Improvement of survival for non-small cell lung cancer over time

Precision nanomedicine to treat non-small cell lung cancer

Lung cancer is a major cause of death worldwide, being often detected at a later stage due to the non-appearance of early symptoms. Therefore, specificity of the treatment is of utmost importance for its effective treatment. Precision medicine is a personalized therapy based on the genomics of the patient to design a suitable drug approach. Genetic mutations render the tumor resistant to specific mutations and the therapy is in vain even though correct medications are prescribed. Therefore, Precision medicine needs to be explored for the treatment of Non-small cell lung cancer (NSCLC). Nanoparticles are widely explored to give personalized interventions to treat lung cancer due to their various advantages like the ability to reach cancer cells, enhanced permeation through tissues, specificity, increased bioavailability, etc. Various nanoparticles (NPs) including gold nanoparticles, carbon nanotubes, aptamer-based NPs etc. were conjugated with biomarkers/diagnostic agents specific to cancer type and were delivered. Various biomarker genes have been identified through precision techniques for the diagnosis and treatment of NSCLC like EGFR, RET, KRAS, ALK, ROS-1, NTRK-1, etc. By incorporating of drug with the nanoparticle through bioconjugation, the specificity of the treatment can be enhanced with this revolutionary treatment. Additionally, integration of theranostic cargos in the nanoparticle would allow diagnosis as well as treatment by targeting the site of disease progression. Therefore, to target NSCLC effectively precision nanomedicine has been adopted in recent times. Here, we present different nanoparticles that are used as precision nanomedicine and their effectiveness against NSCLC disease.

Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection

Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.

Targeting the epithelial-mesenchymal transition (EMT) pathway with combination of Wnt inhibitor and chalcone complexes in lung cancer cells

Non-small cell lung cancer (NSCLC) is the most common type of the lung cancer. Despite development in treatment options in NSCLC, the overall survival ratios is still poor due to epithelial and mesenchymal transition (EMT) feature and associated metastasis event. Thereby there is a need to develop strategy to increase antitumor response against the NSCLC cells by targeting EMT pathway with combination drugs. Niclosamide and chalcone complexes are both affect cancer cell signaling pathways and therefore inhibit the EMT pathway. In this study, it was aimed to increase antitumor response and suppress EMT pathway in NSCLC cells by combining niclosamide and chalcone complexes. SRB cell viability assay was performed to investigate the anticancer activity of drugs. The drugs were tested on both NSCLC cells (A549 and H1299) and normal lung bronchial cells (BEAS-2B). Then the two drugs were combined and their effects on cancer cells were evaluated. Fluorescence imaging and enzyme-linked immunosorbent assay were performed on treated cells to observe the cell death manner. Wound healing assay, real-time quantitative polymerase chain reaction, and western blot analysis were performed to measure EMT pathway activity. Our results showed that niclosamide and chalcone complexes combination kill cancer cells more than normal lung bronchial cells. Compared to single drug administration, the combination of both drugs killed NSCLC cells more effectively by increasing apoptotic activity. In addition, the combination of niclosamide and chalcone complexes decreased multidrug resistance and EMT activity by lowering their gene expressions and protein levels. These results showed that niclosamide and chalcone complexes combination could be a new drug combination for the treatment of NSCLC.

Changes in the Histology of Lung Cancer in Northern Italy: Impact on Incidence and Mortality

This study assessed the incidence, mortality, and survival of lung cancer subtypes of NSCSLC (non-small-cell lung cancer), SCLC (small-cell lung cancer), and other morphologies. It is an observational epidemiological study using 7197 cases from the Reggio Emilia Cancer Registry recorded between 2001 and 2020 in males and females. The incidence of NSCLC in 5104 males indicates a significant 3% annual increase until 2013 and then a decline of -3.2% that is not statistically significant; until 2014, mortality increased significantly (3.2%), but it then decreased non-significantly (-12.1%), especially squamous cell cancer. In 2093 females, the incidence and mortality trends continued to rise significantly through 2012, and then they began to slightly decline (not statistically significant). The two-year relative survival of NSCLC increased from 32% to 38% in males and from 42% to 56% in females. SCLC in males decreased significantly both in incidence and mortality, while in women, it showed a slight increase (significantly for incidence but not for mortality). This study is important because it analyzes the decrease in lung cancer in males and the increase in females in relation to the different histotypes. Our study's findings confirmed a decline in male incidence and death beginning in 2013. We were unable to determine if the drop in cigarette smoking and the introduction of new drugs such as EGFR in first-line therapy were responsible for the lower incidence.

Survival in non-small cell lung cancer patients with versus without prior cancer

Clinical trials on cancer treatments frequently exclude patients with prior cancer, but more evidence is needed to understand their possible effects on outcomes. This study analyzed the prognostic impact of prior cancer in newly diagnosed non-small cell lung cancer (NSCLC) patients while accounting for various patient and cancer characteristics. Using population-based cancer registry data linked with administrative claims data, this retrospective cohort study examined patients aged 15-84 years diagnosed with NSCLC between 2010 and 2015 in Japan. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause mortality in patients with versus without prior cancer. The analysis was stratified according to NSCLC stage and diagnostic time intervals between prior cancers and the index NSCLC. We analyzed 9103 patients (prior cancer: 1416 [15.6%]; no prior cancer: 7687 [84.4%]). Overall, prior cancer had a non-significant mortality HR of 1.07 (95% CI: 0.97-1.17). Furthermore, prior cancer had a significantly higher mortality hazard for diagnostic time intervals of 3 years (HR: 1.23, 95% CI: 1.06-1.43) and 5 years (1.18, 1.04-1.33), but not for longer intervals. However, prior cancer in patients with more advanced NSCLC did not show a higher mortality risk for any diagnostic time interval. Smoking-related prior cancers and prior cancers with poorer prognosis were associated with poorer survival. NSCLC patients with prior cancer do not have an invariably higher risk of mortality, and should be considered for inclusion in clinical trials depending on their cancer stage.

Analyses of P16INK4a gene promoter methylation relative to molecular, demographic and clinical parameters characteristics in non-small cell lung cancer patients: A pilot study

BACKGROUND

The aim of this study was to examine the methylation status of p16^INK4a promoter region in non small cell lung cancer (NSCLC) patients and their associations with single nucleotide polymorphisms (SNPs) of the epidermal growth factor receptor (EGFR) gene, as well as with demographic or clinical characteristics.

