Trends in lung cancer in elderly in Denmark, 1980-2012

Three-year follow-up study reveals improved survival rate in NSCLC patients underwent guideline-concordant diagnosis and treatment

Background

No studies in China have assessed the guideline-concordance level of the first-course of non-small cell lung cancer (NSCLC) diagnosis and treatment and its relationship with survival. This study comprehensively assesses the current status of guideline-concordant diagnosis (GCD) and guideline-concordant treatment (GCT) of NSCLC in China and explores its impact on survival.

Methods

First course diagnosis and treatment data for NSCLC patients in Liaoning, China in 2017 and 2018 (n=1828) were used and classified by whether they underwent GCD and GCT according to Chinese Society of Clinical Oncology (CSCO) guidelines. Pearson's chi-squared test was used to determine unadjusted associations between categorical variables of interest. Logistic models were constructed to identify variables associated with GCD and GCT. Kaplan-Meier analysis and log-rank tests were used to estimate and compare 3-year survival rates. Multivariate Cox proportional risk models were constructed to assess the risk of cancer mortality associated with guideline-concordant diagnosis and treatment.

Results

Of the 1828 patients we studied, 48.1% underwent GCD, and 70.1% underwent GCT. The proportions of patients who underwent both GCD and GCT, GCD alone, GCT alone and neither GCD nor GCT were 36.7%, 11.4%, 33.5% and 18.4%, respectively. Patients in advanced stage and non-oncology hospitals were significantly less likely to undergo GCD and GCT. Compared with those who underwent neither GCD nor GCT, patients who underwent both GCD and GCT, GCD alone and GCT alone had 35.2%, 26.7% and 35.7% higher 3-year survival rates; the adjusted lung cancer mortality risk significantly decreased by 29% (adjusted hazard ratio[aHR], 0.71; 95% CI, 0.53-0.95), 29% (aHR, 0.71; 95% CI, 0.50-1.00) and 32% (aHR, 0.68; 95% CI, 0.51-0.90).

Conclusion

The 3-year risk of death is expected to be reduced by 29% if patients with NSCLC undergo both GCD and GCT. There is a need to establish an oncology diagnosis and treatment data management platform in China to monitor, evaluate, and promote the use of clinical practice guidelines in healthcare settings.

Stereotactic radiosurgery for brain metastases: A retrospective cohort study comparing treatment results between two lung cancer patient age groups, 75 years or older vs 65-74 years

BACKGROUND

There is little information on stereotactic radiosurgery (SRS) results for brain metastases (BMs) in lung cancer patients ≥75 years of age. We aimed to reappraise whether SRS results for patients ≥75 (very elderly) differ from those of patients with 65-74 years old (elderly).

METHODS

This IRB-approved retrospective cohort study was based on our prospectively-accumulated database including 7351 consecutive patients undergoing gamma knife (GK) SRS performed for BMs by two highly experienced neurosurgeons during the 1998-2018 period. We selected a total of 2915 elderly patients (age ≥65 years, 39.7 % of the 7351) with lung cancers (902 females, 2013 males, median age; 72 [maximum; 96] years, 2441 NSCLCs, 474 SCLCs) for this study.

RESULTS

Post-SRS median survival times (MSTs, months) differed significantly between the two lung cancer types, NSCLC (9.0) and SCLC (7.2, p < 0.0001). In NSCLC patients, post-SRS MSTs were significantly shorter in the very elderly (9.7) than those in the elderly (7.8) group (p < 0.0001). However, in SCLC patients, there were no significant MST differences (7.3 vs 6.9, p = 0.52) between the two age groups. In both NSCLC and SCLC patients, neither crude nor cumulative incidences of secondary endpoints in the very elderly group, i.e., neurological death, neurological deterioration, local recurrence, repeat SRS, salvage whole brain radiotherapy and SRS-related complications, were shown to be unfavorable to those in the elderly group.

CONCLUSIONS

Our results suggest that carefully-selected patients ≥75 years of age are not poor candidates for SRS as compared to those 65-74 years old.

