"How Long Have I Got?" in Stage IV NSCLC Patients With at Least 3 Months Up to 10 Years Survival, Accuracy of Long-, Intermediate-, and Short-Term Survival Prediction Is Not Good Enough to Answer This Question

A Combined Cyto- and Histopathological Diagnostic Approach Reduces Time to Diagnosis and Time to Therapy in First Manifestation of Metastatic Spinal Disease: A Cohort Study

Malignant spinal lesions (MSLs) are frequently the first manifestation of malignant disease. Spinal care, diagnostic evaluation, and the initiation of systemic therapy are crucial for outcomes in patients (pts) with advanced cancer. However, histopathology (HP) may be time consuming. The additional evaluation of spinal lesions using cytopathology (CP) has the potential to reduce the time to diagnosis (TTD) and time to therapy (TTT). CP and HP specimens from spinal lesions were evaluated in parallel in 61 pts (CP/HP group). Furthermore, 139 pts in whom only HP was performed were analyzed (HP group). We analyzed the TTD of CP and HP within the CP/HP group. Furthermore, we compared the TTD and TTT between the groups. The mean TTD in CP was 1.7 ± 1.7 days (d) and 8.4 ± 3.6 d in HP (p < 0.001). In 13 pts in the CP/HP group (24.1%), specific therapy was initiated based on the CP findings in combination with imaging and biomarker results before completion of HP. The mean TTT in the CP/HP group was 21.0 ± 15.8 d and was significantly shorter compared to the HP group (28.6 ± 23.3 d) (p = 0.034). Concurrent CP for MSLs significantly reduces the TTD and TTT. As a result, incorporating concurrent CP for analyzing spinal lesions suspected of malignancy might have the potential to enhance pts' quality of life and prognosis in advanced cancer. Therefore, we recommend implementing CP as a standard procedure for the evaluation of MSLs.

Conditional survival analysis of patients with resected non-small cell lung cancer

Background

Conditional survival (CS) analyses provide an estimate of survival accounting for years already survived after treatment. We aim to evaluate the difference between actuarial and conditional survival in patients following lung resection for non-small cell lung cancer (NSCLC). In addition, CS analyses are used to examine whether prognosticators of survival change over time following surgery.

Methods

Patients who underwent anatomic lung resection at a single institution for pathologic stage I-IIIA NSCLC between 2010 and 2021 were identified; those who underwent wedge resection for node-negative tumors ≤2 cm were also included. CS estimates were calculated as the probability of remaining disease-free after x years of nonrecurrence (CSx). Kaplan-Meier, log-rank, and Cox proportional hazard methods for examining CS were used for subgroup comparisons and assessing associations with baseline covariates.

Results

Overall, 863 patients met the study inclusion criteria, with a median follow-up of 44.1 months. Conditional overall survival (OS) and disease-free survival (DFS) were greater than actuarial rates at all time points after surgery. At the time of resection, male sex (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.03 to 1.72; P = .032), tumor size >3 cm (HR, 1.17; 95% CI, 1.11-1.23; P < .001), node positivity (HR, 3.31; 95% CI, 2.52-4.33; P < .001), and American Joint Committee on Cancer stage (P < .001) were associated with DFS. However, if a patient lived 3 years without recurrence (CS3), these factors were no longer prognostic of DFS.

Conclusions

Conditional survival analyses provide dynamic assessments of OS and DFS after NSCLC resection. After 3 years without recurrence, certain characteristics associated with DFS at the time of surgery no longer prognosticate recurrence.

In stage IV pulmonary adenocarcinoma patients, treatment with Traditional Chinese Medicine alone gives prognostically superior results to treatment with Platinum-Based Chemotherapy alone

BACKGROUND

About 30% of pulmonary stage IV adenocarcinomas die within 3 months of diagnosis. Western medical treatments with Platinum-Based Chemotherapy=PBC and tyrosine-kinase inhibitors Targeted Therapy=TT can improve prognosis. In China, Traditional Chinese Medicine herbal treatments (TCM) are often used in addition to PBC and TT. A considerable number of patients refuse Western medical treatments and use TCM alone. However, the survival impact of the latter is unknown.

HYPOTHESES TESTED

Treatment with TCM alone is prognostically superior to PBC alone. Addition of PBC or TT or both TT to TCM improves survival.