METHODS

Formalin-fixed and paraffin-embedded (FFPE) DNA samples extracted from 22 NSCLC patients were analyzed with methylation-specific polymerase chain reaction (PCR) method to obtain promoter methylation profile. The same cohort was genotyped for - 216G > T, -191 C > A, and 181,946 C > T EGFR SNPs.

RESULTS

There was a significant association between methylated p16^INK4a in patients prior therapy (p = 0.017) since a significantly higher frequency of methylated p16^INK4a was detected in these patients (40.9%) in comparison to frequency in patients after therapy (31.8%). Also, a higher frequency of methylated p16^INK4a was detected among patients with leucopenia (p = 0.056). No associations were observed between the methylation status of the p16^INK4a promoter region and EGFR SNPs or other clinical and demographic data in this cohort.

CONCLUSION

High frequency of methylation of the p16^INK4a gene promoter was observed in NSCLC patients prior therapy and with leucopenia that can indicate their significance related to advanced clinical stage.

Assessment of survival outcomes among lung cancer patients at the National and Referral Hospital in Kenya

INTRODUCTION

Lung cancer has a low overall survival rate linked to late diagnosis and metastasis. Unfortunately, comprehensive data within the African continent are limited due to the lack of a registry, low public awareness of lung cancer, financial constraints, and inadequate screening and treatment facilities. In addition, there was a lack of conclusive data in our setting. Therefore, this study aimed to assess survival outcomes among lung cancer patients at Kenyatta National Hospital.

METHODS

A hospital-based retrospective cohort study was performed to examine the survival outcomes of 151 lung cancer patients. All eligible lung cancer patients diagnosed and treated in the facility between January 1, 2018, and December 31, 2020, were included. The patients were retrospectively followed from the date of primary cancer diagnosis until death or the last follow-up period. The Statistical Package for the Social Sciences (SPSS) version 20.0 statistical software was used to enter and analyze the data. Kaplan-Meier survival and Cox regression analysis were employed to determine median survival and predictors of mortality, respectively.

RESULTS

The mean and median follow-time was 18.2 and 17.5 months, respectively. Most (98%) of the patients had non-small cell lung cancer. The 2-year survival rate was 66.7%, with 59.6% of patients having developed distant metastasis during the follow-up, while 25.1% were deceased. The median cancer-specific survival time among the study population was 18.0 ± 3.40 months. Cox regression analyses showed that patients with distant metastasis had five times more risk of dying (AHR: 4.74, 95% CI: 2.1-10.8, p < 0.001) than patients without distant metastasis.

CONCLUSIONS

The overall two-year survival rate of lung cancer patients at the Kenyatta National Hospital was 66.7%, with most patients developed distant metastasis during the follow-up period. Distant metastasis was the only significant predictor of mortality among lung cancer patients in our setting.

Presence of non-Newtonian fluid in invasive pulmonary mucinous adenocarcinomas impacts fluorescence during intraoperative molecular imaging of lung cancer

BACKGROUND

Intraoperative molecular imaging (IMI) with folate-targeted NIR tracers has been shown to improve lesion localization in more than 80% of lung adenocarcinomas. However, mucinous adenocarcinomas (MAs) and invasive mucinous adenocarcinomas (IMAs) of the lung, which are variants of adenocarcinoma, appear to have decreased fluorescence despite appropriate folate receptor expression on the tumor surface. We hypothesized that the etiology may be related to light excitation and emission through non-Newtonian fluid (mucin) produced by goblet and columnar cancer cells.

METHODS

Intraoperative data for 311 subjects were retrospectively reviewed from a prospectively collected 6-year database. For standardization, all patients underwent infusion of the same targeted molecular optical contrast agent (pafolacianine, folate receptor-targeted NIR fluorochrome) for lung cancer resections. Then, the ratio of the mean fluorescence intensity of the tumors and background tissues (TBR) was calculated. Tumors were examined for mucin, FRa, FRb, and immunofluorescent tracer uptake by a board-certified pathologist. The optical properties of mucin analyzed by imaging software were used to create in vitro gel models to explore the effects on NIR tracer fluorescence intensity.

RESULTS

A large proportion (192, 62%) of the patients were female, with an average of 62.8 years and a 34-year mean pack smoking history. There were no severe (Clavien-Dindo > III) complications related to pafolacianine infusion. A total of 195 lesions in the study were adenocarcinomas, of which 19 (6.1%) were of the mucinous subtype. A total of 14/19 of the patients had a smoking history, and more than 74% of the IMA lesions were in the lower lobes. IMA lesions had a lower in situ TBR than nonmucinous adenocarcinomas (2.64 SD 0.23) vs (3.45 SD 0.11), respectively (p < 0.05). Only 9/19 (47%) were localized in situ. Tumor bisection and removal of mucin from IMAs significantly increased pafolacianine fluorescence, with resultant TBR not being significantly different from the control group (4.67 vs 4.89) (p = 0.19). Of the 16 lesions that underwent FR expression analysis, 15/16 had FR presence on cancer cells or tumor-associated macrophages in the tumor microenvironment. There was no statistically significant difference in fluorescence intensity during immunofluorescence analysis (4.99 vs 5.08) (p = 0.16). Physical removal of mucin from IMAs improved the TBR from 3.11 to 4.67 (p < 0.05). In vitro analysis of the impact of synthetic non-Newtonian fluid (agarose 0.5%) on NIR tracer fluorescence showed a decrease in MFI by a factor of 0.25 regardless of the concentration for each 5 mm thickness of mucin.

CONCLUSION

The mucinous subtype of lung adenocarcinomas presents a unique challenge in pafolacianine-targeted IMI-guided resections. The presence of non-Newtonian fluids presents a physical barrier that dampens the excitation of the tracer and fluorescence emission detected by the camera. Knowledge of this phenomenon can allow the surgeon to critically analyze lesion fluorescence parameters during IMI-guided lung cancer resections.