Patient perspectives and experience on the diagnostic pathway of lung cancer: A qualitative study

Objectives:

Lung cancer is one of the most common types of cancer, with high mortality rate and a significant burden of symptoms. It is therefore important to assess patients’ perceived quality of life during the diagnostic process and treatment. Knowledge of and attention to patients’ perspectives, experiences, and expectations in relation to lung cancer diagnostic pathways is limited. The aim of the study is to contribute with patients’ and relatives’ experiences with and their assessment of the quality of a hospital-based lung cancer diagnostic pathway.

Methods:

A qualitative study was conducted, comprising participant observation with 20 patients and semi-structured interviews with further 19 patients referred to the Lung Cancer Package, which initiates a fast track diagnostic pathway in a hospital setting. Data were obtained over a period of 9 months and analysed in collaboration with an interdisciplinary team of health professionals. The purpose was to further develop existing management strategies of the fast track diagnostic pathway based on patient’s perspectives.

Results:

Patients associated the fast track diagnostic pathway with high levels of anxiety due to the immediate risk of a lung cancer diagnosis. Although patients experienced the fast track programme as very challenging, they still wanted to move through the diagnostic pathway as quickly as possible. The patients expressed a need for support from relatives and repeatedly required information in multiple formats from health professionals throughout the diagnostic pathway.

Conclusions:

The study provided insight into the need for developing the fast track diagnostic pathway with a focus on patient anxiety, network involvement, and information strategies. The results qualified clinical practice with an increased focus on managing patients’ anxiety, raised awareness to involve relatives in the diagnostic process, and relaying information in dialogue with patients and their relatives, including management strategies to support patients through diagnostic investigations in the fast track programme.

Outcome of treatment in patients with small cell lung cancer in poor performance status

Background: Patients with small cell lung cancer (SCLC) with poor performance status (PS) especially in the elderly may not benefit from chemotherapy. The aim of this study was to compare survival of treated patients with PS 3-4 with untreated patients.Material and methods: We reviewed the medical records and pathology data for 448 patients diagnosed with small cell carcinoma from 2010 to 2015 and selected all patients in PS 3-4 for review.Results: A total of 87 patients fulfilled the inclusion criteria. Of these, 53 (61%) received chemotherapy (CT), while 34 (39%) did not. The median overall survival (OS) was 5.1 months for the treated patients and 0.7 month for the untreated (p < .001). Multivariate analysis identified lack of treatment with chemotherapy, extensive disease, and PS 4 as independent factors associated with poor prognosis, while age and gender were not. Also, patients with aged ≥70 years who had extended disease had significant improved OS when treated with CT. However, the chance of being treated with CT was significantly influenced by age.Conclusion: CT was associated with improved survival in patients with SCLC with PS 3-4 independent of age and stage of disease. Neither ED, high age, nor poor PS should be used as criteria for omitting CT.

Survival after stereotactic radiotherapy in patients with early-stage non-small cell lung cancer

Introduction: Stereotactic radiotherapy (SBRT) is the treatment of choice for inoperable early stage non-small cell lung cancer (NSCLC). We report analyses of the influence of age on survival after SBRT. Methods and material: From 2005 to 2017, 544 previously un-irradiated patients with early stage NSCLC had SBRT. The data were analyzed in four age groups: A: -69 (176 pts), B: 70-74 (115 pts), C: 75-79 (131 pts) and D: 80 years or older (122 pts). Two SBRT dose regimes were used: 45 Gy/3F (N = 103) and 66 Gy/3F (N = 441). Results: All patients had a follow up (time to censoring, FU) of at least 16 months, the median FU being 48.0 months. The median age was 74.4 years. The overall survival (OS) was associated with age. The median OS was 50.7, 45.9, 45.4 and 33.0 months, and the 5-year OS was 45%, 32%, 33% and 18% in groups A, B, C and D, respectively. No difference was found between groups B and C, while OS in group A was significantly better than remaining groups, and the OS in group D significantly poorer. In multivariable analyses, OS was heavily influenced by age, Charlson's comorbidity index (CCI) and performance status (PS). For lung cancer-specific survival (LCSS), only increasing tumor diameter and PS were associated with poor survival. Conclusions: The OS was influenced by age, but the study suggests that a cut point of 75 year is inappropriate in evaluating the effect of old age on survival. Poor PS was associated with poor OS. CCI influenced OS, but not LCSS, which was only affected by PS and tumor size.

