Delays in the diagnosis of lung cancer

The journey of lung cancer patients from symptoms to diagnosis in Greece. A mixed methods approach

The early diagnosis of lung cancer improves the probability of successful treatment. However, patients and physicians face several difficulties that can considerably delay the diagnostic process. A mixed-methods study that would follow the patient's journey throughout the diagnostic process could alleviate these difficulties. This study aimed to (a) track the patients' journey from the onset of symptoms until diagnosis and, (b) explore the patients' perspective of the journey until diagnosis, on the largest island of Greece. A convergent mixed-methods study was conducted with 94 patients with lung cancer. Patients completed a self-report questionnaire and were interviewed about their symptoms and journey through the healthcare system before their diagnosis. Our findings revealed several problems and delays in the diagnostic process. Both quantitative and qualitative data showed that patients did not recognize their symptoms and sought medical advice in time because they overlooked or attributed their symptoms to 'simpler'/'more common' causes. Furthermore, most patients were diagnosed 1-3 months after their first visit to a physician for their symptoms. Qualitative data analysis revealed three broad categories of problems that delayed diagnosis: (1) physician missteps, (2) administrative problems, and (3) the effect of the Covid-19 pandemic. This study found that major issues and delays prolong the diagnostic process for lung cancer. Therefore, optimization of diagnostic processes at each level of healthcare and interspecialty cooperation programs are needed. Furthermore, population-based interventions and patient education can help lung cancer patients be diagnosed early and improve their quality of life and disease outcomes.

Recommended approaches for screening and early detection of lung cancer in the Middle East and Africa (MEA) region: a consensus statement

Background

The prevalence of lung cancer in the Middle East and Africa (MEA) region has steadily increased in recent years and is generally associated with a poor prognosis due to the late detection of most of the cases. We explored the factors leading to delayed diagnoses, as well as the challenges and gaps in the early screening, detection, and referral framework for lung cancer in the MEA.

Methods

A steering committee meeting was convened in October 2022, attended by a panel of ten key external experts in the field of oncology from the Kingdom of Saudi Arabia, United Arab Emirates, South Africa, Egypt, Lebanon, Jordan, and Turkey, who critically and extensively analyzed the current unmet needs and challenges in the screening and early diagnosis of lung cancer in the region.

Results

As per the experts' opinion, lack of awareness about disease symptoms, misdiagnosis, limited screening initiatives, and late referral to specialists were the primary reasons for delayed diagnoses emphasizing the need for national-level lung cancer screening programs in the MEA region. Screening guidelines recommend low-dose computerized tomography (LDCT) for lung cancer screening in patients with a high risk of malignancy. However, high cost and lack of awareness among the public as well as healthcare providers prevented the judicious use of LDCT in the MEA region. Well-established screening and referral guidelines were available in only a few of the MEA countries and needed to be implemented in others to identify suspected cases early and provide timely intervention thus improving patient outcomes.

Conclusions

There is a great need for large-scale screening programs, preferably integrated with tobacco-control programs and awareness programs for physicians and patients, which may facilitate higher adherence to lung cancer screening and improve survival outcomes.

Targeting lung cancer with clinically relevant EGFR mutations using anti-EGFR RNA aptamer

A significant fraction of non-small cell lung cancer (NSCLC) cases are due to oncogenic mutations in the tyrosine kinase domain of the epidermal growth factor receptor (EGFR). Anti-EGFR antibodies have shown limited clinical benefit for NSCLC, whereas tyrosine kinase inhibitors (TKIs) are effective, but resistance ultimately occurs. The current landscape suggests that alternative ligands that target wild-type and mutant EGFRs are desirable for targeted therapy or drug delivery development. Here we evaluate NSCLC targeting using an anti-EGFR aptamer (MinE07). We demonstrate that interaction sites of MinE07 overlap with clinically relevant antibodies targeting extracellular domain III and that MinE07 retains binding to EGFR harboring the most common oncogenic and resistance mutations. When MinE07 was linked to an anti-c-Met aptamer, the EGFR/c-Met bispecific aptamer (bsApt) showed superior labeling of NSCLC cells in vitro relative to monospecific aptamers. However, dual targeting in vivo did not improve the recognition of NSCLC xenografts compared to MinE07. Interestingly, biodistribution of Cy7-labeled bsApt differed significantly from Alexa Fluor 750-labeled bsApt. Overall, our findings demonstrate that aptamer formulations containing MinE07 can target ectopic lung cancer without additional stabilization or PEGylation and highlights the potential of MinE07 as a targeting reagent for the recognition of NSCLC harboring clinically relevant EGFRs.

A Cross-Sectional Study on the Knowledge and Awareness of Lung Cancer and Screening in Jazan Region, Saudi Arabia

BACKGROUND

Lung cancer (LC) is the most common cause of cancer-related deaths worldwide. With lung cancer often diagnosed at advanced stages, understanding the local population's awareness levels is crucial for designing effective preventive strategies. By identifying gaps in knowledge, the research aims to inform targeted health education efforts, optimize resource allocation, influence policy development, and contribute to the limited body of research on lung cancer awareness in the region, ultimately fostering improved public health outcomes.

METHODS

This was a cross-sectional observational study conducted in Jazan region, Saudi Arabia, from July 2022 to June 2023, 671 participants over 18 years old, encompassing both genders, were gsurveyed. Data was collected through a questionnaire covering sociodemographic characteristics and LC-related awareness. SPSS 23 was used for analysis. Factors associated with knowledge scores were explored using independent t-tests and ANOVA, with the Tukey post-hoc test identifying specific group differences.

RESULTS

The study included 671 participants, most participants were between 18 and 35 years (73.5%), with 38.5% males and 61.5% females. Lung cancer (LC) awareness was high (95.1%), with 4.9% reporting a family history. Knowledge assessment revealed a mean score of 14.66, with 41.6% having low, 49.5% moderate, and 8.9% high knowledge levels. Correct responses were notable for recognizing LC as a common cancer, a leading cause of death, and associating smoking and shisha with risk. Symptoms were well identified. Screening awareness was at 63.5%, with 78.8% willing to undergo tests if at risk. Age, marital status, and occupation were associated with knowledge, while factors like gender, nationality, residency, education, income, and smoking status showed no significant associations.

CONCLUSION

The findings indicate that there are knowledge gaps related to LC and its screening in Jazan region in Saudi Arabia. Effective awareness programs targeting specific sociodemographic groups are needed to improve the early detection and outcomes.

Inhibition of non-small cell lung cancer (NSCLC) proliferation through targeting G6PD

Background

Mounting evidence has linked cancer metabolic reprogramming with altered redox homeostasis. The pentose phosphate pathway (PPP) is one of the key metabolism-related pathways that has been enhanced to promote cancer growth. The glucose 6-phosphate dehydrogenase (G6PD) of this pathway generates reduced nicotinamide adenine dinucleotide phosphate (NADPH), which is essential for controlling cellular redox homeostasis.

Objective

This research aimed to investigate the growth-promoting effects of G6PD in non-small cell lung cancer (NSCLC).

