Can CT Screening Give Rise to a Beneficial Stage Shift in Lung Cancer Patients? Systematic Review and Meta-Analysis

Epidemiology and Survival of Malignant Central Airway Obstruction in Lung Cancer Identified on Cross-Sectional Imaging

BACKGROUND

The prevalence of malignant central airway obstruction at diagnosis and its 5-year incidence are largely unknown, as are basic epidemiological data pertaining to this serious condition. To address these data limitations, we retrospectively collected data from the cohort of patients diagnosed with lung cancer at our institution in 2015 and followed cohort patients 5 years forward, until 2020.

METHODS

We reviewed index PET/CT or CT scans at the time of lung cancer diagnosis to identify the presence, subtype, and severity of malignant central airway obstruction as well as progression/development over the next 5 years.

RESULTS

The prevalence of malignant central airway obstruction affecting the airway lumen by 25% or greater was 17%, and its 5-year incidence of development was 8.2%. Notable associations from the multivariate analysis included a younger age and a stepwise increase in obstruction with increasing stage of disease. Squamous cell carcinoma and small-cell lung cancer were the 2 histologic subtypes with the strongest association with obstruction. The presence of malignant central airway obstruction either at time of diagnosis or on follow-up imaging was associated with significantly shortened survival (multivariate Cox proportional HR for MCAO=1.702, P<0.001).

CONCLUSION

This study provides the first systematic characterization of fundamental epidemiological data on malignant central airway obstructions at a tertiary cancer center in the United States. This data is important to inform research directions and funding efforts of this serious complication. It also serves as a baseline value against which to compare for future studies.

Training Cardiothoracic Residents in Robotic Lobectomy Is Cost-Effective With No Change in Clinical Outcomes

Objective: Our objective was to evaluate for any changes in quality or cost when robotic lung resection is used with significant trainee participation. Methods: All anatomic lung resections between January 2006 and June 2016 were identified from a prospectively maintained database. Clinical data were recorded by double entry. Cost and cancer-related data were gathered from the business analytics department and tumor registry. Robotic outcomes were compared to an ongoing thoracotomy and video-assisted thoracic surgery (VATS) experience. Propensity scores using age, sex, and comorbidities were assigned for statistical analysis. Survival was evaluated using the Kaplan-Meier method. Results: Of 523 consecutive cases, 483 were included (211 robotic, 210 thoracotomy, 62 VATS). There were 74 robotic cases (35%) performed by trainees as the console surgeon. Length of stay was shortest for robotics (3 days) compared to thoracotomy (7 days, P < 0.001) and VATS (5 days, P = 0.010). Complications occurred in 33% of robotic cases, 42% of VATS cases (P = 0.854), and 52% of thoracotomy cases (P < 0.001). Stage I non-small cell lung cancer 3-year overall survival for robotics, thoracotomy, and VATS was 79.5%, 74.3%, and 74.0%, respectively (P > 0.25). There was no significant difference in negative margin rates. Total cost related to the hospitalization for surgery was $5,721 less for robotics compared to thoracotomy (P = 0.003) but comparable to VATS. Trainees served as console surgeon in 0% of cases in the first 2 years of robotics but increased to 79% in the last year of the study. Conclusions: Robotic lung resection can be safely performed and taught in an academic medical center without sacrificing quality or cost.

Geographic differences in therapy for stage I non-small-cell lung cancer in older adults

BACKGROUND

Geographic and socioeconomic factors impact patient treatment choices for certain cancers. Whether they impact treatment in older adults with lung cancer is unknown. We investigated geographic differences in treatment for stage I non-small-cell lung cancer (NSCLC) in older adults in the United States.

METHODS

Using the Surveillance, Epidemiology and End Results Database 18th submission, a cohort of stage I NSCLC patients ≥60-years-old was created. Treatment differences (surgery or radiation alone) by geographic location and socioeconomic factors were analyzed.