Pre-operative Physical Performance Is Associated With Early Return to Work in Peri-operative Lung Cancer Patients

Little is known about the factors related to return to work (RTW) in patients with peri-operative lung cancer (LC). This study aimed to investigate whether pre-operative physical performance is associated with early RTW in patients with peri-operative LC. A total of 59 patients who wished to resume work after lung resection surgery were included and were divided into three groups: early RTW (within 14 days after discharge), delayed RTW (within 15-90 days), and non-RTW (failure of RTW within 90 days). The early RTW group had significantly lower scores on the modified Medical Research Council dyspnea scale (mMRC) and significantly higher scores on the Euro Quality of Life 5-Dimension 3-Level (EQ-5D-3L) than the non-RTW group. Multivariate logistic regression analysis showed that EQ-5D-3L scores were significantly associated with early RTW, and mMRC scores and knee extensor strength tended to be associated with early RTW. Better pre-operative quality of life, mild dyspnea, and greater lower limb muscle strength tended to be associated with early RTW in patients with peri-operative LC.

Non-Price-Related Determinants of Value and Access for Novel Non-small Cell Lung Cancer Treatments: A Cross-Country Review of HTA Decision Making

INTRODUCTION

Access and funding for newly approved treatments for non-small cell lung cancer (NSCLC) are often dependent on Health Technology Assessment (HTA) involving cost-effectiveness analysis. Whilst methods used by HTA agencies share many similarities, final decisions may differ. This may be the result, not just of price considerations, but also of variation in value judgements by different agencies. The aim of this study was to review international HTA evaluations to identify determinants of value and access for NSCLC treatments.

METHODS

A targeted review and analysis was undertaken of published HTAs for NSCLC across HTA agencies in six countries (Australia, Canada, England, France, Ireland and Scotland). Analysis of extracted data consisted of three stages: descriptive analysis, bivariate analysis and multivariable analysis.

RESULTS

The analysis included 163 HTAs that assessed oncological treatments for NSCLC from 2003 to 2019. The majority of HTA decisions (67.5%) were positive. However, some evidence of heterogeneity in HTA decisions and the factors informing them were identified. The most influential factors included in the multivariate model related to the HTA agency conducting the appraisal, the year of market authorisation, treatment type and the line of treatment.

CONCLUSION

Heterogenous decision-making frameworks can present a challenge to developing HTA submissions. This research contributes to understanding decision-making factors and why countries make different decisions.

Demographic and Clinical Outcomes of Brazilian Patients With Stage III or IV Non-Small-Cell Lung Cancer: Real-World Evidence Study on the Basis of Deterministic Linkage Approach

Non–small-cell lung cancer (NSCLC) is the most common type of lung cancer and accounts for 80%-90% of the cases. In Brazil, between 2018 and 2019, lung cancer was ranked as the second most frequent cancer among men and the fourth among women. The primary objectives were to describe the journey and survival rates of patients with advanced NSCLC treated in the Brazilian private health care system (HCS).

The Effect of Adding Biological Factors to the Decision-Making Process for Spinal Metastasis of Non-Small Cell Lung Cancer

Molecular target therapies have markedly improved the survival of non-small cell lung cancer (NSCLC) patients, especially those with epidermal growth factor receptor (EGFR) mutations. A positive EGFR mutation is even more critical when the chronicity of spinal metastasis is considered. However, most prognostic models that estimate the life expectancy of spinal metastasis patients do not include these biological factors. We retrospectively reviewed 85 consecutive NSCLC patients who underwent palliative surgical treatment for spinal metastases to evaluate the following: (1) the prognostic value of positive EGFR mutation and the chronicity of spinal metastasis, and (2) the clinical significance of adding these two factors to an existing prognostic model, namely the New England Spinal Metastasis Score (NESMS). Among 85 patients, 38 (44.7%) were EGFR mutation-positive. Spinal metastasis presented as the initial manifestation of malignancy in 58 (68.2%) patients. The multivariate Cox proportional hazard model showed that the chronicity of spinal metastasis (hazard ratio (HR) = 1.88, p = 0.015) and EGFR mutation positivity (HR = 2.10, p = 0.002) were significantly associated with postoperative survival. The Uno’s C-index and time-dependent AUC 6 months following surgery significantly increased when these factors were added to NESMS (p = 0.004 and p = 0.022, respectively). In conclusion, biological factors provide an additional prognostic value for NSCLC patients with spinal metastasis.

Early-Stage Non-Small Cell Lung Cancer Stereotactic Body Radiation Therapy (SBRT) Outcomes in an Equal Access Military Setting

Introduction Lung stereotactic body radiation therapy (SBRT) is a first-line treatment for early-stage lung cancer in non-surgical candidates or those who refuse surgery. We compared our institutional outcomes from a unique patient population with decreased barriers to care with a recently published prospective series. Materials and methods  We retrospectively reviewed all patients who received definitive lung SBRT at the Walter Reed National Military Medical Center from 2015 to 2020. All patients underwent a positron emission tomography-computed tomography (PET-CT) and all were presented at a multidisciplinary tumor board. Patients were treated on a Trubeam linear accelerator (LINAC)-based system with daily cone-beam CT. The results were qualitatively compared to outcomes from prospective studies including RTOG 0236 and RTOG 0618. Results A total of 105 patients with 114 lesions were included. Median age was 77 years and 54.7% had ≥ 40-pack year smoking history. 36.8% did not have pathologic confirmation. With a median follow-up of 24 months, three-year local control (LC), disease-free survival (DFS) and overall survival (OS) rates were 92.4%, 81.0%, and 80.0%, respectively. Rates of Grade 1 and 2 toxicity were 21.9% and 6.7% and no patients experienced Grade ≥ 3 toxicity. Conclusions In our military setting with universal coverage and routine multidisciplinary care, lung SBRT provides outcomes comparable to prospective studies conducted at high-volume academic centers. More than one-third of patients were treated empirically without pathologic confirmation of disease, demonstrating a difference between clinical trials and community practice. Further investigation is warranted to integrate multidisciplinary management and achieve equal access to care to bridge existing health disparities in the community setting.

Treatment patterns and clinical outcomes in patients with advanced non-small cell lung cancer initiating first-line treatment in the US community oncology setting: a real-world retrospective observational study

Purpose

Treatments for advanced non-small cell lung cancer (NSCLC) have evolved to include targeted and immuno-oncology therapies, which have demonstrated clinical benefits in clinical trials. However, few real-world studies have evaluated these treatments in the first-line setting.