Increasing incidence and survival in oral cancer: a nationwide Danish study from 1980 to 2014

BACKGROUND

Oral carcinomas (OCs) make up a significant proportion of head and neck carcinomas (HNCs) and are an important cause of morbidity and mortality globally. The purpose of this population-based study was to determine trends in incidence and survival in OC in the Danish population from 1980 to 2014.

MATERIAL AND METHODS

This study covered all patients registered in the nationwide Danish cancer registry (DCR) in the period 1980-2014. Age-adjusted incidence rate (AAIR) per 100,000 and annual percentage change (APC) were evaluated. Also, 5-year overall survival (OS) was calculated with Cox regression analysis in relation to location, gender, age, and calendar year at diagnosis.

RESULTS

Altogether, 8299 patients with oral cancer were identified, 5062 (61%) of whom were males and 3237 (39%) were females. The median age at diagnosis was 63 years. The AAIR of patients with OC increased from 1.9 per 100,000 in 1980 to 3.5 per 100,000 in 2014, and we observed a significant increase in 5-year OS of 12% points (a relative increase of 38%) from the period 1980-1984 to 2005-2009. Women were found to have a better prognosis than men.

CONCLUSIONS

We found an unexpected increase in the age-standardized incidence of OC during the last 30 years in Denmark, and also an improvement in survival. The 5-year OS was significantly better in recent years even when we adjusted the analysis for relevant covariates.

Lung cancer guidelines in Sweden, Denmark, Norway and Finland: a comparison

BACKGROUND

The Nordic countries are similar in terms of demographics and health care organization. Yet there are marked differences in lung cancer mortality, for which Denmark historically has had the poorest outcome. One of several possible reasons for these differences could have to do with how lung cancer is diagnosed and treated in the different Nordic countries. However, among the four most populous Nordic countries: Sweden, Denmark, Norway and Finland, there is a paucity of knowledge about differences and similarities in recommendations in the national guidelines for non-small cell lung cancer (NSCLC) and the methodology by which the guidelines are developed.

METHODS

We identified and evaluated the development and content of the available clinical care guidelines for NSCLC in the four countries. Moreover, we compared the integrated cancer pathways in these countries. We have used case examples to illustrate areas with clear differences in clinical care recommendations.

RESULTS

There are notable differences in the methodology by which the guidelines are developed, published and updated to comply with international recommendations. The Norwegian guidelines are developed and updated according to the most rigorous methodology and have so far been updated most frequently. We found that on the basis of recommendations patients with NSCLC are treated differently with regard to bevacizumab therapy and radiation dosing regimens. Cerebral imaging practices in patients with locally advanced NSCLC also differ. There is, moreover, a marked difference with regard to efforts to help patients to quit smoking. All except Finland have integrated cancer pathways for fast track diagnosis and treatment. Guidelines for follow-up of lung cancer patients also differ, with the Danish follow-up regimen as the most comprehensive. To obtain consensus on optimal clinical care, areas with differences in recommendations or where recommendations are based on a low level of evidence should be subjected to further studies.