RESULTS

Forty-three thousand three hundred and eighty-seven stage I NSCLC patients were analyzed. Demographics and socioeconomic factors varied across all 13 states (p < 0.001). Surgery was the most common treatment in all states (range 58.6% in AK to 86.5% in CT) (all p < 0.001). Our multivariable analysis found older individuals had higher odds of getting radiation as compared to surgery (odds ratio [OR]: 1.22 for 65-69 years-old to OR: 8.95 for 85+ years-old; p < 0.001). Multiple states (LA, HI, IA, MI, WA, NM) were associated with increased odds of radiation use (vs. surgery alone) (all p < 0.05). People with lower education level (OR: 0.98) and median income (OR: 0.99) and non-Black race (OR: 0.52 for "other" to OR: 0.68 for "White" race with respect to Black race) were associated with lower odds of radiation (p < 0.05).

CONCLUSIONS

Our study identified treatment differences for stage I NSCLC patients in the United States related to demographics, socioeconomic factors, and geographic location.

Association of Exercise Behavior with Overall Survival in Stage I-IIIA Lung Cancer

Rationale: Exercise assessments may help predict outcomes for patients with diagnosed lung cancer. Objectives: We examined the relationship between prediagnosis exercise behavior and clinical outcomes among patients with stage I-IIIA lung cancer. Methods: In a retrospective cohort study of patients with stage I-IIIA lung cancer at Kaiser Permanente Colorado who had at least one Exercise Vital Sign assessment-a questionnaire tool to help promote exercise in chronic disease management-within the year before diagnosis, we defined exercise behavior as active (any min/wk of moderate-to-vigorous-intensity physical activity) or inactive (no moderate-to-vigorous physical activity). The outcomes were 1) overall survival (OS) and 2) acute healthcare use (AHCU). We used the Kaplan-Meier method, Cox proportional hazard model, and negative binomial regression model to analyze the effects of exercise on outcomes, adjusting for demographic, socioeconomic, clinical, and lung-cancer characteristics. Results: Among 552 patients with lung cancer, 230 (42%) were identified as physically active before their diagnosis of cancer. There was no significant difference in the stage distribution between active and inactive patients. The median survival times were 2.4 years for the active group and 1.8 years for inactive patients (P < 0.001). The mean rates (standard deviations) of AHCU were 1.09 (1.55) and 2.31 (5.61) per person-year for active and inactive groups, respectively (P < 0.01). Active exercise, compared with inactivity, was associated with better OS (hazard ratio, 0.52 [0.39-0.69]) and lower AHCU (rate ratio, 0.63 [0.49-0.80]) in unadjusted analyses; in adjusted analyses, active exercise was associated with better OS (hazard ratio, 0.62 [0.45-0.86]), but AHCU was not lower by a statistically significant amount (rate ratio, 0.82 [0.65-1.04]). Conclusions: Prediagnosis active exercise was associated with better OS after diagnosis of stage I-IIIA lung cancer. Exercise assessments may help predict outcomes, risk-stratify patients for curative-intent therapy, and identify those who would benefit from increased physical activity and exercise.

Trajectories of Self-reported Physical Functioning and Symptoms in Lung Cancer Survivors

BACKGROUND

Lung cancer survivors are at risk of accelerated declines in physical functioning attributed to cancer treatment. However, it is unknown whether patients experience the same rate of functional decline and how symptoms may contribute to different trajectories.

OBJECTIVES

The aims of this study were to identify interindividual differences in the pattern and rate of change in self-reported functioning in lung cancer survivors and examine whether and how symptoms are related to physical functioning over time.

METHODS

This was a secondary data analysis in 72 lung cancer survivors. Multilevel modeling was used to estimate trajectories of self-reported physical functioning over 1 year and assess the relation between functioning, fatigue, depressive symptoms, and pain severity across time.