Methods

Clinical characteristics and G6PD expression levels in lung tissues of 64 patients diagnosed with lung cancer at the King Chulalongkorn Memorial Hospital (Bangkok, Thailand) during 2009-2014 were analyzed. G6PD activity in NSCLC cell lines, including NCI-H1975 and NCI-H292, was experimentally inhibited using DHEA and siG6PD to study cancer cell proliferation and migration.

Results

The positive expression of G6PD in NSCLC tissues was detected by immunohistochemical staining and was found to be associated with squamous cells. G6PD expression levels and activity also coincided with the proliferation rate of NSCLC cell lines. Suppression of G6PD-induced apoptosis in NSCLC cell lines by increasing Bax/Bcl-2 ratio expression. The addition of D-(-)-ribose, which is an end-product of the PPP, increased the survival of G6PD-deficient NSCLC cell lines.

Conclusion

Collectively, these findings demonstrated that G6PD might play an important role in the carcinogenesis of NSCLC. Inhibition of G6PD might provide a therapeutic strategy for the treatment of NSCLC.

microRNAs in exhaled breath condensate for diagnosis of lung cancer in a resource-limited setting: a concise review

Lung cancer is one of the common cancers globally with high mortality and poor prognosis. Most cases of lung cancer are diagnosed at an advanced stage due to limited diagnostic resources. Screening modalities, such as sputum cytology and annual chest radiographs, have not proved sensitive enough to impact mortality. In recent years, annual low-dose computed tomography has emerged as a potential screening tool for early lung cancer detection, but it may not be a feasible option for developing countries. In this context, exhaled breath condensate (EBC) analysis has been evaluated recently as a noninvasive tool for lung cancer diagnosis. The breath biomarkers also have the advantage of differentiating various types and stages of lung cancer. Recent studies have focused more on microRNAs (miRNAs) as they play a key role in tumourigenesis by regulating the cell cycle, metastasis and angiogenesis. In this review, we have consolidated the current published literature suggesting the utility of miRNAs in EBC for the detection of lung cancer.

Age and cancer type: associations with increased odds of receiving a late diagnosis in people with advanced cancer

PURPOSE

In order to deliver appropriate and timely care planning and minimise avoidable late diagnoses, clinicians need to be aware of which patients are at higher risk of receiving a late cancer diagnosis. We aimed to determine which demographic and clinical factors are associated with receiving a 'late' cancer diagnosis (within the last 12 weeks of life).

METHOD

Retrospective cohort study of 2,443 people who died from cancer ('cancer decedents') in 2013-2015. Demographic and cancer registry datasets linked using patient-identifying Community Health Index numbers. Analysis used binary logistic regression, with univariate and adjusted odds ratios (SPSS v25).

RESULTS

One third (n = 831,34.0%) received a late diagnosis. Age and cancer type were significantly associated with late cancer diagnosis (p < 0.001). Other demographic factors were not associated with receiving a late diagnosis. Cancer decedents with lung cancer (Odds Ratios presented in abstract are the inverse of those presented in the main text, where lung cancer is the reference category. Presented as 1/(OR multivariate)) were more likely to have late diagnosis than those with bowel (95% Confidence Interval [95%CI] Odds Ratio (OR)1.52 (OR1.12 to 2.04)), breast or ovarian (95%CI OR3.33 (OR2.27 to 5.0) or prostate (95%CI OR9.09 (OR4.0 to 20.0)) cancers. Cancer decedents aged > 85 years had higher odds of late diagnosis (95%CI OR3.45 (OR2.63 to 4.55)), compared to those aged < 65 years.

CONCLUSIONS

Cancer decedents who were older and those with lung cancer were significantly more likely to receive late cancer diagnoses than those who were younger or who had other cancer types.

Cancer stage at diagnosis: Comparison of insurance status in SEER to the Department of Defense Cancer Registry

BACKGROUND

Military individuals, retirees, and their families have free care or minimal out-of-pocket costs in the US military health system (MHS). In contrast, out-of-pocket costs in the US general population vary substantially. This study compared cancer patients with various insurance types in the general population to those in the MHS in cancer stage at diagnosis.

METHODS

Patients were identified from the US Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Tumor stage at diagnosis of breast, prostate, lung, and colon cancers during 2007-2013 was compared between ACTUR and SEER insurance categories of "insured," "insured-no specifics," "any Medicaid," and "uninsured," A multivariable logistic regression analysis estimated the odds ratio (OR) of late stage (Stages III and IV) versus early stage (Stages I and II) cancers comparing SEER insurance status to ACTUR.

RESULTS

There were 18,440 eligible patients identified from ACTUR and 831,959 patients identified from SEER. For all cancer types, patients in the SEER-insured/no specifics, Medicaid, and uninsured groups had significantly greater likelihood of late stage diagnosis compared to ACTUR patients. The adjusted ORs were greatest among uninsured and Medicaid patients. The SEER-insured group also had a significantly higher odds of advanced stage disease than ACTUR patients for prostate cancer and lung cancer.

CONCLUSION

Patients in the MHS with universal access to healthcare were diagnosed at an earlier stage than those in the general population. This difference was most evident compared to Medicaid and uninsured groups.

RNA‑binding protein quaking 5 inhibits the progression of non‑small cell lung cancer by upregulating netrin‑4 expression

It was recently reported that netrin‑4 (Ntn‑4), a component of the extracellular matrix, when downregulated, is involved in the progression of several types of cancer, including breast cancer, colorectal tumours, neuroblastoma and gastric cancer. In the present study, the level of Ntn‑4 was examined in a public non‑small cell lung cancer (NSCLC) dataset from the Netherlands Cancer Institute. This analysis revealed that the mRNA expression level of Ntn‑4 was lower in the samples of patients with NSCLC compared with that in the control samples. Consistent with the mRNA level, the protein level of Ntn‑4 was also found to be decreased in NSCLC cells. However, both the function of Ntn‑4 and the underlying mechanisms of Ntn‑4 downregulation in NSCLC have yet to be fully elucidated. As was anticipated, the overexpression of Ntn‑4 led to a marked decrease in the proliferation, migration and invasion of NSCLC cells. Notably, RNA‑binding protein quaking 5 (Qki‑5) was found to exhibit antitumor activity in lung cancer, not only by enhancing the level of Ntn‑4 by binding to Ntn‑4 mRNA, but also by suppressing the proliferation, invasion and migration of NSCLC cells. However, Qki‑5 is known to be frequently downregulated in NSCLC. Moreover, the knockdown of Ntn‑4 was found to reverse the suppressive effects of Qki‑5 on NSCLC progression both in vitro and in vivo. Taken together, the findings of the present study demonstrate that Ntn‑4 is able to suppress the progression of NSCLC, and that the level of Ntn‑4 can be regulated by Qki‑5. Therefore, Ntn‑4 may be a novel diagnostic and therapeutic target for the treatment of NSCLC.

Clinical Trial and Real-World Outcomes of Patients With Metastatic NSCLC in the Post-Platinum-Based Chemotherapy Failure Setting

Introduction

A literature review was undertaken to identify clinical trials and real-world studies of patients with stage IV NSCLC who had progressed on or after treatment with platinum-based chemotherapy.