METHODS

In this prospective observational, non-interventional study of 1017 consecutive first-onset stage IV NSCLC patients with up to 10 years follow-up, 261 who Died of Disease (DOD) within 3 months were omitted, as they never got the optimal Western medical therapies. All 218 non-adenocarcinomas were also omitted, leaving 538 stage IV adenocarcinomas treated by TCM alone (n = 29), PBC alone (N = 19) and TCM and other Western medical combinations (299 TCM and PBC, 50 TCM and TT, 141 TCM and PBC and TT) with 3 - 120 months follow-up. Survivals were compared using Alive with Disease (AWD) and DOD as endpoints.

RESULTS

The patients treated only with TCM had 7 months better median survival than those that received PBC alone (17 and 10 months). The patients that received TCM and PBC had a better median survival (24 months) than TCM alone and much better than PBC alone. None of the patients that received TCM alone survived > 54 months, whereas 18% of TCM and PBC patients survived much longer. Over the observation period of 3 - 120 months, survivals of TCM and TT, TCM and PBC and TT, and TCM and PBC were not different and therefore grouped as TCM and Western medicines. Median survival times of PBC alone and TCM alone were lower than that of TCM and Western medical treatments (p < 0.0001, 10, 17 and 27 months).

CONCLUSIONS

Pulmonary stage IV adenocarcinoma patients with at least 3 months survival, treated with TCM alone have a significantly better survival than those treated with PBC alone. Adding Western PBC, TT or both to TCM further improves prognosis.

Efficacy and safety of nanoparticle albumin-bound paclitaxel in advanced non-small cell lung cancer: A systematic review and meta-analysis of clinical trials and observational studies

Background

The efficacy and safety of nanoparticle albumin-bound paclitaxel (nab-paclitaxel) in advanced non-small cell lung cancer (NSCLC) have yielded inconsistent findings.

Materials and methods

We conducted a systematic review and meta-analysis, including comparative and noncomparative trials and cohort studies, to assess the efficacy and safety of nab-paclitaxel in advanced NSCLC. The search covered PubMed, CENTRAL, Scopus, and ClinicalTrials.gov until October 2022. Efficacy outcomes (OR, PR, progressive disease, OS, and PFS) and safety outcomes (neutropenia, leukopenia, thrombocytopenia, anemia, and sensory neuropathy) were analyzed.

Results

Our meta-analysis included data from 35 studies (9 RCTs, 2 cohort studies, and 24 noncomparative studies). Nab-paclitaxel significantly improved OR rate (RRRCT 1.35 [95% CI 1.19, 1.53], I2 = 36.6%; RRcohort 1.67 [95% CI 1.30, 2.14], I2 = 4.3%) and PR rate (RRRCT 1.34 [95% CI 1.18, 1.53], I2 = 38.8%; RRcohort 1.59 [95% CI 1.22, 2.07], I2 = 19.4%) compared to the control group. It further demonstrated more pronounced benefits in squamous cell carcinoma and as a second-line treatment. Pooled evidence from the RCTs also indicated improved OS (HR 0.90 [95% CI 0.81, 0.99], I2 = 9.2%) and PFS (HR 0.84 [95% CI 0.76, 0.93], I2 = 14.5%) However, evidence on the reduction of adverse events with nab-paclitaxel treatment was insufficient, and biases in study selection and detection may have influenced the results.

Conclusions

Nab-paclitaxel enhances OR, PR, PFS, and marginally improves OS in advanced NSCLC, particularly in patients with prior chemotherapy. Further research is needed to establish its safety advantages.

Body Composition and Radiomics From 18 F-FDG PET/CT Together Help Predict Prognosis for Patients With Stage IV Non-Small Cell Lung Cancer

PURPOSE

To determine whether integration of data on body composition and radiomic features obtained using baseline 18 F-FDG positron emission tomography/computed tomography (PET/CT) images can be used to predict the prognosis of patients with stage IV non-small cell lung cancer (NSCLC).

METHODS

A total of 107 patients with stage IV NSCLC were retrospectively enrolled in this study. We used the 3D Slicer (The National Institutes of Health, Bethesda, Maryland) software to extract the features of PET and CT images. Body composition measurements were taken at the L3 level using the Fiji (Curtis Rueden, Laboratory for Optical and Computational Instrumentation, University of Wisconsin, Madison) software. Independent prognostic factors were defined by performing univariate and multivariate analyses for clinical factors, body composition features, and metabolic parameters. Data on body composition and radiomic features were used to build body composition, radiomics, and integrated (combination of body composition and radiomic features) nomograms. The models were evaluated to determine their prognostic prediction capabilities, calibration, discriminatory abilities, and clinical applicability.

