hsa‐miR‐340‐5p may affect cisplatin resistance by mediating SOX2 expression in SCLC cells, which may provide a potential target for the therapy of chemoresistant SCLCs.

A phase I and extension study of S-1 and carboplatin for previously untreated patients aged 75 years or more with advanced non-small cell lung cancer -TCOG 1101

PURPOSE

Combination carboplatin and S-1 is active in the treatment of non-small cell lung cancer (NSCLC). However, data on this combination for elderly patients with NSCLC are insufficient.

METHODS

Eligibility criteria were no prior chemotherapy, Stage IIIB or IV NSCLC, performance status 0-1, age ≥ 75 years, and adequate hematological, hepatic, and renal functions. Carboplatin was administered on day 1 and S-1 was administered orally, twice a day, between days 1 and 14, repeated every 3 weeks. In phase I, the primary purpose was determination of the recommended dose. Starting doses of carboplatin and S-1 were area under the curve (AUC) of 4 and 80 mg/m²/day, respectively. In the extension study, the effects and tolerability of this combination therapy of recommended dose were confirmed.

RESULTS

A total of 10 patients were entered into phase I and 14 patients were entered into the extension study. The recommended doses for this drug combination are AUC 5 for carboplatin and 80 mg/m²/day every 3 weeks for S-1. With carboplatin and S-1 combination therapy at the recommended dose, the response rate was 30.0% [95% confidence interval (CI) 12-54%] and the disease control rate was 90.0% (95% CI 68-99%). Thrombocytopenia and neutropenia were major adverse events.

CONCLUSIONS

The recommended doses for this combination therapy are carboplatin AUC 5 and S-1 80 mg/m²/day every 3 weeks, and this combination is effective with tolerable toxicities for advanced NSCLC patients ≥ 75 years old.

Does progress achieved in the treatment of patients with metastatic non-small-cell lung cancer reach the elderly population? A cohort study from a cancer centre from Eastern Switzerland

OBJECTIVE

Treatment options for non-small-cell lung cancer (NSCLC) have been evolving. The goal of our study was to evaluate whether novel therapeutics are used in the elderly population and improve outcomes to a similar extent as in young patients.

METHODS

We enrolled patients registered in the Cancer Registry of Eastern Switzerland and grouped them into four cohorts: Elderly patients aged ≥70 years diagnosed 2005-2007 and 2015-2016 (elderly cohorts 1,2) were compared to cohorts of patients < 70 years diagnosed during the same time periods (young cohorts 1,2).

RESULTS

499 individuals were analysed. Median cancer-specific survival in the elderly cohorts 1 and 2 was 3.9 months and 6.3 months, respectively, and 8.0 and 12.7 months in the young cohorts 1 and 2. 12-month survival significantly improved over ten years only in younger patients (35.6% and 54.9%), however not in the elderly cohorts (20% vs. 35%). Proportion of patients receiving any line of systemic treatment remained lower in the elderly cohorts (53% vs. 78%).

CONCLUSION

Despite the increase in median cancer-specific survival in both cohorts, a significant and clinically meaningful improvement of 12-month cancer-specific survival was only seen in young patients. The adoption of novel treatment approaches is lagging behind in the elderly population.

Real-world use and survival outcomes of immune checkpoint inhibitors in older adults with non-small cell lung cancer

BACKGROUND

Limited data exist regarding the characteristics and survival outcomes of older adults with non-small cell lung cancer (NSCLC) who receive immune checkpoint inhibitors in routine oncology practice.

METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 1256 patients aged ≥65 years who were diagnosed with pathologically confirmed stage I to stage IV NSCLC between 2002 and 2015 and initiated nivolumab or pembrolizumab in 2016. We examined patient characteristics and overall survival from the time of immune checkpoint inhibitor initiation through December 31, 2017.