Methods

The EMBASE and MEDLINE databases were used to search for English-language studies published between September 28, 2017, and September 28, 2021. Studies were included in the review if they (1) were clinical trials or real-world analyses of one or more treatment regimens for patients with stage IV NSCLC who had progressed on or after treatment with platinum-based chemotherapy, (2) contained an end point including efficacy, effectiveness, or safety, and (3) included 45 or more patients.

Results

In total, there were 15 publications (nine unique trials and three real-world studies) included. Sample size ranged from 49 to 1253 patients. At least one treatment arm in eight of the nine clinical trials reported an overall response rate of ≥15%. Median progression-free survival (PFS) and overall survival ranged from 1.9 to 5.2 months and 5.4 to 15.4 months in clinical trials and 4.4 to 6.8 months and 8.3 to 18.0 months in real-world studies, respectively. Within studies reporting median PFS, a median PFS of more than or equal to 3 months was reported in eight of 11 clinical trials and both real-world studies. Discontinuation due to adverse events ranged from 1.9% to 18% across all included studies.

Conclusions

Patients with stage IV NSCLC had limited response and a high burden of adverse events during treatment after progression on platinum-containing chemotherapy. There remains a pressing unmet need for additional, effective, and tolerable treatment options in this setting.

Exploring the efficacy of artificial neural networks in predicting lung cancer recurrence: a retrospective study based on patient records

Background

Lung cancer remains a significant public health concern, accounting for a considerable number of cancer-related deaths worldwide. Neural networks have emerged as a promising tool that can aid in the diagnosis and treatment of various cancers. Consequently, there has been a growing interest in exploring the potential of artificial intelligence (AI) methods in medicine. The present study aimed to evaluate the effectiveness of a neural network in predicting lung cancer recurrence.

Methods

The study employed retrospective data from 2,296 medical records of patients diagnosed with lung cancer and admitted to the Warmińsko-Mazurskie Center for Lung Diseases in Olsztyn, Poland. The statistical software STATISTICA 7.1, equipped with the Neural Networks module (StatSoft Inc., Tulsa, USA), was utilized to analyze the data. The neural network model was trained using patient information regarding gender, treatment, smoking status, family history, and symptoms of cancer.

Results

The study employed a multilayer perceptron neural network with a two-phase learning process. The network demonstrated high predictive ability, as indicated by the percentage of correct classifications, which amounted to 87.5%, 89.1%, and 89.9% for the training, validation, and test sets, respectively.

Conclusions

The findings of this study support the potential usefulness of a neural network-based predictive model in assessing the risk of lung cancer recurrence. Further research is warranted to validate these findings and to explore AI's broader implications in cancer diagnosis and treatment.

Association Between Antibiotic Prescribing and Time to Diagnosis of Head and Neck Cancer

Importance

Diagnostic delay can negatively affect patient outcomes in head and neck cancer (HNC). Neck mass and other symptoms of undiagnosed HNC may be treated with antibiotics, delaying diagnosis and treatment, despite current clinical practice guidelines.

Objective

To investigate temporal trends, associated factors, and time from symptom onset to antibiotic prescribing before an HNC diagnosis.

Design, Setting, and Participants

A retrospective cohort study was conducted using data obtained from a deidentified electronic health records data set from January 1, 2011, to December 31, 2018. Patients with HNC enrolled in the data set for at least 1 year before diagnosis date determined by either 1 inpatient encounter or first of 2 outpatient encounters within 6 months were included. Data analysis was conducted from May 1 to November 9, 2022.

Exposure

Antibiotic prescription within 3 months before HNC diagnosis date.

Main Outcomes and Measures

The primary outcome was days from the first documented symptom to HNC diagnosis.

Results

The cohort included 7811 patients with HNC (4151 [53.1%] men, mean [SD] age, 60.2 [15.8] years). At least 1 antibiotic was prescribed for 1219 patients (15.6%) within 3 months before HNC diagnosis. This represented an increase over the 8.9% prescribing rate during the baseline period 12 to 9 months before diagnosis. The rate of antibiotic prescribing within 3 months before diagnosis did not change significantly over time (quarterly percent change, 0.49%; 95% CI, -3.06% to 4.16%). Patients receiving an antibiotic prescription within 3 months of an HNC diagnosis had a 21.1% longer time between symptom onset and HNC diagnoses (adjusted rate ratio [ARR], 1.21; 95% CI, 1.14-1.29). Compared with diagnosis by otolaryngologists, primary care/internal medicine physicians were most likely to prescribe antibiotics for patients who were diagnosed with a presenting symptom (adjusted prevalence ratio, 1.60; 95% CI, 1.27-2.02). In patients presenting with neck mass/swelling, those presenting with other symptoms were more likely to have longer intervals from symptom onset to diagnosis (ARR, 1.31; 95% CI, 1.08-1.59).

Conclusions and Relevance

The findings of this cohort study suggest there is an increased rate of antibiotic prescription in the 3 months before HNC diagnosis, which is associated with an increased time to diagnosis. These findings identify an area for improvement in HNC care and guidelines.

Impact of radiographer immediate reporting of X-rays of the chest from general practice on the lung cancer pathway (radioX): a randomised controlled trial

The National Optimal Lung Cancer Pathway recommends rapid progression from abnormal chest X-rays (CXRs) to CT. The impact of the more rapid reporting on the whole pathway is unknown. The aim of this study was to determine the impact of immediate reporting of CXRs requested by primary care by radiographers on the time to diagnosis of lung cancer.

METHOD

People referred for CXR from primary care to a single acute district general hospital in London attended sessions that were prerandomised to either immediate radiographer (IR) reporting or standard radiographer (SR) reporting within 24 hours. CXRs were subsequently reported by radiologists blind to the radiographer reports to test the reliability of the radiographer report. Radiographer and local radiologist discordant cases were reviewed by thoracic radiologists, blinded to reporter.

RESULTS

8682 CXRs were performed between 21 June 2017 and 4 August 2018, 4096 (47.2%) for IR and 4586 (52.8%) for SR. Lung cancer was diagnosed in 49, with 27 (55.1%) for IR. The median time from CXR to diagnosis of lung cancer for IR was 32 days (IQR 19, 70) compared with 63 days (IQR 29, 78) for SR (p=0.03).8258 CXRs (95.1%) were reported by both radiographers and local radiologists. In the 1361 (16.5%) with discordance, the reviewing thoracic radiologists were equally likely to agree with local radiologist and radiographer reports.

CONCLUSIONS

Immediate reporting of CXRs from primary care reduces time to diagnosis of lung cancer by half, likely due to rapid progress to CT. Radiographer reports are comparable to local radiologist reports for accuracy.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN21818068. Registered on 20 June 2017.