RESULTS

Within the sample, average physical functioning did not significantly decrease (coefficient, -0.46; 95% confidence interval [CI] = -2.85 to 0.94) over time. However, among individual lung cancer survivors, baseline physical functioning varied significantly (SD, 20.76; 95% CI, 16.84-25.59) and changed at significantly different rates over 1 year (SD, 3.50; 95% CI, 2.13-5.68). Fatigue, assessed over 1 year, was the only significant symptom predictor of physical functioning changes over time (coefficient = 1.03; 95% CI, 0.79-1.27).

CONCLUSIONS

In this sample of lung cancer survivors, not all survivors experienced the same rate of self-reported functional decline and those with lower levels of fatigue reported better physical functioning.

IMPLICATIONS FOR PRACTICE

Nurses should recognize that some lung cancer survivors may have faster rates of functional declines than others, which may be related to fatigue severity. Early identification and management of fatigue could help avoid or delay future disability.

Effects of curative-intent lung cancer therapy on functional exercise capacity and patient-reported outcomes

PURPOSE

Lung cancer treatment can lead to negative health consequences. We analyzed the effects of curative-intent lung cancer treatment on functional exercise capacity (EC) and patient-reported outcomes (PROs).

METHODS

We performed a prospective, observational cohort study of consecutive patients with stage I-IIIA lung cancer undergoing curative-intent therapy and assessed functional EC (primary outcome, six-minute walk distance (6MWD)), cancer-specific quality of life (QoL) (secondary outcome, European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC-QLQ-C30) summary score), and exploratory outcomes including dyspnea (University of California San Diego Shortness of Breath Questionnaire (UCSD SOBQ)) and fatigue Brief Fatigue Inventory (BFI)) symptoms before and at 1 to 3 months post-treatment. We analyzed the time effect of treatment on outcomes using multivariable generalized estimating equations.

RESULTS

In 35 enrolled participants, treatment was associated with a clinically meaningful and borderline-significant decline in functional EC ((mean change, 95% CI) 6MWD = - 25.4 m (- 55.3, + 4.47), p = 0.10), clinically meaningful and statistically significant higher dyspnea (UCSD SOBQ = + 13.1 (+ 5.7, + 20.6), p = 0.001) and fatigue (BFI = + 10.0 (+ 2.9, + 17.0), p = 0.006), but no clinically meaningful or statistically significant change in cancer-specific QoL (EORTC-QLQ-C30 summary score = - 3.4 (- 9.8, + 3.0), p = 0.30).

CONCLUSIONS

Among the first prospective analysis of the effect of curative-intent lung cancer treatment on functional EC and PROs, we observed worsening dyspnea and fatigue, and possibly a decline in functional EC but not cancer-specific QoL at 1 to 3 months post-treatment. Interventions to reduce treatment-related morbidities and improve lung cancer survivorship may need to focus on reducing dyspnea, fatigue, and/or improving functional EC.

Prognostic effect of implementation of the mass low-dose computed tomography lung cancer screening program: a hospital-based cohort study

Low-dose computed tomography lung cancer screening aims to detect early-stage lung cancers in order to decrease the incidence of advanced-stage lung cancers and to reduce lung cancer mortality. We analyzed the time trends of lung cancer stage distribution and mortality rates after the gradual implementation of the low-dose computed tomography lung cancer screening in a hospital-based cohort. Using the hospital-based cancer registry data on lung cancer number and death from 2007 to 2014, we aim to evaluate the trends in stage distribution and mortality rate after the gradual implementation of low-dose computed tomography lung cancer screening program over recent years. From 2007 to 2014, overall 2542 cases of lung cancers were diagnosed according to hospital-based cancer registry. For the 1-year mortality rate, the mortality rate decreased gradually from 48.16 to 37.04% between 2007 and 2014. For the 5-year mortality rate, the mortality rate decreased gradually from 88.49 to 69.44% between 2007 and 2014. There was a gradual decrease in stage IV lung cancer with the corresponding sharp increase in stage I early lung cancer after following the implementation of the large volume of the low-dose computed tomography examination between the years 2011 and 2014. In conclusion, these results suggest that the gradual implementation of low-dose computed tomography lung screening program could lead to a remarkable decrease in lung cancer mortality and a remarkable stage shift in the trend over time in this hospital-based cohort.