RESULTS

The median patient age at the time of immune checkpoint inhibitor initiatiton was 75.3 years (interquartile range, 8.5). A substantial percentage of patients were initially diagnosed with stage IV disease (42.6%) and had ≥2 comorbid conditions (48.7%). Using a claims-based proxy, 11.5% of patients had poor performance status and 12.6% had a history of autoimmune conditions. The median overall survival after initiation of immune checkpoint inhibitor was 9.3 months (95% CI, 8.5-10.5 months). The 1-year survival rate was 43.0% (95% CI, 40.2-45.7%). In multivariable analyses, multiple comorbid conditions, squamous histology, a history of nonplatinum doublet systemic therapy, recent radiotherapy, and a shorter time from initial diagnosis to treatment initiation were found to be statistically significantly associated with an increased hazard of death. Demographics, poor performance status, and prior autoimmune conditions were not significantly associated with the hazard of death.

CONCLUSIONS

Many older adults with NSCLC who initiated immune checkpoint inhibitors had multiple comorbidities, a history of autoimmune disease, or poor performance status. Factors associated with poor prognosis among patients with advanced NSCLC were also associated with worse survival in older adults treated with immune checkpoint inhibitors.

Clinical factors associated with treatment toxicity of pemetrexed plus platinum in elderly patients with non-small cell lung cancer

BACKGROUND

This study was to explore the clinical factors associated with treatment toxicities of pemetrexed plus platinum in elderly patients with non-small cell lung cancer (NSCLC).

METHODS

Chemo-naive patients aged ≥ 70 with advanced NSCLC treated with pemetrexed plus platinum were included. Medical records were reviewed and clinical data, including age, gender, smoking status, comorbidities, EGFR mutation status, chemotherapy regimens, previous use of epidermal growth factor receptor-tyrosine kinase inhibitors, treatment-related hematologic, renal, and hepatic toxicities, and treatment responses, were analyzed. Comorbidity conditions were evaluated by using the Simplified Comorbidity Score (SCS) and Charlson Comorbidity Index Score (CCIS).

RESULTS

A total of 144 patients were included. In the univariate analysis, patients with SCS >9 (p = 0.006) and cigarette smoking (p = 0.028) were associated with a significantly higher rate of grade 3/4 neutropenia than their counterpart. Carboplatin use was associated with a higher rate of grade 3/4 thrombocytopenia than cisplatin use (p = 0.028). In the multivariate analysis, SCS >9 was associated with a significantly higher risk of anemia of any grade (odds ratio [OR]: 2.72, 95% confidence interval [CI]: 1.09-6.77). Carboplatin use was associated a higher risk of any grade (OR: 4.61, 95% CI: 1.07-19.90) and grade 3/4 thrombocytopenia (OR: 7.37, 95% CI: 1.36-39.92). No clinical factors were found to be associated with hepatic and renal toxicities.

CONCLUSION

High SCS and carboplatin use were associated with hematological toxicities with pemetrexed plus platinum use in elderly patients with NSCLC.

Efficacy and safety of first-line pembrolizumab monotherapy in elderly patients (aged ≥ 75 years) with non-small cell lung cancer

PURPOSE

Pembrolizumab is an effective front-line treatment for advanced non-small cell lung cancer (NSCLC) in patients expressing high levels of programmed death-ligand 1 (PD-L1). However, it is unclear whether first-line pembrolizumab has similar efficacy among elderly (aged ≥ 75 years) and younger patients. This study aimed to investigate the safety and efficacy of front-line pembrolizumab monotherapy in older adults with NSCLC expressing high PD-L1.

METHODS

A total of 128 patients with advanced NSCLC expressing high PD-L1, including 47 older adults, received first-line pembrolizumab monotherapy at ten institutions in Japan, between February 2017 and February 2018. Data related to patient characteristics, efficacy of pembrolizumab therapy, and the type and severity of adverse events were recorded.