Exploring equity in cancer treatment, survivorship, and service utilisation for culturally and linguistically diverse migrant populations living in Queensland, Australia: a retrospective cohort study

BACKGROUND

There is strong international evidence documenting inequities in cancer care for migrant populations. In Australia, there is limited information regarding cancer equity for Culturally and Linguistically Diverse (CALD) migrant populations, defined in this study as migrants born in a country or region where English is not the primary language. This study sought to quantify and compare cancer treatment, survivorship, and service utilisation measures between CALD migrant and Australian born cancer populations.

METHODS

A retrospective cohort study was conducted utilising electronic medical records at a major, tertiary hospital. Inpatient and outpatient encounters were assessed for all individuals diagnosed with a solid tumour malignancy in the year 2016 and followed for a total of five years. Individuals were screened for inclusion in the CALD migrant or Australian born cohort. Bivariate analysis and multivariate logistic regression were used to compare treatment, survivorship, and service utilisation measures. Sociodemographic measures included age, sex, post code, employment, region of birth and marital status.

RESULTS

A total of 523 individuals were included, with 117 (22%) in the CALD migrant cohort and 406 (78%) in the Australian-born cohort. CALD migrants displayed a statistically significant difference in time from diagnosis to commencement of first treatment for radiation (P = 0.03) and surgery (P = 0.02) and had 16.6 times higher odds of declining recommended chemotherapy than those born in Australia (P = 0.00). Survivorship indicators favoured CALD migrants in mean time from diagnosis to death, however their odds of experiencing disease progression during the study period were 1.6 times higher than those born in Australia (P = 0.04). Service utilisation measures displayed that CALD migrants exhibited higher numbers of unplanned admissions (P = < 0.00), longer cumulative length of those admissions (P = < 0.00) and higher failure to attend scheduled appointments (P = < 0.00).

CONCLUSION

This novel study has produced valuable findings in the areas of treatment, survivorship, and service utilisation for a neglected population in cancer research. The differences identified suggest potential issues of institutional inaccessibility. Future research is needed to examine the clinical impacts of these health differences in the field of cancer care, including the social and institutional determinants of influence.

Tumor-educated platelet blood tests for Non-Small Cell Lung Cancer detection and management

Liquid biopsy approaches offer a promising technology for early and minimally invasive cancer detection. Tumor-educated platelets (TEPs) have emerged as a promising liquid biopsy biosource for the detection of various cancer types. In this study, we processed and analyzed the TEPs collected from 466 Non-small Cell Lung Carcinoma (NSCLC) patients and 410 asymptomatic individuals (controls) using the previously established thromboSeq protocol. We developed a novel particle-swarm optimization machine learning algorithm which enabled the selection of an 881 RNA biomarker panel (AUC 0.88). Herein we propose and validate in an independent cohort of samples (n = 558) two approaches for blood samples testing: one with high sensitivity (95% NSCLC detected) and another with high specificity (94% controls detected). Our data explain how TEP-derived spliced RNAs may serve as a biomarker for minimally-invasive clinical blood tests, complement existing imaging tests, and assist the detection and management of lung cancer patients.

Symptoms and signs of lung cancer prior to diagnosis: case-control study using electronic health records from ambulatory care within a large US-based tertiary care centre

OBJECTIVE

Lung cancer is the most common cause of cancer-related death in the USA. While most patients are diagnosed following symptomatic presentation, no studies have compared symptoms and physical examination signs at or prior to diagnosis from electronic health records (EHRs) in the USA. We aimed to identify symptoms and signs in patients prior to diagnosis in EHR data.

DESIGN

Case-control study.

SETTING

Ambulatory care clinics at a large tertiary care academic health centre in the USA.

PARTICIPANTS, OUTCOMES

We studied 698 primary lung cancer cases in adults diagnosed between 1 January 2012 and 31 December 2019, and 6841 controls matched by age, sex, smoking status and type of clinic. Coded and free-text data from the EHR were extracted from 2 years prior to diagnosis date for cases and index date for controls. Univariate and multivariable conditional logistic regression were used to identify symptoms and signs associated with lung cancer at time of diagnosis, and 1, 3, 6 and 12 months before the diagnosis/index dates.

RESULTS

Eleven symptoms and signs recorded during the study period were associated with a significantly higher chance of being a lung cancer case in multivariable analyses. Of these, seven were significantly associated with lung cancer 6 months prior to diagnosis: haemoptysis (OR 3.2, 95% CI 1.9 to 5.3), cough (OR 3.1, 95% CI 2.4 to 4.0), chest crackles or wheeze (OR 3.1, 95% CI 2.3 to 4.1), bone pain (OR 2.7, 95% CI 2.1 to 3.6), back pain (OR 2.5, 95% CI 1.9 to 3.2), weight loss (OR 2.1, 95% CI 1.5 to 2.8) and fatigue (OR 1.6, 95% CI 1.3 to 2.1).

CONCLUSIONS

Patients diagnosed with lung cancer appear to have symptoms and signs recorded in the EHR that distinguish them from similar matched patients in ambulatory care, often 6 months or more before diagnosis. These findings suggest opportunities to improve the diagnostic process for lung cancer.

How Timely Is Diagnosis of Lung Cancer? Cohort Study of Individuals with Lung Cancer Presenting in Ambulatory Care in the United States

The diagnosis of lung cancer in ambulatory settings is often challenging due to non-specific clinical presentation, but there are currently no clinical quality measures (CQMs) in the United States used to identify areas for practice improvement in diagnosis. We describe the pre-diagnostic time intervals among a retrospective cohort of 711 patients identified with primary lung cancer from 2012-2019 from ambulatory care clinics in Seattle, Washington USA. Electronic health record data were extracted for two years prior to diagnosis, and Natural Language Processing (NLP) applied to identify symptoms/signs from free text clinical fields. Time points were defined for initial symptomatic presentation, chest imaging, specialist consultation, diagnostic confirmation, and treatment initiation. Median and interquartile ranges (IQR) were calculated for intervals spanning these time points. The mean age of the cohort was 67.3 years, 54.1% had Stage III or IV disease and the majority were diagnosed after clinical presentation (94.5%) rather than screening (5.5%). Median intervals from first recorded symptoms/signs to diagnosis was 570 days (IQR 273-691), from chest CT or chest X-ray imaging to diagnosis 43 days (IQR 11-240), specialist consultation to diagnosis 72 days (IQR 13-456), and from diagnosis to treatment initiation 7 days (IQR 0-36). Symptoms/signs associated with lung cancer can be identified over a year prior to diagnosis using NLP, highlighting the need for CQMs to improve timeliness of diagnosis.

A systematic review of interventions to recognise, refer and diagnose patients with lung cancer symptoms

Patients with lung cancer (LC) often experience delay between symptom onset and treatment. Primary healthcare professionals (HCPs) can help facilitate early diagnosis of LC through recognising early signs and symptoms and making appropriate referrals. This systematic review describes the effect of interventions aimed at helping HCPs recognise and refer individuals with symptoms suggestive of LC. Seven studies were synthesised narratively. Outcomes were categorised into: Diagnostic intervals; referral and diagnosis patterns; stage distribution at diagnosis; and time interval from diagnosis to treatment. Rapid access pathways and continuing medical education for general practitioners can help reduce LC diagnostic and treatment delay. Awareness campaigns and HCP education can help inform primary HCPs about referral pathways. However, campaigns did not significantly impact LC referral rates or reduce diagnostic intervals. Disease outcomes, such as LC stage at diagnosis, recurrence, and survival were seldom measured. Review findings highlight the need for longitudinal, powered, and controlled studies.