Methods

Adult patients with advanced NSCLC who initiated first-line treatment with chemotherapy, targeted therapies (TT), or immuno-oncology–based regimens in the US Oncology Network (USON) between March 1, 2015, and August 1, 2018, were included and followed up through February 1, 2019. Data were sourced from structured fields of USON electronic health records. Patient and treatment characteristics were assessed descriptively, with Kaplan-Meier methods used to evaluate time-to-event outcomes, including time to treatment discontinuation (TTD) and overall survival (OS). Adjusted Cox regression analyses and inverse probability of treatment weighting (IPTW) were performed to control for covariates that may have affected treatment selection and outcomes.

Results

Of 7746 patients, 75.6% received first-line systemic chemotherapy, 11.7% received immuno-oncology monotherapies, 8.5% received TT, and 4.2% received immuno-oncology combination regimens. Patients who received immuno-oncology monotherapies had the longest median TTD (3.5 months; 95% confidence interval [CI], 2.8–4.2) and OS (19.9 months; 95% CI, 16.6–24.1). On the basis of multivariable Cox regression and IPTW, immuno-oncology monotherapy was associated with reduced risk of death and treatment discontinuation relative to other treatments.

Conclusion

These results suggest that real-world outcomes in this community oncology setting improved with the introduction of immuno-oncology therapies. However, clinical benefits are limited in certain subgroups and tend to be reduced compared with clinical trial observations.

Electronic supplementary material

The online version of this article (10.1007/s00432-020-03414-4) contains supplementary material, which is available to authorized users.

High-Plex and High-Throughput Digital Spatial Profiling of Non-Small-Cell Lung Cancer (NSCLC)

Profiling the tumour microenvironment (TME) has been informative in understanding the underlying tumour-immune interactions. Multiplex immunohistochemistry (mIHC) coupled with molecular barcoding technologies have revealed greater insights into the TME. In this study, we utilised the Nanostring GeoMX Digital Spatial Profiler (DSP) platform to profile a non-small-cell lung cancer (NSCLC) tissue microarray for protein markers across immune cell profiling, immuno-oncology (IO) drug targets, immune activation status, immune cell typing, and pan-tumour protein modules. Regions of interest (ROIs) were selected that described tumour, TME, and normal adjacent tissue (NAT) compartments. Our data revealed that paired analysis (n = 18) of matched patient compartments indicate that the TME was significantly enriched in CD27, CD3, CD4, CD44, CD45, CD45RO, CD68, CD163, and VISTA relative to the tumour. Unmatched analysis indicated that the NAT (n = 19) was significantly enriched in CD34, fibronectin, IDO1, LAG3, ARG1, and PTEN when compared to the TME (n = 32). Univariate Cox proportional hazards indicated that the presence of cells expressing CD3 (hazard ratio (HR): 0.5, p = 0.018), CD34 (HR: 0.53, p = 0.004), and ICOS (HR: 0.6, p = 0.047) in tumour compartments were significantly associated with improved overall survival (OS). We implemented both high-plex and high-throughput methodologies to the discovery of protein biomarkers and molecular phenotypes within biopsy samples, and demonstrate the power of such tools for a new generation of pathology research.

Returning to work in lung cancer survivors-a multi-center cross-sectional study in Germany

Purpose

To investigate the work situation of lung cancer survivors and to identify the factors associated with their returning to work.

Methods

Descriptive analysis and logistic regression were used to evaluate study population characteristics and independent factors of subsequently returning to work. To analyze time to return to work, Cox regression was used.

Results

The study sample included 232 lung cancer survivors of working age from 717 enrolled participants in the multi-center cross-sectional LARIS (Quality of Life and Psychosocial Rehabilitation in Lung Cancer Survivors) study. About 67% of the survivors were not employed during the survey. More than 51% of the survivors who were employed before their illness did not return to their work. The survivors who had returned to their careers were younger, associated with higher household income, lower fatigue score, and stable relationship and vocational training. Patients who received social service counseling showed a higher chance of regaining their career.

Conclusions

Lung cancer survivors were found to be associated with a high risk of unemployment and very low professional reintegration after interruption due to illness. More comprehensive studies are needed to support lung cancer survivors and targeting of patients in need of special attention in rehabilitation that would benefit from the findings in the present study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-020-05886-z.

In silico and in vitro approaches to evaluate the bioactivity of Cassia auriculata L extracts

The present study is an attempt to evaluate the in vitro anti-inflammatory and in silico anticancer potentials of the plant Cassia auriculata (CA). The aerial parts of CA were subjected to solvent extraction, and the extracts were fractionised by gas chromatography and mass spectrometry analysis for its phytochemical content. The antiinflammatory activity of the extracts were confirmed by the IC50 value of 125.02 µg/ml for red blood cell membrane stabilisation and 195.7 µg/ml for inhibition of protein denaturation activity. The interaction of bioactive compounds of CA ethanol extract with target protein was predicted through molecular docking studies, serine/threonine-protein kinase B (AKT1), responsible for development and progression of lung cancer using AutoDock tools. Extensive studies have been carried out on a range of kinase inhibitors targeting Akt, but obtaining promising results is a challenge yet due to its toxicity and resistance issues. Yohimbine, undecanoic acid 10-methyl-ethyl ester and chrysin significantly bind to the target protein with least binding energy. Hence, the present paper establishes the anti-inflammatory and anticancer capacities of CA ethanol extract as an alternative to the existing therapeutic approach to inflammation and cancer through a systematic in vitro and in silico approaches supplementing the findings.

Long-term survival trends in patients with unresectable stage III non-small cell lung cancer receiving chemotherapy and radiation therapy: a SEER cancer registry analysis

Background

To evaluate the value of new therapies for non-small cell lung cancer (NSCLC), it is necessary to understand overall survival (OS) rates associated with previous standard therapies and how these rates have evolved over time.

Methods

We retrospectively analyzed data from patients enrolled in the Surveillance, Epidemiology, and End Results (SEER) cancer registry. Adults with unresectable, stage III NSCLC treated with chemoradiotherapy were grouped by diagnosis year (2000–2002; 2003–2005; 2006–2008; 2009–2011; 2012–2013). The primary endpoint was OS (data cut-off, December 31, 2014), estimated using the Kaplan–Meier estimator. Temporal survival-trend significance was tested using a two-sided log-rank trend test.