Low-dose computed tomography for lung cancer screening in high-risk populations: a systematic review and economic evaluation

BACKGROUND

Diagnosis of lung cancer frequently occurs in its later stages. Low-dose computed tomography (LDCT) could detect lung cancer early.

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of LDCT lung cancer screening in high-risk populations.

DATA SOURCES

Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library.

METHODS

Clinical effectiveness - a systematic review of randomised controlled trials (RCTs) comparing LDCT screening programmes with usual care (no screening) or other imaging screening programmes [such as chest X-ray (CXR)] was conducted. Bibliographic sources included MEDLINE, EMBASE, Web of Science and The Cochrane Library. Meta-analyses, including network meta-analyses, were performed. Cost-effectiveness - an independent economic model employing discrete event simulation and using a natural history model calibrated to results from a large RCT was developed. There were 12 different population eligibility criteria and four intervention frequencies [(1) single screen, (2) triple screen, (3) annual screening and (4) biennial screening] and a no-screening control arm.

RESULTS

Clinical effectiveness - 12 RCTs were included, four of which currently contribute evidence on mortality. Meta-analysis of these demonstrated that LDCT, with ≤ 9.80 years of follow-up, was associated with a non-statistically significant decrease in lung cancer mortality (pooled relative risk 0.94, 95% confidence interval 0.74 to 1.19). The findings also showed that LDCT screening demonstrated a non-statistically significant increase in all-cause mortality. Given the considerable heterogeneity detected between studies for both outcomes, the results should be treated with caution. Network meta-analysis, including six RCTs, was performed to assess the relative clinical effectiveness of LDCT, CXR and usual care. The results showed that LDCT was ranked as the best screening strategy in terms of lung cancer mortality reduction. CXR had a 99.7% probability of being the worst intervention and usual care was ranked second. Cost-effectiveness - screening programmes are predicted to be more effective than no screening, reduce lung cancer mortality and result in more lung cancer diagnoses. Screening programmes also increase costs. Screening for lung cancer is unlikely to be cost-effective at a threshold of £20,000/quality-adjusted life-year (QALY), but may be cost-effective at a threshold of £30,000/QALY. The incremental cost-effectiveness ratio for a single screen in smokers aged 60-75 years with at least a 3% risk of lung cancer is £28,169 per QALY. Sensitivity and scenario analyses were conducted. Screening was only cost-effective at a threshold of £20,000/QALY in only a minority of analyses.

LIMITATIONS

Clinical effectiveness - the largest of the included RCTs compared LDCT with CXR screening rather than no screening. Cost-effectiveness - a representative cost to the NHS of lung cancer has not been recently estimated according to key variables such as stage at diagnosis. Certain costs associated with running a screening programme have not been included.

CONCLUSIONS

LDCT screening may be clinically effective in reducing lung cancer mortality, but there is considerable uncertainty. There is evidence that a single round of screening could be considered cost-effective at conventional thresholds, but there is significant uncertainty about the effect on costs and the magnitude of benefits.

FUTURE WORK

Clinical effectiveness and cost-effectiveness estimates should be updated with the anticipated results from several ongoing RCTs [particularly the NEderlands Leuvens Longkanker Screenings ONderzoek (NELSON) screening trial].

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016048530.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Exercise capacity and cancer-specific quality of life following curative intent treatment of stage I-IIIA lung cancer

PURPOSE

Lung cancer survivors are at risk for health impairments resulting from the effects and/or treatment of lung cancer and comorbidities. Practical exercise capacity (EC) assessments can help identify impairments that would otherwise remain undetected. In this study, we characterized and analyzed the association between functional EC and cancer-specific quality of life (QoL) in lung cancer survivors who previously completed curative intent treatment.