RESULTS

Overall, 47 patients [40 men and 7 women; median age 79 (range 75-88) years] were included in our analysis. In patients who received first-line pembrolizumab monotherapy, overall response, disease control rates, median progression-free survival (PFS), and median overall survival (OS) were 53.1%, 74.4%, 7.0 months, and not reached, respectively. Common adverse events included anorexia, fatigue, skin rash, and hypothyroidism. Two treatment-related deaths were noted, due to pneumonitis and infection. First-line pembrolizumab monotherapy was associated with improved PFS in patients with non-progressive disease (PD). In patients with non-PD and good performance status (PS), pembrolizumab monotherapy improved OS.

CONCLUSIONS

Elderly patients with NSCLC expressing high PD-L1 tolerated front-line pembrolizumab monotherapy well. Their survival outcomes were equivalent to those of younger patients. In patients with non-PD, first-line pembrolizumab monotherapy may improve PFS; in conjunction with good PS, it additionally improves OS.

Response to Afatinib in a Patient with Non-Small Cell Lung Cancer Harboring HER2 R896G Mutation: A Case Report

Purpose

HER2 mutations are identified in approximately 2% of non-small-cell lung cancer (NSCLC) cases; however, until now, there are no approved standard targeted therapy for NSCLC patients harboring HER2 mutations.

Case presentation

We present a 63-year-old male with a long smoking history, who was diagnosed with stage IV squamous cell lung cancer. After the failures of two lines of treatment with carboplatin plus gemcitabine and nidaplatin plus docetaxel, in turn, the patient received a next-generation sequencing of circulating tumor DNA to seek for potential treatment opportunities. A HER2 R896G mutation was identified with an allelic fraction of 50.77%. The patient received afatinib 40 mg a day and reached a partial response after two months of treatment. The progression-free survival was more than 14 months and the treatment of afatinib was ongoing. During the treatment, treatment-related paronychia and stomatitis occurred and relieved without any management.

Conclusion

This is the first case report describing a NSCLC patient harboring a rare HER2 R896G mutation who responds to afatinib. This case suggests that afatinib might be efficacious in NSCLC patients harboring HER2 R896G mutations, and these results need to be further studied in prospective clinical trials.

Temporal phenotyping by mining healthcare data to derive lines of therapy for cancer

Lines of therapy (LOT) derived from real-world healthcare data not only depict real-world cancer treatment sequences, but also help define patient phenotypes along the course of disease progression and therapeutic interventions. The sequence of prescribed anticancer therapies can be defined as temporal phenotyping resulting from changes in morphological (tumor staging), biochemical (biomarker testing), physiological (disease progression), and behavioral (physician prescribing and patient adherence) parameters. We introduce a novel methodology that is a two-part approach: 1) create an algorithm to derive patient-level LOT and 2) aggregate LOT information via clustering to derive temporal phenotypes, in conjunction with visualization techniques, within a large insurance claims dataset. We demonstrated the methodology using two examples: metastatic non-small cell lung cancer and metastatic melanoma. First, we generated a longitudinal patient cohort for each cancer type and applied a set of rules to derive patient-level LOT. Then the LOT algorithm outputs for each cancer type were visualized using Sankey plots and K-means clusters based on durations of LOT and of gaps in therapy between LOT. We found differential distribution of temporal phenotypes across clusters. Our approach to identify temporal patient phenotypes can increase the quality and utility of analyses conducted using claims datasets, with the potential for application to multiple oncology disease areas across diverse healthcare data sources. The understanding of LOT as defining patients' temporal phenotypes can contribute to continuous health learning of disease progression and its interaction with different treatment pathways; in addition, this understanding can provide new insights that can be applied by tailoring treatment sequences for the patient phenotypes who will benefit.

Comparative Effectiveness of Chemotherapy, Rituximab, and Bendamustine in Medicare Beneficiaries With Mantle-Cell Lymphoma

BACKGROUND

Over the past 2 decades, rituximab, bortezomib, and bendamustine have been approved to treat mantle-cell lymphoma (MCL). To date, few studies have evaluated the comparative effectiveness of these novel agents. Therefore, this study evaluated the comparative effectiveness of those novel agents in elderly patients newly diagnosed with MCL.