RESULTS

Eight radiomic features relevant to progression-free survival (PFS) were selected. Multivariate analysis showed that the visceral fat area/subcutaneous fat area ratio independently predicted PFS ( P = 0.040). Using the data for body composition, radiomic features, and integrated features, nomograms were established for the training (areas under the curve = 0.647, 0.736, and 0.803, respectively) and the validation sets (areas under the receiver operating characteristic = 0.625, 0.723, and 0.866, respectively); the integrated model showed better prediction ability than that of the other 2 models. The calibration curves revealed that the integrated nomogram exhibited a better agreement between the estimation and the actual observation in terms of prediction of the probability of PFS than that of the other 2 models. Decision curve analysis revealed that the integrated nomogram was superior to the body composition and radiomics nomograms for predicting clinical benefit.

CONCLUSION

Integration of data on body composition and PET/CT radiomic features can help in prediction of outcomes in patients with stage IV NSCLC.

Tumor Treating Fields (TTFields) Therapy Concomitant with Taxanes for Cancer Treatment

Non-small cell lung cancer, ovarian cancer, and pancreatic cancer all present with high morbidity and mortality. Systemic chemotherapies have historically been the cornerstone of standard of care (SOC) regimens for many cancers, but are associated with systemic toxicity. Multimodal treatment combinations can help improve patient outcomes; however, implementation is limited by additive toxicities and potential drug-drug interactions. As such, there is a high unmet need to develop additional therapies to enhance the efficacy of SOC treatments without increasing toxicity. Tumor Treating Fields (TTFields) are electric fields that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. The therapy is locoregional and is delivered noninvasively to the tumor site via a portable medical device that consists of field generator and arrays that are placed on the patient's skin. As a noninvasive treatment modality, TTFields therapy-related adverse events mainly consist of localized skin reactions, which are manageable with effective acute and prophylactic treatments. TTFields selectively target cancer cells through a multi-mechanistic approach without affecting healthy cells and tissues. Therefore, the application of TTFields therapy concomitant with other cancer treatments may lead to enhanced efficacy, with low risk of further systemic toxicity. In this review, we explore TTFields therapy concomitant with taxanes in both preclinical and clinical settings. The summarized data suggest that TTFields therapy concomitant with taxanes may be beneficial in the treatment of certain cancers.

Toward a More Just System of Care in Molecular Pathology

Policy Points American health care policy must be critically assessed to establish the role it plays in sustaining and alleviating the health disparities that currently exist in molecular genetic testing. It is critical to understand the economic and sociocultural influences that drive patients to undergo or forgo molecular testing, especially in marginalized patient populations. A multipronged solution with actions necessary from multiple stakeholders is required to reduce the cost of health care, rebalance regional disparities, encourage physician engagement, reduce data bias, and earn patients' trust.

CONTEXT

The health status of a population is greatly influenced by both biological processes and external factors. For years, minority and low socioeconomic patient populations have faced worse outcomes and poorer health in the United States. Experts have worked extensively to understand the issues and find solutions to alleviate this disproportionate burden of disease. As a result, there have been some improvements and successes, but wide gaps still exist. Diagnostic molecular genetic testing and so-called personalized medicine are just now being integrated into the current American health care system. The way in which these tests are integrated can either exacerbate or reduce health disparities.

METHODS

We provide case scenarios-loosely based on real-life patients-so that nonexperts can see the impacts of complex policy decisions and unintentional biases in technology without needing to understand all the intricacies. We use data to explain these findings from an extensive literature search examining both peer-reviewed and gray literature.

FINDINGS

Access to diagnostic molecular genetic testing is not equitable or sufficient, owing to at least five major factors: (1) cost to the patient, (2) location, (3) lack of provider buy-in, (4) data-set bias, and (5) lack of public trust.

CONCLUSIONS

Molecular genetic pathology can be made more equitable with the concerted efforts of multiple stakeholders. Confronting the five major factors identified here may help us usher in a new era of precision medicine without its discriminatory counterpart.