Results

Of 12,865 eligible patients, 59.1% were male, 59.9% had stage IIIB disease, and 62.7% had non-squamous histology. Median age at diagnosis was 67 years. Overall, 10,899 (84.7%) patients died and 1966 (15.3%) were censored/lost to follow-up. Median follow-up (95% confidence interval [CI]) was 80 (77–82) months; median OS (95% CI) was 15 (15–16) months; 1- and 3-year survival probabilities (95% CI) were 57.7% (56.9–58.6) and 24.1% (23.3–24.8), respectively. Stratification by diagnosis year showed consistent improvements in survival over time (p < 0.0001 for trend). Median OS was 12, 14, 15, 18, and 19 months in successive cohorts.

Conclusions

OS in patients diagnosed with unresectable, stage III NSCLC between 2003 and 2013 was consistent with that from clinical studies of sequential/concurrent chemoradiotherapy. Despite improvement over time, median OS was < 2 years and mortality remained high during the first year post-diagnosis.

Projected Reductions in Absolute Cancer-Related Deaths from Diagnosing Cancers Before Metastasis, 2006-2015

BACKGROUND

New technologies are being developed for early detection of multiple types of cancer simultaneously. To quantify the potential benefit, we estimated reductions in absolute cancer-related deaths that could occur if cancers diagnosed after metastasis (stage IV) were instead diagnosed at earlier stages.

METHODS

We obtained stage-specific incidence and survival data from the Surveillance, Epidemiology, and End Results Program for 17 cancer types for all persons diagnosed ages 50 to 79 years in 18 geographic regions between 2006 and 2015. For a hypothetical cohort of 100,000 persons, we estimated cancer-related deaths under assumptions that cancers diagnosed at stage IV were diagnosed at earlier stages.

RESULTS

Stage IV cancers represented 18% of all estimated diagnoses but 48% of all estimated cancer-related deaths within 5 years. Assuming all stage IV cancers were diagnosed at stage III, 51 fewer cancer-related deaths would be expected per 100,000, a reduction of 15% of all cancer-related deaths. Assuming one third of metastatic cancers were diagnosed at stage III, one third diagnosed at stage II, and one third diagnosed at stage I, 81 fewer cancer-related deaths would be expected per 100,000, a reduction of 24% of all cancer-related deaths, corresponding to a reduction in all-cause mortality comparable in magnitude to eliminating deaths due to cerebrovascular disease.

CONCLUSIONS

Detection of multiple cancer types earlier than stage IV could reduce at least 15% of cancer-related deaths within 5 years, affecting not only cancer-specific but all-cause mortality.

IMPACT

Detecting cancer before stage IV, including modest shifts to stage III, could offer substantial population benefit.

Prognosis of advanced stage non-small-cell lung cancer patients receiving chemotherapy: adenocarcinoma <em>versus</em> squamous cell carcinoma

BACKGROUND In Indonesia, lung cancer is one of the most prevalent solid cancer with the highest mortality rate. However, studies to identify prognostic factors associated with mortality are lacking. Thus, this study was aimed to determine the association of histological subtypes and prognosis of advanced stage non-small-cell lung cancer (NSCLC) patients receiving chemotherapy. METHODS This study focused on a retrospective cohort consisting of 60 patients with advanced stage NSCLC and treated with chemotherapy. Patients with NSCLC stage IIIB or stage IV, age ≥18 years, and good performance status were recruited. The outcomes were one-year mortality and treatment response. Gender, age, body mass index, staging, and performance status were evaluated. Chi-square and Fisher’s exact tests were used. RESULTS Two common histological subtypes, adenocarcinoma (68.3%) and squamous cell carcinoma (31.7%), were observed among all subjects. Four patients (6.7%) died during one-year observation period. Mortality rate was higher in squamous cell carcinoma (10.5%) patients than in adenocarcinoma (4.9%). Underweight patients had higher risk of death (relative risk [RR] = 1.09, 95% confidence interval [CI] = 1.00–1.19) and disease progression (RR = 1.30, 95% CI = 1.12–1.51). In adenocarcinoma, metastasis was a risk for progressive disease (RR = 1.35, 95% CI = 1.09–1.66). In squamous cell carcinoma, men had a lower risk of disease progression (RR = 0.11, 95% CI = 0.03–0.41). CONCLUSIONS Squamous cell carcinoma had comparable one-year mortality and disease progression rate with adenocarcinoma type in advanced stage NSCLC. However, underweight patients had a higher risk of mortality and disease progression.

Health-Related Quality of Life With Carboplatin-Paclitaxel or nab-Paclitaxel With or Without Pembrolizumab in Patients With Metastatic Squamous Non-Small-Cell Lung Cancer

PURPOSE

In the phase 3 KEYNOTE-407 study, the addition of pembrolizumab to carboplatin-paclitaxel/nab-paclitaxel significantly improved overall survival, progression-free survival, and objective response rate in patients with previously untreated metastatic squamous non-small-cell lung cancer (NSCLC), with little impact on severe toxicity. We present patient-reported outcomes (PROs) from KEYNOTE-407.

METHODS

Patients were randomly assigned to receive 4 cycles of pembrolizumab 200 mg or placebo once every 3 weeks plus carboplatin plus paclitaxel or nab-paclitaxel, followed by pembrolizumab or placebo for an additional 31 cycles. Health-related quality of life (HRQoL) was evaluated using the European Organisation for Research and Treatment of Cancer Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) and Quality of Life Questionnaire-Lung Cancer Module 13 (QLQ-LC13). Key PRO endpoints were change from baseline to weeks 9 and 18 (during and after platinum therapy) in the QLQ-C30 global health status/quality of life (GHS/QoL) score and time to deterioration in the composite endpoint of cough, chest pain, or dyspnea from the QLQ-C30 and QLQ-LC13. Two-sided, nominal P values are provided.