PATIENTS AND METHODS

All newly diagnosed MCL patients aged 66 or older were identified from Surveillance, Epidemiology, and End Results Program (SEER)-Medicare databases from 1999 to 2013. Patients were categorized into 4 groups on the basis of their first-line treatment regimens: chemotherapy alone, rituximab ± chemotherapy, bortezomib ± chemotherapy, and bendamustine ± chemotherapy. Multivariable proportional hazard regressions with 1-year follow-up from treatment were performed to compare the all-cause, MCL-specific, and noncancer mortality rates. Sensitivity analyses using propensity score-adjusted and instrumental variable-adjusted regressions were also conducted.

RESULTS

A total of 1215 MCL patients were included. The bortezomib group was not included in the primary analyses because of the small sample size (n = 24). On multivariable analyses, the rituximab group showed significant decrease in both 1-year all-cause mortality (hazard ratio [HR] = 0.38, 95% confidence interval [CI], 0.25-0.59) and MCL-specific mortality (HR = 0.38; 95% CI, 0.24-0.60) compared to the chemotherapy-alone group. The bendamustine group showed significant decrease in 1-year MCL-specific mortality (HR = 0.49; 95% CI, 0.24-0.99) compared to the chemotherapy-alone group. The results from sensitivity analyses were similar to those from primary analyses.

CONCLUSION

For elderly patients with newly diagnosed MCL, rituximab-based regimen and bendamustine-based regimen as first-line treatment significantly decreased 1-year mortality rates compared to chemotherapy alone.

Treatment of metastatic non-small cell lung cancer: 2018 guidelines of the Italian Association of Medical Oncology (AIOM)

The treatment landscape of metastatic non-small cell lung cancer (NSCLC) has dramatically evolved in recent years, since the recognition of several clinical-biological entities requiring personalized treatment approaches, leading to significant improvements in patients' survival outcomes. In particular, targeted therapies acting against EGFR, ALK, and ROS1, and immunotherapeutic agents modulating the PD-1/PD-L1 axis, represent new milestones in the treatment of advanced disease, supporting a chemotherapy backbone within a multidisciplinary model. The Italian Association of Medical Oncology (AIOM) has developed evidence-based guidelines for the management of lung tumors. Given the epidemiologic relevance, this report is dedicated to the treatment of advanced/metastatic NSCLC. These guidelines serve as a practical tool for oncologists, physicians, and other healthcare professionals to easily embrace the updated key points of NSCLC treatment strategies. Considering the upcoming introduction of potential new standards of care in several disease settings, these guidelines represent a benchmark from which to move forward.

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

Background

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

Methods

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

Results

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

Conclusion

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

Observational Prospective Study to Determine the Evolution of the Symptomatic Profile of Metastatic Non-Small Cell Lung Cancer (NSCLC) Patients and Its Relation to the Control of the Disease

OBJECTIVE

To evaluate the evolution of disease-related symptoms and its relationship with the control of the disease in first-line treatment in patients with metastatic non-small cell lung cancer (NSCLC).

METHODS

This was an observational, prospective, national and multicentre study with two visits in which the following were collected: (1) baseline visit: sociodemographic and clinical variables (2) visit after completing the 4-6 chemotherapy cycles: criteria for ending treatment, control of the disease and clinical variables. Ad hoc questionnaires were collected to assess the frequency of symptoms (evaluated by the patient), and quality-of-life questionnaires to assess the intensity of symptoms (using the Lung Cancer Symptom Scale, LCSS), and interference in the patient's daily life, assessed by the patient and by the investigator.