Lung Cancer Presenting as Upper Extremity Musculoskeletal Pain: A Case Report

Adenocarcinoma is a tragically common iteration of lung cancer. Risk factors included primary or secondary exposure to tobacco smoke, family history of the disease, and occupationally related hazards, among others. Metastasis to various distant organs may present quite late and in unusual ways, providing a challenge to healthcare providers. A combination of imaging, biopsy, and histochemical analysis can be used to clinch the diagnosis and guide management. Effective treatment relies on a prompt diagnosis, from surgery to radiation and chemotherapy. Our case illustrates how an advanced metastatic lung cancer clinically manifested as something as seemingly benign as shoulder pain.

Promoting moderate-to-vigorous physical activities in patients with advanced lung cancer: preferences and social cognitive factors, and the mediating roles

PURPOSE

The purpose of this study is to assess the prevalence and preferences of moderate-to-vigorous physical activities (MVPA) in patients with advanced lung cancer, explore the social cognitive factors that were associated with MVPA and interest in PA counseling and program, and examine the mediating role of social cognitive factors.

METHODS

This was a cross-sectional study. Questionnaires on PA levels, PA counseling and programming preferences, and social cognitive variables (social support and self-efficacy) were administered to 105 patients with advanced lung cancer. Linear regression model was used to explore the social cognitive factors associated with MVPA, and logistic regression model was used to explore the factors associated with interest in PA counseling and program. Mediation analysis was used to examine the mediating role of self-efficacy on social support and MVPA.

RESULTS

Merely 30.5% of patients met the recommended level of MVPA; however, the majority of patients (89.5%) were interested in PA program. Social support (β = 0.60; p = 0.007) and self-efficacy (β = 1.06; p = 0.027) were positively associated with MVPA. Specifically, self-efficacy mediated the relationship between social support and MVPA (β = 0.63, p = 0.004).

CONCLUSION

The majority of the patients with advanced lung cancer did not meet the recommended level of MVPA; however, they are interested in receiving PA counseling and joining PA programs. Social support was key to promoting higher levels of MVPA, and the association was mediated by self-efficacy. The established mediating model provides insights into designing PA programs and targeting the mediating variable, self-efficacy, to enhance the level of MVPA.

The prognosis of different types of pleural tags based on radiologic-pathologic comparison

Objectives

There are increasing numbers of studies of pleural tags (PTs). The purpose of this case series was to classify the PTs in patients with peripheral pulmonary adenocarcinoma based on radiologic-pathologic comparison and to study the prognosis.

Methods

The clinical, imaging, pathological and prognostic data of 161 patients with peripheral pulmonary adenocarcinoma in three hospitals were analyzed retrospectively. We classified PTs using computed tomography (CT) for pathologic comparison.

Results

According to the relationship between tumors and pleural on CT images, PTs were classified into four types: type 1, one or more linear pleural tag; type 2, one or more linear pleural tag with soft tissue component at the pleural end; type 3, one soft tissue cord-like pleural tag; type 4, directly abutting the visceral pleura, pulling or pushing the visceral pleura. In these PTs, the incidence of visceral pleural invasion (VPI) was high in type 2 (46.88%) and type 3 (56.41%) of PTs. Our prognostic analysis showed that micropapillary or solid histological subtype (HR = 5.766, 95% CI: 1.435–23.159, P = 0.014) and type 3 of PTs (HR = 11.058, 95% CI: 1.349–90.623, P = 0.025) were two independent risk factors for tumor progression.

Conclusions

PT is a risk factor for poor prognosis in patients with peripheral pulmonary adenocarcinoma, the presence of which on CT images can remind us to provide patients with a more reasonable treatment.

Prognostic value of integrating circulating tumour cells and cell-free DNA in non-small cell lung cancer

Background

Non-small cell lung cancer (NSCLC) often presents at an incurable stage, and majority of patients will be considered for palliative treatment at some point in their disease. Despite recent advances, the prognosis remains poor, with a median overall survival of 12–18 months. Liquid biopsy-based biomarkers have emerged as potential candidates for predicting prognosis and response to therapy in NSCLC patients. This pilot study evaluated whether combining circulating tumour cells and clusters (CTCs) and cell-free DNA (cfDNA) can predict progression-free survival (PFS) in NSCLC patients.

Methods

CTC and cfDNA/ctDNA from advanced stage NSCLC patients were measured at study entry (T⁰) and 3-months post-treatment (T¹). CTCs were enriched using a spiral microfluidic chip and characterised by immunofluorescence. ctDNA was assessed using an UltraSEEK® Lung Panel. Kaplan-Meier plots were generated to investigate the contribution of the presence of CTC/CTC clusters and cfDNA for PFS. Cox proportional hazards analysis compared time to progression versus CTC/CTC cluster counts and cfDNA levels.

Results

Single CTCs were found in 14 out of 25 patients, while CTC clusters were found in 8 out of the 25 patients at T⁰. At T¹, CTCs were found in 7 out of 18 patients, and CTC clusters in 1 out of the 18 patients. At T⁰, CTC presence and the combination of CTC cluster counts with cfDNA levels were associated with shorter PFS, p = 0.0261, p = 0.0022, respectively.

Conclusions

Combining CTC cluster counts and cfDNA levels could improve PFS assessment in NSCLC patients. Our results encourage further investigation on the combined effect of CTC/cfDNA as a prognostic biomarker in a large cohort of advanced stage NSCLC patients.

Defining timeliness in care for patients with lung cancer: a scoping review

OBJECTIVES

Early diagnosis and reducing the time taken to achieve each step of lung cancer care is essential. This scoping review aimed to examine time points and intervals used to measure timeliness and to critically assess how they are defined by existing studies of the care seeking pathway for lung cancer.

METHODS

This scoping review was guided by the methodological framework for scoping reviews by Arksey and O'Malley. MEDLINE, EMBASE, CINAHL and PsycINFO electronic databases were searched for articles published between 1999 and 2019. After duplicate removal, all publications went through title and abstract screening followed by full text review and inclusion of articles in the review against the selection criteria. A narrative synthesis describes the time points, intervals and measurement guidelines used by the included articles.

RESULTS

A total of 2113 articles were identified from the initial search. Finally, 68 articles were included for data charting process. Eight time points and 14 intervals were identified as the most common events researched by the articles. Eighteen different lung cancer care guidelines were used to benchmark intervals in the included articles; all were developed in Western countries. The British Thoracic Society guideline was the most frequently used guideline (20%). Western guidelines were used by the studies in Asian countries despite differences in the health system structure.

CONCLUSION

This review identified substantial variations in definitions of some of the intervals used to describe timeliness of care for lung cancer. The differences in healthcare delivery systems of Asian and Western countries, and between high-income countries and low-income-middle-income countries may suggest different sets of time points and intervals need to be developed.