RESULTS

A total of 554 and 553 patients completed ≥ 1 QLQ-C30 or ≥ 1 QLQ-LC13 assessment, respectively. GHS/QoL score improved for the pembrolizumab-combination group (least squares [LS] mean [95% CI] change from baseline: week 9, 1.8 [-0.9 to 4.4]; week 18, 4.3 [1.7 to 6.9]) and deteriorated in the placebo-combination group (week 9, -1.8 [-4.4 to 0.7]; week 18, -0.57 [-3.3 to 2.2]). Between-group differences were improved for the pembrolizumab-combination group (difference in LS mean scores: week 9, 3.6 [95% CI, 0.3 to 6.9], nominal P = .0337; week 18, 4.9 [1.4 to 8.3], nominal P = .0060). Median time to deterioration in cough, chest pain, or dyspnea was not reached in either group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06]; nominal P = .125).

CONCLUSION

Addition of pembrolizumab to chemotherapy maintained or improved HRQoL measurements relative to baseline and improved HRQoL versus chemotherapy alone at weeks 9 and 18. These results support use of pembrolizumab plus chemotherapy as first-line therapy for metastatic squamous NSCLC.

Evidence That Established Lung Cancer Mortality Disparities in American Indians Are Not Due to Lung Cancer Genetic Testing and Targeted Therapy Disparities

BACKGROUND

American Indians and Alaska Natives (AI/AN) continue to experience extreme lung cancer health disparities. The state of Minnesota is home to over 70,000 AI/AN, and this population has a 2-fold increase in lung cancer mortality compared to other races within Minnesota. Genetic mutation testing in lung cancer is now a standard of high-quality lung cancer care, and EGFR mutation testing has been recommended for all adenocarcinoma lung cases, regardless of smoking status. However, genetic testing is a controversial topic for some AI/AN.

PATIENTS AND METHODS

We performed a multisite retrospective chart review funded by the Minnesota Precision Medicine Grand Challenge as a demonstration project to examine lung cancer health disparities in AI/AN. We sought to measure epidemiology of lung cancer among AI receiving diagnosis or treatment in Minnesota cancer referral centers as well as rate of EGFR testing. The primary outcome was the rate of EGFR mutational analysis testing among cases and controls with nonsquamous, non-small-cell lung cancer. We secured collaborations with 5 health care systems covering a diverse geographic and demographic population.

RESULTS

We identified 200 cases and 164 matched controls from these sites. Controls were matched on histology, smoking status, sex, and age. In both groups, about one third of subjects with adenocarcinoma received genetic mutation testing.

CONCLUSION

There was no significant difference in mutation testing in AI compared to non-AI controls at large health care systems in Minnesota. These data indicate that other factors are likely contributing to the higher mortality in this group.

Risk of second primary malignancy after non-small cell lung cancer: a competing risk nomogram based on the SEER database

Background

With the improvement of survival for non-small cell lung cancer (NSCLC), research focused on second primary malignancy (SPM) in NSCLC survivors is becoming urgent. This study aimed to estimate the risk of SPM in NSCLC patients.

Methods

We retrospectively analysed NSCLC patients diagnosed between 2004 and 2010 in SEER database. We firstly evaluated the crude and cumulative incidence of SPM. SPM incidence in NSCLC survivors compared to that in the reference population was calculated as standardized incidence ratio (SIR). A competing risk nomogram was also built, to predict the incidence of SPM.

Results

The crude and 10-year cumulative incidences of SPM were 4.04% and 5.05%, respectively, while the SIR was 1.62. The nomogram was well calibrated and had good discriminative ability, with c-index of 0.80. It showed a significantly wide interval of SPM cumulative incidence between the first and tenth-decile according to the risk model (1.04% vs. 16.70%, P<0.05). The decision curve analysis indicated that the clinical net benefit of risk model was larger than that in other scenarios (all-screening or no-screening) in a range of threshold probabilities (1% to 20%).

Conclusions

Our study firstly performed a systematic estimation of the incidence of SPM in NSCLC, which implied the necessity of a risk predicting model. We developed the first competing risk nomogram to predict the risk of SPM, which performed well in the evaluation and might be helpful for individualized SPM screening.

A novel LncRNA-based prognostic score reveals TP53-dependent subtype of lung adenocarcinoma with poor survival

The prognostic signatures play an essential role in the era of personalised therapy for cancer patients including lung adenocarcinoma (LUAD). Long noncoding RNA (LncRNA), a relatively novel class of RNA, has shown to play a crucial role in all the areas of cancer biology. Here, we developed and validated a robust LncRNA-based prognostic signature for LUAD patients using three different cohorts. In the discovery cohort, four LncRNAs were identified with 10% false discovery rate and a hazard ratio of >10 using univariate Cox regression analysis. A risk score, generated from the four LncRNAs' expression, was found to be a significant predictor of survival in the discovery and validation cohort (p = 9.97 × 10 ^-8 and 1.41 × 10 ^-3 , respectively). Further optimisation of four LncRNAs signature in the validation cohort, generated a three LncRNAs prognostic score (LPS), which was found to be an independent predictor of survival in both the cohorts ( p = 1.00 × 10 ^-6 and 7.27 × 10 ^-4 , respectively). The LPS also significantly divided survival in clinically important subsets, including Stage I ( p = 9.00 × 10 ^-4 and 4.40 × 10 ^-2 , respectively), KRAS wild-type (WT), KRAS mutant ( p = 4.00 × 10 ^-3 and 4.30 × 10 ^-2 , respectively) and EGFR WT ( p = 2.00 × 10 ^-4 ). In multivariate analysis LPS outperformed, eight previous prognosticators. Further, individual members of LPS showed a significant correlation with survival in microarray data sets. Mutation analysis showed that high-LPS patients have a higher mutation rate and inactivation of the TP53 pathway. In summary, we identified and validated a novel LncRNA signature LPS for LUAD.

Proton therapy for non-small cell lung cancer: the road ahead

Proton therapy is an evolving radiotherapy modality with indication for numerous cancer types. With the benefits of reducing dose and sparing normal tissue, protons offer a clear physical and dosimetric advantage over photon radiotherapy for many patients. However, its impact on one type of disease, non-small cell lung cancer (NSCLC), is still not fully understood. Our review aims to highlight the data for using proton therapy in NSCLC, with a focus on the clinical data-or lack thereof-supporting proton treatment for early and advanced stage disease. In evaluating these data, we consider how future directions and advances in proton technology give rise for hope in defining a role for protons in improving NSCLC outcomes. We close with considerations for next steps and the challenges ahead in using proton therapy for this unique patient population.