RESULTS

A total of 155 patients were included. Patients predominantly described tiredness (24.1%) and pain (23.9%) as the symptoms that appeared "frequently or continuously". A statistically significant decrease in scores for symptoms of cough (15.4 points), dyspnoea (8.5 points), pain (9.5 points) and discomfort related to their illness (9 points) was observed between visits. Patients who achieved a complete or partial response showed a statistically significant reduction in the cough, dyspnoea, pain and disconfort frequency. Regarding the intensity, cough was the only symptom that showed  a statistically significant decrease for both the patient and the investigator. Tiredness/asthenia and pain were the symptoms with the greatest interference in daily life at baseline according to the patient; however, according to the investigator, they were mood and quality/quantity of sleep, although none of them were significant. But changes in the score of the interference questionnaire between visits were not statistically significantly related to the control of the disease. However, average score according to both investigator and patients showed a significant correlation with ECOG status.

CONCLUSION

The first-line treatment of NSCLC is correlated with an improvement in the symptomatic evolution of advanced NSCLC patients.

FUNDING

Roche.

Trends and Patterns of Disparities in Burden of Lung Cancer in the United States, 1974-2015

Background: Although lung cancer incidence and mortality have been declining since the 1990s, the extent to which such progress has been made is unequal across population segments. Updated epidemiologic data on trends and patterns of disparities are lacking.

Methods: Data on lung cancer cases and deaths during 1974 to 2015 were extracted from the Surveillance, Epidemiology, and End Results program. Age-standardized lung cancer incidence and mortality and their annual percent changes were calculated by histologic types, demographic variables, and tumor characteristics.

Results: Lung cancer incidence decreased since 1990 (1990 to 2007: annual percent change, −0.9 [95% CI, −1.0%, −0.8%]; 2007 to 2015: −2.6 [−2.9%, −2.2%]). Among adults aged between 20 and 39 years, a higher incidence was observed among females during 1995 to 2011, after which a faster decline in female lung cancer incidence (males: −2.5% [−2.8%, −2.2%]; females: −3.1% [−4.7%, −1.5%]) resulted in a lower incidence among females. The white population had a higher incidence than the Black population for small cell carcinoma since 1987. Black females were the only group whose adenocarcinoma incidence plateaued since 2012 (−5.0% [−13.0%, 3.7%]). A higher incidence for squamous cell carcinoma was observed among Black males and females than among white males and females during 1974 to 2015. After circa 2005, octogenarians and older patients constituted the group with the highest lung cancer incidence. Incidence for localized and AJCC/TNM stage I lung cancer among octogenarians and older patients plateaued since 2009, while mortality continued to rise (localized: 1.4% [0.6%, 2.1%]; stage I: 6.7% [4.5%, 9.0%]).

Conclusions: Lung cancer disparities prevail across population segments. Our findings inform effective approaches to eliminate lung cancer disparities by targeting at-risk populations.

Phase II Study of a Bi-Weekly Chemotherapy Regimen of Combined Liposomal Paclitaxel and Nedaplatin for the Treatment of Advanced Squamous Cell Lung Cancer

The platinum-based, two-drug, 3-week regimen is currently the main first-line chemotherapy program for the treatment of advanced squamous cell lung cancer. The aim of this phase II clinical study was to evaluate the efficacy and adverse events of the bi-weekly program of liposomal paclitaxel combined with nedaplatin as a first-line treatment for advanced squamous cell lung cancer. A total of 52 cases of advanced squamous cell lung cancer were included in this phase II clinical trial. Patients received intravenous infusion of liposomal paclitaxel (100 mg/m²) and nedaplatin (50 mg/m²) on days 1 and 15 of a 4-week cycle. Each patient received two to six cycles of chemotherapy, consistent with the regimen of combined liposomal paclitaxel and nedaplatin. The total effective rate of this chemotherapy program was 37.5%. The median progression-free survival time was 8.5 months (95% confidence interval: 7.8–9.2). The median survival time was 16 months (95% confidence interval: 14.1–17.9). The main adverse event was myelosuppression. Grade 3 leukopenia was noted in seven patients (13.5%), and no grade 4 leukopenia was observed. Grade 3 anemia was noted in four patients (7.7%), and no grade 4 anemia was observed. In addition, no grade 2 or higher thrombocytopenia and no grade 3 or 4 non-bone marrow toxicity was detected. The bi-weekly program of liposomal paclitaxel combined with nedaplatin is effective for the treatment of advanced squamous cell lung cancer, with high safety and few adverse events. However, additional studies are warranted to confirm these results. The trial was registered under the number ChiCTR-OIN-17011423.