Prediction of overall survival of non-small cell lung cancer with bone metastasis: an analysis of the Surveillance, Epidemiology and End Results (SEER) database

Background

The prognosis of non-small cell lung cancer (NSCLC) patients with bone metastasis is extremely repulsive. The aim of this study was to potentially characterize the prevalence, associated factors and to establish a prognostic nomogram to predict the overall survival (OS) of NSCLC patients with bone metastasis.

Methods

The Surveillance, Epidemiology and End Results (SEER) database was used to collected NSCLC cases during 2010–2015. The cases with incomplete clinicopathological information were excluded. Finally, 484 NSCLC patients with bone metastasis were included in the present study and randomly divided into the training (n=340) and validation (n=144) cohorts in a ratio of 7:3 based on R software. NSCLC patients with bone metastasis were selected to investigate predictive factors for OS and cancer-specific survival (CSS) using the multivariable Cox proportional hazards regression. A nomogram incorporating these prognostic factors was developed and evaluated by a concordance index (C-index), calibration plots, and risk group stratifications.

Results

In the Cox proportional hazards model, sex, race, American Joint Committee on Cancer (AJCC) N, T stage, liver metastasis, and chemotherapy were regarded as prognostic factors of OS. The nomogram based on sex, race, AJCC N, T stage, liver metastasis and chemotherapy was developed for cancer-specific death to predict 1-, 3-, and 5-year survival rate with good performance. The C-index of established nomogram was 0.695 for cancer-specific death in the study population with an acceptable calibration.

Conclusions

The female gender, the patients with chemotherapy and not liver metastasis may indicate improved survival. However, the global prospective data with the latest tumor, node, metastasis (TNM) classification is needed to further improve this model.

SHOX2 methylation in Vietnamese patients with lung cancer

BACKGROUND

DNA methylation on cytosine in the CpG dinucleotides is one of the most common epigenetic perturbations taking place during cancer initiation, progression, occurrence and resistance therapy. DNA methylation seems to be sufficiently stable epigenetic modification to be utilized as a cancer biomarker in in vitro diagnostic (IVD) settings. Nowadays, the SHOX2 methylation (mSHOX2) is one of the most valuable DNA methylation biomarkers of lung cancer that is the leading cause of cancer death. It is being continuously validated across ethnicities, lifestyles and lifespan. This study focused on characteristics of mSHOX2 in Vietnamese patients with lung cancer since a lack of investigation and evidence of its utility in this country.

METHODS

The probe and primer sets were designed according to the MethyLight method for quantitative assessment of the mSHOX2 in 214 formalin-fixed paraffin-embedded (FFPE) lung tissues and 57 plasma samples.

RESULTS

mSHOX2 in FFPE tissues allowed discriminating benign and malignant lung diseases with 60% (95% CI 50.7-68.8%) sensitivity and 90.4% (95% CI 82.6-95.5%) specificity. Importantly, based on mSHOX2 in plasma, lung cancer could be detected with 83.3% (95% CI 65.3-94.4%) sensitivity and 92.6% (95% CI 75.7-99.1%) specificity, respectively. There were insignificant associations between mSHOX2 with age, cancer stage, EGFR mutation and serum CEA, CYFRA21-1 concentrations except for that gender.

CONCLUSION

Our study indicated that mSHOX2 was satisfactory for distinguishing malignant from benign lung tissue and noninvasively detecting lung cancer.

Advances in Diagnostic Bronchoscopy

The increase in incidental discovery of pulmonary nodules has led to more urgent requirement of tissue diagnosis. The peripheral pulmonary nodules are especially challenging for clinicians. There are various modalities for diagnosis and tissue sampling of pulmonary lesions, but most of these modalities have their own limitations. This has led to the development of many advanced technical modalities, which have empowered pulmonologists to reach the periphery of the lung safely and effectively. These techniques include thin/ultrathin bronchoscopes, radial probe endobronchial ultrasound (RP-EBUS), and navigation bronchoscopy—including virtual navigation bronchoscopy (VNB) and electromagnetic navigation bronchoscopy (ENB). Recently, newer technologies—including robotic-assisted bronchoscopy (RAB), cone-beam CT (CBCT), and augmented fluoroscopy (AF)—have been introduced to aid in the navigation to peripheral pulmonary nodules. Technological advances will also enable more precise tissue sampling of smaller peripheral lung nodules for local ablative and other therapies of peripheral lung cancers in the future. However, we still need to overcome the CT-to-body divergence, among other limitations. In this review, our aim is to summarize the recent advances in diagnostic bronchoscopy technology.

Shape-sensing robotic-assisted bronchoscopy for pulmonary nodules: initial multicenter experience using the Ion™ Endoluminal System

BACKGROUND

Traditional bronchoscopy provides limited approach to peripheral nodules. Shape-sensing robotic-assisted bronchoscopy (SSRAB, Ion™ Endoluminal System) is a new tool for minimally invasive peripheral nodule biopsy. We sought to answer the research question: Does SSRAB facilitate sampling of pulmonary nodules during bronchoscopists' initial experience?

METHODS

The lead-in stage of a multicenter, single-arm, prospective evaluation of the Ion Endoluminal System (PRECIsE) is described. Enrolled subjects ≥ 18 years old had recent computed tomography evidence of one or more solid or semi-solid pulmonary nodules ≥ 1.0 to ≤ 3.5 cm in greatest dimension and in any part of the lung. Subjects were followed at 10- and 30-days post-procedure. This stage provided investigators and staff their first human experience with the SSRAB system; safety and procedure outcomes were analyzed descriptively. Neither diagnostic yield nor sensitivity for malignancy were assessed in this stage. Categorical variables are summarized by percentage; continuous variables are summarized by median/interquartile range (IQR).

RESULTS

Sixty subjects were enrolled across 6 hospitals; 67 nodules were targeted for biopsy. Median axial, coronal and sagittal diameters were < 18 mm with a largest cardinal diameter of 20.0 mm. Most nodules were extraluminal and distance from the outer edge of the nodule to the pleura or nearest fissure was 4.0 mm (IQR: 0.0, 15.0). Median bronchial generation count to the target location was 7.0 (IQR: 6.0, 8.0). Procedure duration (catheter-in to catheter-out) was 66.5 min (IQR: 50.0, 85.5). Distance from the catheter tip to the closest edge of the virtual nodule was 7.0 mm (IQR: 2.0, 12.0). Biopsy completion was 97.0%. No pneumothorax or airway bleeding of any grade was reported.

CONCLUSIONS

Bronchoscopists leveraged the Ion SSRAB's functionality to drive the catheter safely in close proximity of the virtual target and to obtain biopsies. This initial, multicenter experience is encouraging, suggesting that SSRAB may play a role in the management of pulmonary nodules. Clinical Trial Registration identifier and date NCT03893539; 28/03/2019.