Trends in Survival Based on Treatment Modality in Non-Small Cell Lung Cancer Patients: A Population-Based Study

Objectives: We examined the trends in survival based on treatment modality among non-small cell lung cancer (NSCLC) patients in the province of Ontario, Canada, from 2007 to 2015. Methods: We investigated the trends in survival based on treatment modality. Results: Among 56,417 identified patients, the mean age at diagnosis was 70.1 years (SD = 10.7). Treatment modalities varied significantly over time (p<.001). Overall, 23.0% of patients received surgical treatments. We observed more than 20% increase in five-year survival rates for all surgical groups over time. Conclusions: Patients undergoing sublobar/lobar resections had higher survival rate.

Cascaded Wx: A Novel Prognosis-Related Feature Selection Framework in Human Lung Adenocarcinoma Transcriptomes

Artificial neural network-based analysis has recently been used to predict clinical outcomes in patients with solid cancers, including lung cancer. However, the majority of algorithms were not originally developed to identify genes associated with patients' prognoses. To address this issue, we developed a novel prognosis-related feature selection framework called Cascaded Wx (CWx). The CWx framework ranks features according to the survival of a given cohort by training neural networks with three different high- and low-risk groups in a cascaded fashion. We showed that this approach accurately identified features that best identify the patients' prognoses, compared to other feature selection algorithms, including the Cox proportional hazards and Coxnet models, when applied to The Cancer Genome Atlas lung adenocarcinoma (LUAD) transcriptome data. The prognostic potential of the top 100 genes identified by CWx outperformed or was comparable to those identified by the other methods as assessed by the concordance index (c-index). In addition, the top 100 genes identified by CWx were found to be associated with the Wnt signaling pathway, providing biologically relevant evidence for the value of these genes in predicting the prognosis of patients with LUAD. Further analyses of other cancer types showed that the genes identified by CWx had the highest prognostic values according to the c-index. Collectively, the CWx framework will potentially be of great use to prognosis-related biomarker discoveries in a variety of diseases.

Microsatellite instability in endometrial cancer: New purpose for an old test

Historically, microsatellite instability testing has been used to identify endometrial cancer patients with Lynch Syndrome. Now, it is also being used to identify those who may be immunotherapy candidates.

Prostaglandin E-Major Urinary Metabolite (PGE-MUM) as a Tumor Marker for Lung Adenocarcinoma

Background: Prostaglandin E2 (PGE2) is metabolized to prostaglandin E-major urinary metabolite (PGE-MUM). Enhanced cyclooxygenase-2 (COX-2) expression demonstrated in lung adenocarcinoma indicates increased PGE-MUM levels in patients with lung adenocarcinoma. Objectives: We aimed to elucidate the clinical usefulness of measuring PGE-MUM as an indicator of tumor burden in patients with lung adenocarcinoma. Methods: PGE-MUM was measured by a radioimmunoassay in control healthy volunteers (n = 124) and patients with lung adenocarcinoma (n = 54). Associations between PGE-MUM levels and clinical characteristics of the patients (including lung cancer stage and TNM factors (T: Tumor, N: Node, M: Metastasis) were examined. Results: PGE-MUM levels were significantly elevated in patients with lung adenocarcinoma. A PGE-MUM level of 14.9 μg/g∙Cr showed 70.4% sensitivity and 67.7% specificity for the diagnosis of lung adenocarcinoma. PGE-MUM levels tended to be positively correlated with cancer progression as determined by the TNM staging system. Advanced stage (stage III, stage IV, and recurrence) was significantly associated with high PGE-MUM levels by logistic regression analysis. No apparent correlation was demonstrated between PGE-MUM and carcinoma embryonic antigen (CEA) levels. Conclusions: PGE-MUM can be a promising biomarker reflecting the systemic tumor burden of lung adenocarcinoma.

Versatile Pt NCs-based chemotherapeutic agents significantly induce the apoptosis of cisplatin-resistant non-small cell lung cancer

Recently, the incidence of lung cancer is generally rising along with air pollution and smoking, and non-small cell lung cancer (NSCLC) accounts for nearly 85% among all lung cancer diagnoses. With the development of chemotherapy, the drug resistance rate of common platinum-based chemotherapeutic drugs (like cisplatin) is gradually increased, which seriously affects the chemotherapy efficiency and survival rate of patients. In this study, polyethylenimine caged platinum nanoclusters (PEI-caged Pt NCs) were proposed as a new chemotherapeutic agent to apply in the treatment of NSCLC, choosing the classical cisplatin-resistant A549/DDP cells and normal A549 cells as targets. It was found that our Pt NCs-based chemotherapeutic drugs showed its preferable therapeutic effect in cisplatin-resistant NSCLC through the results of confocal microscopic images, cell counting kit-8 test, cell apoptosis assay and western blot. Most importantly, in the cisplatin-resistance A549/DDP cells, this kind of agents could enter the nucleus obviously, and emerged a superior inhibitory and apoptotic effects than A549 via activating p53 protein and the related signaling pathways. Comparing with the traditional chemotherapy drugs, these Pt NCs-based chemotherapeutic agents exhibit great potential and advantages in the treatment and diagnosis of NSCLC regardless of the therapeutic effect or toxic side effects, especially the drug resistance.

Anticancer activity of methylene blue via inhibition of heat shock protein 70

INTRODUCTION

Heat shock protein 70 (Hsp70) and heat shock protein 90 (Hsp90) chaperones are indispensable to lung cancer cells for their survival and proliferation. In this study we evaluated and compared anticancer potential of methylene blue (MB) as an Hsp70 inhibitor, novobiocin (NB) a well-known Hsp90 inhibitor and their combination.

METHODS

In vitro evaluation was done by cell viability assays, fluorescent staining, and flow cytometry analysis using A549 non-small cell lung cancer cells. In vivo anticancer activity was investigated by evaluating oxidative stress, tumor biomarkers, weight, lung microarchitecture, and Hsp70 and Hsp90 inhibitions via immunoblotting in benzo[a]pyrene induced lung carcinogenesis mice model.