Overall survival, costs and healthcare resource use by number of regimens received in elderly patients with newly diagnosed metastatic triple-negative breast cancer

Aim: This analysis estimated the overall survival, treatment patterns and economic burden of elderly metastatic triple-negative breast cancer patients. Materials & methods: Patients (≥66 years) with metastatic triple-negative breast cancer were identified from the SEER-Medicare database. Treatment patterns were defined in terms of first, second and third or more regimens. Healthcare resource use and costs were reported over the follow-up period and over the treatment duration of each regimen. Results: A total of 51% of patients did not receive chemotherapy. Taxanes were most commonly used. Median survival was 7 months. The mean cumulative (per patient per month) cost per patient was US$73,586 (US$10,084). Mean cost in first and second regimen were US$26,950 and US$33,347. Conclusion: About half of patients did not receive chemotherapy. Receipt of increasing regimens led to higher mean costs and healthcare resource use.

Comparative Effectiveness of Computed Tomography- Versus Ultrasound-Guided Percutaneous Radiofrequency Ablation Among Medicare Patients 65 Years of Age or Older With Hepatocellular Carcinoma

BACKGROUND

For patients with hepatocellular carcinoma (HCC) not eligible for surgical resection, radiofrequency ablation (RFA) is a promising technique that reduces the risk of disease progression.

OBJECTIVES

To evaluate whether the trend of image guidance for RFA is moving toward the more expensive computed tomography (CT) technology and to determine the clinical benefits of CT guidance over the ultrasound (US) guidance.

METHODS

A cohort of 463 patients was identified from the Surveillance, Epidemiology, and End Results and Medicare-linked database. The temporal trends in use of image guidance were assessed using the Cochrane-Armitage test. The associations between modality of image guidance and survival, complications, and costs were assessed using the Cox regression model, the logistic regression model, and the generalized linear model, respectively.

RESULTS

The use of CT-guided RFA increased sharply, from 20.7% in 2002 to 75.9% in 2011. Compared with CT-guided RFA, those who received US-guided RFA had comparable risk of periprocedural and delayed postprocedural complications. Stratified analyses by tumor size also showed no statistically significant difference. In adjusted survival analysis, no statistically significant difference was observed in overall and cancer-specific survival. Nevertheless, the cost of CT-guided RFA ($2847) was higher than that of US-guided RFA ($1862).

CONCLUSIONS

Despite its rapid adoption over time, CT-guided RFA incurred higher procedural costs than US-guided RFA but did not significantly improve postprocedural complications and survival. Echoing the American Board of Internal Medicine's Choosing Wisely campaign and the American Society of Clinical Oncology's Value of Cancer Care initiative, findings from our study call for critical evaluation of whether CT-guided RFA provides high-value care for patients with HCC.

Clinical prognostic model for older patients with advanced non-small cell lung cancer

BACKGROUND

Older patients with non-small cell lung cancer (NSCLC) are often not prescribed standard therapy. It is important to know which older patients would be candidates for aggressive therapy based on their prognosis, and to develop a model that can help determine prognosis.

METHODS

Data on older patients (≥70 years) enrolled on 38 NCI cooperative group trials of advanced NSCLC from 1991 to 2011 were analyzed. Multivariable Cox PH model was built with a stepwise selection. We derived a prognostic score using the estimated Cox PH regression coefficient. We then calculated the area under receiver operating characteristic (ROC) curve of survival in the testing set.