Cancer-Incidence, prevalence and mortality in the oldest-old. A comprehensive review

Chronic health conditions are commonplace in older populations. The process of aging impacts many of the world's top health concerns. With the average life expectancy continuing to climb, understanding patterns of morbidity in aging populations has become progressively more important. Cancer is an age-related disease, whose risk has been proven to increase with age. Limited information is published about the epidemiology of cancer and the cancer contribution to mortality in the 85+ age group, often referred to as the oldest-old. In this review, we perform a comprehensive assessment of the most recent (2011-2016) literature on cancer prevalence, incidence and mortality in the oldest-old. The data shows cancer prevalence and cancer incidence increases until ages 85-89, after which the rates decrease into 100+ ages. However the number of overall cases has steadily increased over time due to the rise in population. Cancer mortality continues to increase after age 85+. This review presents an overview of plausible associations between comorbidity, genetics and age-related physiological effects in relation to cancer risk and protection. Many of these age-related processes contribute to the lowered risk of cancer in the oldest-old, likewise other certain health conditions may "protect" from cancer in this age group.

Comparison of the accuracy of 99mTc-3P4-RGD2 SPECT and CT in diagnosing solitary pulmonary nodules

The aim of the present study was to compare technetium-99m-(polyethylene glycol-4)₃-(Arg-Gly-Asp)₂ (99mTc-3P₄-RGD₂) single-photon emission computed tomography (SPECT) and computed tomography (CT) in the noninvasive differentiation of solitary pulmonary nodules (SPNs). The present study prospectively investigated a consecutive series of 24 patients with SPN, who were newly diagnosed using radiography between September 2012 and January 2014. All patients underwent 99mTc-3P₄-RGD₂ SPECT and CT scans using a dual-head variable-angle γ-camera equipped with high-resolution collimators. A blinded panel of two thoracic radiologists for CT and three nuclear physicians for SPECT analyzed the images using a 5-grade scale. The SPECT images were also semi-quantitatively evaluated using tumor to non-tumor localization ratios (T/NT). The results were verified by pathological examination of the biopsy material obtained from each patient with SPN, and receiver operating characteristic (ROC) curves were generated from these results. The present results revealed that there were 17 malignant and 7 benign SPNs among the 24 patients with SPN. The mean size of the SPN was 2.1±0.6 cm. Sensitivity of visual analysis for SPECT and CT were 100.0 and 82.4%, respectively, and specificity was 71.4% for the two methods. When the T/NT SPECT semiquantitative analysis (ratio, 1.64) was used as a cut-off, the sensitivity and specificity of SPECT were 100.0 and 71.4%, respectively. The areas under the ROC curves were 0.840 for visual analysis of SPECT [95% confidence interval (CI), 0.600–1.000], 0.849 for semiquantitative analysis of SPECT (95% CI, 0.618–1.000) and 0.815 for CT (95% CI, 0.626–1.000). In conclusion, the present results suggest that 99mTc-3P₄-RGD₂ SPECT is more accurate than CT in the detection of malignant SPN, and visual analysis appears to be sufficient for the characterization of SPN.

Comparison of survival of chronic obstructive pulmonary disease patients with or without a localized non-small cell lung cancer

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) and non-small cell lung cancer (NSCLC) are often co-existing diseases with poor prognosis. The aim of this study was to compare survival in COPD patients with localized NSCLC treated with stereotactic body radiotherapy (NSCLC group) with COPD patients without a malignant diagnosis (non-malignant group).

MATERIALS AND METHODS

The NSCLC group was prospectively recorded at the Department of Oncology from 2007 to 2013. The non-malignant group was selected among patients referred to the Department of Respiratory Medicine from 2005 until 2011 suspected of thoracic malignancy but without the malignant diagnosis maintained.

RESULTS

In a propensity score matched comparison the median overall survival was 53 vs. 71 months in the NSCLC and non-malignant groups, respectively (p<0.001). Subgroup analyses showed survival for patients with mild/moderate COPD was affected statistically significant with a higher mortality rate by a diagnosis of localized NSCLC with hazard ratio=2.62 (95% CI: 1.47-4.68) while an insignificant higher mortality rate with hazard ratio=1.22 (95% CI: 0.71-2.08) was found in patient with severe/very severe COPD.

CONCLUSION

Despite the serious prognosis of COPD, a localized NSCLC diagnosis negatively affects survival in COPD patients. However, stereotactic body radiotherapy should still be considered for COPD patients diagnosed with localized NSCLC.