METHODS

In a cross-sectional study of 62 lung cancer survivors who completed treatment ≥ 1 month previously, we assessed functional EC with the 6-min walk distance (6MWD) and cancer-specific QoL with the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC-QLQ-C30). Cancer-specific QoL was defined using a validated composite EORTC-QLQ-C30 summary score. Univariable (UVA) and multivariable linear regression analyses (MVA) were performed to assess the relationship between functional EC and cancer-specific QoL.

RESULTS

Lung cancer survivors had reduced functional EC (mean 6MWD = 335 m, 65% predicted) and QoL (mean EORTC-QLQ-C30 summary score = 77, scale range 0-100). In UVA, 6MWD was significantly associated with cancer-specific QoL (R2 = 0.16, p = 0.001). In MVA, in a final model that also included heart failure, obstructive sleep apnea, and psychiatric illness, 6MWD was independently associated with cancer-specific QoL (partial R2 = 0.20, p = 0.001).

CONCLUSIONS

Functional EC was independently associated with cancer-specific QoL in lung cancer patients postcurative intent treatment. Exercise-based interventions aimed at improving EC may improve cancer-specific QoL in these patients.

Challenges and research opportunities for lung cancer screening in China

Following publication of the results of the National Lung Screening Trial in the United States, a randomized controlled trial in Italy (ITALUNG) and two simulation studies in China reported similar findings in 2017 favoring lung cancer screening with low-dose computed tomography among smokers. With such advances in lung cancer screening, worldwide interest has gradually shifted from evaluating whether refining lung cancer screening protocols is effective in preventing deaths. However, there are several practical problems to be resolved, including the balance of enrollment criteria and cost effectiveness, precise measurements to reduce false positive findings, risk-based optimization of screening frequency, challenges associated with cancer heterogeneity, strategies to combine image screening with novel biomarkers, dynamic monitoring of the natural history of cancer, accurate identification and diagnosis of cases among huge populations, and the impact of tobacco control policy and environment protection. As one in three individuals with lung cancer worldwide resides in China, these questions pose great challenges as well as research opportunities for population screening programs in China.

An Autoantibody Against Human DNA-Topoisomerase I Is a Novel Biomarker for Non-Small Cell Lung Cancer

BACKGROUND

We previously reported a novel tumor-associated antigen with a molecular weight of approximately 48 kDa that was a fragment derived from human DNA-topoisomerase I. The aim of this study is to further investigate the clinical significance of the autoantibody in patients with non-small cell lung cancer (NSCLC).

METHODS

We determined serum levels of the autoantibody in 127 NSCLC patients, 127 age-, sex-, and smoking history-matched healthy control subjects, and 38 patients with pulmonary benign tumors by using a specific enzyme linked immunosorbent assay for the autoantibody. We then statistically evaluated its clinical application value.

RESULTS

Serum levels of the autoantibody in NSCLC patients were significantly higher than in healthy control subjects and patients with benign tumors (p = 0.001). The percentage of sera with a positive level of the autoantibody was 71.8%, 65.6%, 41.9%, and 48.0% in stages I, II, III, and IV of the cancer, respectively (p = 0.049). The area under the receiver-operating characteristics curve was 0.971 (95% confidence interval: 0.953 to 0988) for healthy controls and patients with benign tumors versus early stage NSCLC patients. Moreover, the overall survival rate of the patients in stages I, II, and IV with negative levels of the autoantibody was significantly lower than that of patients with positive levels of the autoantibody (p = 0.013, 0.023, and 0.047 for stages I, II, and IV, respectively).

CONCLUSIONS

Our results indicate that the autoantibody can be used as a novel biomarker for the early diagnosis and prognosis of NSCLC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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