Downregulated ADAMTS1 Incorporating A2M Contributes to Tumorigenesis and Alters Tumor Immune Microenvironment in Lung Adenocarcinoma

Simple Summary

Lung cancer is the most dreadful cancer type and has the worst cancer-related clinical outcomes. This study used specimens from the in-house lung cancer cohort and public cohort to verify the roles of downregulated ADAMTS1, a protease remodeling extracellular matrix, to facilitate cancer promotion and progress. Based on the clinical specimens, cell and animal study with the aid of the public databases, we concluded that downregulated expression of ADAMTS1 might promote tumor progression and metastasis and modify the tumor microenvironment in lung cancer. Further investigation would be required for its application in treating lung cancer.

Abstract

Lung adenocarcinoma (LUAD) still holds the most dreadful clinical outcomes worldwide. Despite advanced treatment strategies, there are still some unmet needs. Next-generation sequencing of large-scale cancer genomics discovery projects combined with bioinformatics provides the opportunity to take a step forward in meeting clinical conditions. Based on in-house and The Cancer Genome Atlas (TCGA) cohorts, the results showed decreased levels of ADAMTS1 conferred poor survival compared with normal parts. Gene set enrichment analyses (GSEA) indicated the negative correlation between ADAMTS1 and the potential roles of epithelial–mesenchymal transition (EMT), metastasis, and poor prognosis in LUAD patients. With the knockdown of ADAMTS1, A549 lung cancer cells exhibited more aggressive behaviors such as EMT and increased migration, resulting in cancer metastasis in a mouse model. The pathway interaction network disclosed the linkage of downregulated α2-macroglobulin (A2M), which regulates EMT and metastasis. Furthermore, immune components analysis indicated a positive relationship between ADAMTS1 and the infiltrating levels of multiple immune cells, especially anticancer CD4⁺ T cells in LUAD. Notably, ADAMTS1 expression was also inversely correlated with the accumulation of immunosuppressive myeloid-derived suppressor cells and regulatory T cells, implying the downregulated ADAMTS1 mediated immune adjustment to fit the tumor survival disadvantages in LUAD patients. In conclusion, our study indicates that ADAMTS1 interacts with A2M in regulating EMT and metastasis in LUAD. Additionally, ADAMTS1 contributes to poor prognosis and immune infiltration in LUAD patients

Clinical and Biological Interpretation of Survival Curves of Cancer Patients, Exemplified With Stage IV Non-Small Cell Lung Cancers With Long Follow-up

Worldwide, 18.1 million new invasive cancers and 9.9 million cancer deaths occurred in 2020. Lung cancer is the second most frequent (11.4%) and, with 1.8 million deaths, remains the leading cause of cancer mortality. About 1.7 million of lung cancers are of the non-small cell lung cancer (NSCLC) subtype, and of these, 60%-70% are in advanced stage IV at the time of diagnosis. Thus, the annual worldwide number of new NSCLC stage IV patients is about 1 million, and they have a very poor prognosis. Indeed, 25%-30% die within 3 months of diagnosis. However, the survival duration of the remaining 700,000 new patients per year surviving >3 months varies enormously. Surprisingly, little research has been done to explain these survival differences, but recently it was found that classical patient, tumour and treatment features cannot accurately distinguish short- and very long-term survivors. What then are the causes of these bewildering survival variations amongst "the same cancers"? Clonality, proliferation differences, neovascularization, intra-tumour heterogeneity, genetic inhomogeneity and other cancer hallmarks play important roles. Considering each of these, single or combined, can greatly improve our understanding. Another technique is analysis of the survival curve of a seemingly homogeneous group of cancer patients. This can give valuable information about the existence of subgroups and their biological characteristics. Different basic survival curves and what their shapes tell about the biological properties of these invasive cancers are discussed. Application of this analysis technique to the survival curve of 690 stage IV NSCLC patients with a 3.2-120.0-month survival suggests that this seemingly homogeneously group of patients probably consists of 4-8 subgroups with a very different survival. A subsequent detailed mathematical analysis shows that a model of 8 subgroups gives a very good match with the original survival curve of the whole group. In conclusion, the survival curve of a seemingly homogeneous group of cancer patients can give valuable information about the existence of subgroups and their biological characteristics. Application of this technique to 690 NSCLC Stage IV patients makes it probable that 8 different subgroups with very different survival rates exist in this group of cancers.