The role of multimorbidity in short-term mortality of lung cancer patients in Spain: a population-based cohort study

AIM

Chronic diseases often occur simultaneously and tend to be associated with adverse health outcomes, but limited research has been undertaken to understand their role in lung cancer mortality. Therefore, this study aims to describe the prevalence and patterns of having one (comorbidity) or ≥ 2 chronic diseases (multimorbidity) among lung cancer patients in Spain, and to examine the association between comorbidity or multimorbidity and short-term mortality risk at six months after cancer diagnosis.

METHODS

In this population-based cohort study, data were drawn from two Spanish population-based cancer registries, Girona and Granada, and electronic health records. We identified 1259 adult lung cancer patients, diagnosed from 1st January 2011 to 31st December 2012. We identified the most common patterns of individual comorbidities and their pairwise correlations. We used a flexible parametric modelling approach to assess the overall short-term mortality risk 6 months after cancer diagnosis by levels of comorbidity after adjusting for age, sex, smoking status, province of residence, surgery, cancer stage, histology, and body mass index.

RESULTS

We found high prevalence of comorbidity in lung cancer patients, especially among the elderly, men, those diagnosed with advanced-stage tumours, smokers, and obese patients. The most frequent comorbidities were chronic obstructive pulmonary disease (36.6%), diabetes (20.7%) and heart failure (16.8%). The strongest pairwise correlation was the combination of heart failure with renal disease (r = 0.20, p < 0.01), and heart failure with diabetes (r = 0.16, p < 0.01). Patients with either one or two or more comorbidities had 40% higher overall mortality risk than those without comorbidities (aHR for comorbidity: 1.4, 95%CI: 1.1-1.7; aHR for multimorbidity: 1.4, 95%CI: 1.1-1.8), when relevant confounding factors were considered.

CONCLUSIONS

The presence of comorbid diseases, rather than the number of comorbidities, was associated with increasing the risk of short-term lung cancer mortality in Spain. Comorbidity was a consistent and independent predictor of mortality among lung cancer patients, six months after diagnosis. The most common comorbid conditions were age-, obesity- and tobacco-related diseases. Our findings highlight the need to develop targeted preventive interventions and more personalised clinical guidelines to address the needs of lung cancer patients with one or more comorbidities in Spain.

First-Year Healthcare Resource Utilization Costs of Five Major Cancers in Japan

Reports on the expenditure of cancer treatments per patient using comprehensive data remain unavailable in Japan. This study aimed to use Japan’s cancer registry data and health service utilization data for evaluating the disease-specific, per-patient costs of five major cancers—stomach, lung, colorectal, liver, and breast cancers. We used a database linking the 2017 data from a hospital-based cancer registry and the health service utilization data from the Diagnosis Procedure Combination survey. All patients who started their first treatment course at each hospital were included. The costs were calculated using the total volume of the health services provided and the unit fee information included in the data. We analyzed 304,698 patients. Lung cancer had the highest healthcare cost per-patient for the first year of diagnosis and the longest median hospitalization duration. Conversely, breast cancer showed the lowest cost and the shortest median hospitalization duration. However, in the first month after diagnosis, colorectal cancer showed the highest cost. Subsequently, the gaps between the costs of the five common cancers drastically diminished. The cancer type having the longest hospitalization duration had the highest overall healthcare resource utilization costs. This information is essential for care planning and research studies.

The Nanosystems Involved in Treating Lung Cancer

Even though there are various types of cancer, this pathology as a whole is considered the principal cause of death worldwide. Lung cancer is known as a heterogeneous condition, and it is apparent that genome modification presents a significant role in the occurrence of this disorder. There are conventional procedures that can be utilized against diverse cancer types, such as chemotherapy or radiotherapy, but they are hampered by the numerous side effects. Owing to the many adverse events observed in these therapies, it is imperative to continuously develop new and improved strategies for managing individuals with cancer. Nanomedicine plays an important role in establishing new methods for detecting chromosomal rearrangements and mutations for targeted chemotherapeutics or the local delivery of drugs via different types of nano-particle carriers to the lungs or other organs or areas of interest. Because of the complex signaling pathways involved in developing different types of cancer, the need to discover new methods for prevention and detection is crucial in producing gene delivery materials that exhibit the desired roles. Scientists have confirmed that nanotechnology-based procedures are more effective than conventional chemotherapy or radiotherapy, with minor side effects. Several nanoparticles, nanomaterials, and nanosystems have been studied, including liposomes, dendrimers, polymers, micelles, inorganic nanoparticles, such as gold nanoparticles or carbon nanotubes, and even siRNA delivery systems. The cytotoxicity of such nanosystems is a debatable concern, and nanotechnology-based delivery systems must be improved to increase the bioavailability, biocompatibility, and safety profiles, since these nanosystems boast a remarkable potential in many biomedical applications, including anti-tumor activity or gene therapy. In this review, the nanosystems involved in treating lung cancer and its associated challenges are discussed.

Recent Advances in Curcumin Treated Non-Small Cell Lung Cancers: An Impetus of Pleiotropic Traits and Nanocarrier Aided Delive ry

Characterized by the abysmal 18% five year survival chances, non-small cell lung cancers (NSCLCs) claim more than half of their sufferers within the first year of being diagnosed. Advances in biomedical engineering and molecular characterization have reduced the NSCLC diagnosis via timid screening of altered gene expressions and impaired cellular responses. While targeted chemotherapy remains a major option for NSCLCs complications, delayed diagnosis, and concurrent multi-drug resistance remain potent hurdles in regaining normalcy, ultimately resulting in relapse. Curcumin administration presents a benign resolve herein, via simultaneous interception of distinctly expressed pathological markers through its pleiotropic attributes and enhanced tumor cell internalization of chemotherapeutic drugs. Studies on NSCLC cell lines and related xenograft models have revealed a consistent decline in tumor progression owing to enhanced chemotherapeutics cellular internalization via co-delivery with curcumin. This presents an optimum readiness for screening the corresponding effectiveness in clinical subjects. Curcumin is delivered to NSCLC cells either (i) alone, (ii) in stoichiometrically optimal combination with chemotherapeutic drugs, (iii) through nanocarriers, and (iv) nanocarrier co-delivered curcumin and chemotherapeutic drugs. Nanocarriers protect the encapsulated drug from accidental and non-specific spillage. A unanimous trait of all nanocarriers is their moderate drug-interactions, whereby native structural expressions are not tampered. With such insights, this article focuses on the implicit NSCLC curative mechanisms viz-a-viz, free curcumin, nanocarrier delivered curcumin, curcumin + chemotherapeutic drug and nanocarrier assisted curcumin + chemotherapeutic drug delivery.