RESULTS

The final analysis included 1467 patients, who were randomly divided into a training (n = 963) and a testing set (n = 504). The prognostic risk score was calculated as: 3 (if male) + 3 (if PS = 1) + 8 (if PS = 2) + 11 (if initial stage = IV) + 4 (if weight loss). Patients were classified into two prognostic groups: good (0-8) and poor (≥9). The median survival in the two groups in the testing set were 13.15 (95% CI, 10.82-15.91) and 8.52 months (95% CI, 7.5-9.63), respectively. The model had area under the 1-year and 2-year ROCs (0.6 and 0.65, respectively) that were higher than existing models.

CONCLUSIONS

Male gender, poor performance status, distant metastases and recent weight loss predict for poor overall survival (OS) in older patients with advanced NSCLC. This study proposes a simple prognostic model for older adults with advanced NSCLC.

Investigation on Advanced Non-Small-Cell Lung Cancer among Elderly Patients Treated with Chinese Herbal Medicine versus Chemotherapy: A Pooled Analysis of Individual Data

Purpose

Many patients with advanced non-small-cell lung cancer (NSCLC) seek help from Chinese herbal medicine (CHM). The purpose of this study was to investigate the survival between CHM and chemotherapy (CT) treatment of patients aged ≥60 years with advanced Epidermal Growth Factor Receptor (EGFR) wild type NSCLC and Karnofsky Performance Status (KPS) ≥ 60.

Methods

We extracted individual data of all eligible patients from 1 randomized control trial and 2 cohort studies and performed a pooled analysis. Survival outcomes of patients were compared between CHM group and CT group using Cox regression model stratified for study.

Results

A total of 486 patients were included in the study, including 262 patients in the CHM group and 224 patients in the CT group. The median overall survival time was 10.9 (95% confidence intervals [CI]: 8.9-13.0) months in CHM group and 9.8 (95% CI: 8.1-11.5) days in CT group (p=0.592). The adjusted hazard ratio (HR) and 95% CI for CHM compared to CT are 0.98 (0.87, 1.10, p=0.751) in the stratified Cox regression model. Stratified analysis showed a trend that previously treated elderly patients with EGFR wild type advanced NSCLC probably gain greater survival benefit from CHM (adjusted HR:0.83, 95% CI: 0.68-1.01, p=0.063).

Conclusions

There might be no significant difference in survival for elderly patients with advanced EGFR wild type NSCLC between the CHM and CT groups in the current study. And previously treated elderly patients with advanced NSCLC probably receive greater benefit from CHM. However, limited by the design and unpreplanned study hypothesis, the results must be confirmed by randomized control trial before making a conclusion.

Geriatric assessment in clinical practice for patients with stage IV non-small-cell lung cancer: The Grup de Investigació I Divulgació Oncològica experience

Therapeutic decision-making for older patients with stage IV non-small-cell lung cancer (NSCLC) with no identifiable activating mutation is complex. In this prospective study, we evaluated the usefulness of geriatric assessment (GA) in identifying frail patients. Stage IV NSCLC patients ≥70 years of age were evaluated with GA and classified according to this evaluation into three different groups: fit, vulnerable and frail. Classifications based on GA, treatment decision, toxicity and overall survival were analysed. In total, 93 patients were included. Median age was 76 (70-92) years and 90% were men. Most patients had performance status (PS) 0 or 1 (82%), unrelated to their GA (p = 0.006). GA groups were associated with overall survival (p = 0.000), treatment decision (p = 0.0001), and toxicity (p = 0.0001). Chemotherapy was delivered to 100% of fit patients, to 48% of vulnerable patients, and to only 8% of frail patients (p = 0.000). Toxicity was higher in vulnerable patients than in fit individuals (p = 0.000). Multivariable analysis showed PS (p = 0.001), active treatment (p < 0.001) and GA group (p = 0.001) to be prognostic factors related to survival. Our results suggest that GA identified patients with poor natural prognosis.