RESULTS

Using A549 NSCLC cells, we found MB demonstrated lower cell viability versus NB. Together, MB + NB resulted in further decrease in cell viability. SRB assay revealed significantly superior and similar potency for MB versus NB and MB + NB (1:1) versus MB, respectively. Fluorescent staining and flow cytometry analysis displayed early apoptosis by MB (11.4%); early and late apoptosis by MB + NB (13.8%). In vivo, MB significantly inhibited Hsp70. Furthermore, MB significantly alleviated tumor biomarkers (ADA and LDH) and improved lung histopathological features more than NB. Additionally, MB significantly improved SOD, not more than MB + NB or NB and improved LPO.

CONCLUSION

MB demonstrated potent anticancer activity in vitro and in vivo via inhibition of Hsp70 in benzo[a]pyrene induced lung carcinogenesis in mice.

Survival Comparison in Patients with Stage IV Lung Cancer in Academic versus Community Centers in the United States

INTRODUCTION

Although metastatic NSCLC is widely treated in both academic centers (ACs) and community-based centers (CCs), it is unclear whether outcomes are similar across both settings. A growing variety of chemotherapies and targeted agents for an increasingly histology- and molecular-based treatment strategy could provide an advantage to patients treated in ACs. Using the National Cancer Database, we investigated whether treatment at ACs was associated with a survival advantage in metastatic NSCLC.

METHODS

We conducted a retrospective analysis of the National Cancer Database after the introduction of novel NSCLC chemotherapy agents from 1998 to 2010. The primary outcome was 2-year survival, which was analyzed by using a multivariable regression model controlling for age, year of diagnosis, sex, primary payer, histologic type, facility type (AC versus CC), and an interaction term allowing a time-based comparison of survival between ACs and CCs. Alpha was set to 0.001 because of the size of the data set.

RESULTS

There were 193,279 patients included in this study. The percentage of patients achieving 2-year survival was higher in ACs versus in CCs in 1998 (11.5% versus 9.2% [+2.3%]), and by 2010, the difference had increased to 17.4% versus 13.1% (+4.3%). Multivariable analysis confirmed a significant relative increase in 2-year survival associated with ACs versus with CCs from 1998 to 2010 (p = 0.0005). A histology-dependent survival difference was also noted in adenocarcinoma versus in squamous cell carcinoma (10.2% versus 9.9% in 1998 [+0.3%], increasing to 17.3% versus 10.1% in 2010 [+7.2%]). Adenocarcinoma survival also varied by treatment facility, with the difference in 2-year survival in ACs versus in CCs increasing from 12.3% versus 9.1% (+3.2%) in 1998 to 20.5% versus 15.5% (+5%) in 2010, with a trend toward significance in our multivariable model (p = 0.005).

CONCLUSIONS

A greater increase in survival was noted in ACs than in CCs over this time period, and it was particularly pronounced among patients with adenocarcinoma versus in those with squamous cell carcinoma. Given the known advances in adenocarcinoma treatment compared with in squamous cell lung cancer over this time period, our study suggests that potential treatment-related disparities may exist between ACs and CCs. Further study will be needed to validate this disparity in health care and address opportunities to improve survival in patients with stage IV NSCLC across treatment settings.

Prognostic value of pretreatment prognostic nutritional index in non-small cell lung cancer: A systematic review and meta-analysis

BACKGROUND:

The pretreatment prognostic nutritional index has been considered a potential prognostic biomarker in patients with non-small cell lung cancer (NSCLC), but this remains controversial. Therefore, we performed a meta-analysis to systematically assess the prognostic value of the prognostic nutritional index in patients with NSCLC.

METHODS:

We systematically searched PubMed, EMBASE, Web of Science, and CNKI. The hazard ratios (HRs) with their corresponding 95% confidence intervals (CIs) were used to evaluate the link between the prognostic nutritional index and the oncological outcomes of patients with NSCLC, including overall survival, disease-free survival/recurrence-free survival, and progression-free survival.

RESULTS:

Fifteen studies were included in this meta-analysis. Twelve of these studies explored the association between the prognostic nutritional index and the overall survival of patients with NSCLC. Our pooled analysis indicated that a low prognostic nutritional index was significantly related to adverse overall survival (HR 1.61; 95% CI 1.44, 1.81; P < 0.001). Our results also showed that the prognostic nutritional index was a negative predictor for disease-free survival/recurrence-free survival, and progression-free survival in patients with NSCLC.

CONCLUSION:

Our meta-analysis demonstrated that there was a close association between the prognostic nutritional index value and prognosis in NSCLC patients and that the prognostic nutritional index may act as a useful prognostic biomarker in NSCLC patients.

Dosimetric Predictors of Symptomatic Cardiac Events After Conventional-Dose Chemoradiation Therapy for Inoperable NSCLC

INTRODUCTION

We hypothesized that higher cardiac doses correlates with clinically significant cardiotoxicity after standard-dose chemoradiation therapy (CRT) (∼60 Gy) for inoperable NSCLC.

METHODS

We retrospectively reviewed the records of 140 patients with inoperable NSCLC treated with concurrent CRT from 2007 to 2015. Extracted data included baseline cardiac status, dosimetric parameters to the whole heart (WH) and cardiac substructures, and the development of post-CRT symptomatic cardiac events (acute coronary syndrome [ACS], arrhythmia, pericardial effusion, pericarditis, and congestive heart failure [CHF]). Competing risks analysis was used to estimate time to cardiac events.

RESULTS

Median follow-up was 47.4 months. Median radiation therapy dose was 61.2 Gy (interquartile range, 60 to 66 Gy). Forty patients (28.6%) developed 47 symptomatic cardiac events at a median of 15.3 months to first event. On multivariate analysis, higher WH doses and baseline cardiac status were associated with an increased risk of symptomatic cardiac events. The 4-year cumulative incidence of symptomatic cardiac events was 48.6% versus 18.5% for mean WH dose ≥ 20 Gy versus < 20 Gy, respectively (p = 0.0002). Doses to the WH, ventricles, and left anterior descending artery were associated with ACS/CHF, whereas doses to the WH and atria were not associated with supraventricular arrhythmias. Symptomatic cardiac events (p = 0.0001) were independently associated with death.

CONCLUSIONS

Incidental cardiac irradiation was associated with subsequent symptomatic cardiac events, particularly ACS/CHF, and symptomatic cardiac events were associated with inferior survival. These results support the minimization of cardiac doses among patients with inoperable NSCLC receiving standard-dose CRT.