Lung Cancer Inequalities in Stage of Diagnosis in Ontario, Canada

Lung cancer is the most common cancer and cause of cancer death in Canada, with approximately 50% of cases diagnosed at stage IV. Sociodemographic inequalities in lung cancer diagnosis have been documented, but it is not known if inequalities exist with respect to immigration status. We used multiple linked health-administrative databases to create a cohort of Ontarians 40-105 years of age who were diagnosed with an incident lung cancer between 1 April 2012 and 31 March 2017. We used modified Poisson regression with robust standard errors to examine the risk of diagnosis at late vs. early stage among immigrants compared to long-term residents. The fully adjusted model included age, sex, neighborhood-area income quintile, number of Aggregated Diagnosis Group (ADG) comorbidities, cancer type, number of prior primary care visits, and continuity of care. Approximately 62% of 38,788 people with an incident lung cancer from 2012 to 2017 were diagnosed at a late stage. Immigrants to the province were no more likely to have a late-stage diagnosis than long-term residents (63.5% vs. 62.0%, relative risk (RR): 1.01 (95% confidence interval (CI): 0.99-1.04), adjusted relative risk (ARR): 1.02 (95% CI: 0.99-1.05)). However, in fully adjusted models, people with more comorbidities were less likely to have a late-stage diagnosis (adjusted relative risk (ARR): 0.82 (95% CI: 0.80-0.84) for those with 10+ vs. 0-5 ADGs). Compared to adenocarcinoma, small cell carcinoma was more likely to be diagnosed at a late stage (ARR: 1.29; 95% CI: 1.27-1.31), and squamous cell (ARR: 0.89; 95% CI: 0.87-0.91) and other lung cancers (ARR: 0.93; 95% CI: 0.91-0.94) were more likely to be diagnosed at an early stage. Men were also slightly more likely to have late-stage diagnosis in the fully adjusted model (ARR: 1.08; 95% CI: 1.05-1.08). Lung cancer in Ontario is a high-fatality cancer that is frequently diagnosed at a late stage. Having fewer comorbidities and being diagnosed with small cell carcinoma was associated with a late-stage diagnosis. The former group may have less health system contact, and the latter group has the lung cancer type most closely associated with smoking. As lung cancer screening programs start to be implemented across Canada, targeted outreach to men and to smokers, increasing awareness about screening, and connecting every Canadian with primary care should be system priorities.

Understanding the patient journey to diagnosis of lung cancer

Objective

This research describes the clinical pathway and characteristics of two cohorts of patients. The first cohort consists of patients with a confirmed diagnosis of lung cancer while the second consists of patients with a solitary pulmonary nodule (SPN) and no evidence of lung cancer. Linked data from an electronic medical record and the Louisiana Tumor Registry were used in this investigation.

Materials and methods

REACHnet is one of 9 clinical research networks (CRNs) in PCORnet®, the National Patient-Centered Clinical Research Network and includes electronic health records for over 8 million patients from multiple partner health systems. Data from Ochsner Health System and Tulane Medical Center were linked to Louisiana Tumor Registry (LTR), a statewide population-based cancer registry, for analysis of patient’s clinical pathways between July 2013 and 2017. Patient characteristics and health services utilization rates by cancer stage were reported as frequency distributions. The Kaplan-Meier product limit method was used to estimate the time from index date to diagnosis by stage in lung cancer cohort.

Results

A total of 30,559 potentially eligible patients were identified and 2929 (9.58%) had primary lung cancer. Of these, 1496 (51.1%) were documented in LTR and their clinical pathway to diagnosis was further studied. Time to diagnosis varied significantly by cancer stage. A total of 24,140 patients with an SPN were identified in REACHnet and 15,978 (66.6%) had documented follow up care for 1 year. 1612 (10%) had no evidence of any work up for their SPN. The remaining 14,366 had some evidence of follow up, primarily office visits and additional chest imaging.

Conclusion

In both cohorts multiple biopsies were evident in the clinical pathway. Despite clinical workup, 70% of patients in the lung cancer cohort had stage III or IV disease. In the SPN cohort, only 66% were identified as receiving a diagnostic work-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08067-1.

Wait times in the management of non-small cell lung carcinoma before, during and after regionalization of lung cancer care: a high-resolution analysis

Background

Timeliness can have a substantial effect on treatment outcomes, prognosis and quality of life for patients with lung cancer. We sought to evaluate changes in wait times for patients with non–small cell lung carcinoma (NSCLC) and to identify bottlenecks in cancer care.

Methods

We included patients who received treatment with curative intent or palliative treatment for NSCLC, diagnosed through mediastinal staging by a thoracic surgeon. Data were collected from 3 cohorts over 3 time periods: before the regionalization of lung cancer care (2005–2007, C1), immediately postregionalization (2011–2013, C2) and 5 years after regionalization (2016–2017, C3). Total wait time and delays along treatment pathways were compared across cohorts using multivariate Cox proportionality models.

Results

Our total sample size was 299 patients. Overall, there was no significant difference in total wait time among the 3 cohorts. However, wait time from symptom onset to first physician visit significantly increased in C3 compared with C2 (hazard ratio [HR] 0.41, p < 0.01) and C1 (HR 0.43, p < 0.01). Time from first physician visit to computed tomography (CT) scan significantly decreased in C3 compared with C2 (HR 1.54, p < 0.01). Time from abnormal CT scan to first surgeon visit also significantly decreased in C2 (HR 1.43, p < 0.01) and C3 (HR 4.47, p < 0.01) compared with C1, and between C3 and C2 (HR 2.67, p < 0.01). In contrast, time from first surgeon visit to completion of staging significantly increased in C2 (HR 0.36, p < 0.01) and C3 (HR 0.24, p < 0.01) compared with C1, as well as between C3 and C2 (HR 0.60, p < 0.01). Time to first treatment after completion of staging was significantly shorter for C3 than C1 (HR 1.58, p < 0.01).

Conclusion

Trends toward a reduction in wait time are evident 5 years after the regionalization of lung cancer care, primarily led by shorter wait times for CT scans and thoracic surgeon consults. However, wait times can further be reduced by addressing delays in staging completion and patient and provider education to identify the early signs of NSCLC.

What Matters Most to Lung Cancer Patients? A Qualitative Study in Italy and Belgium to Investigate Patient Preferences

Background: The potential value of patient preference studies has been recognized in clinical individual treatment decision-making between clinicians and patients, as well as in upstream drug decision-making. Drug developers, regulators, reimbursement and Health Technology Assessment (HTA) bodies are exploring how the use of patient preference studies could inform drug development, regulatory benefit risk-assessment and reimbursement decisions respectively. Understanding patient preferences may be especially valuable in decisions regarding Non-Small Cell Lung Cancer (NSCLC) treatment options, where a variety of treatment options with different characteristics raise uncertainty about which features are most important to NSCLC patients. As part of the Innovative Medicines Initiative PREFER project, this qualitative study aimed to identify patient-relevant lung cancer treatment characteristics.

Methods: This study consisted of a scoping literature review and four focus group discussions, 2 in Italy and 2 in Belgium, with a total of 24 NSCLC patients (Stages III-IV). The focus group discussions sought to identify which treatment characteristics patients find most relevant. The discussions were analyzed thematically using a thematic inductive analysis.

Results: Patients highlighted themes reflecting: 1) positive effects or expected gains from treatment such as greater life expectancy and maintenance of daily functioning, 2) negative effects or adverse events related to therapy that negatively impact patients’ daily functioning such as fatigue and 3) uncertainty regarding the duration and type of treatment effects. These overarching themes were consistent among patients from Belgium and Italy, suggesting that treatment aspects related to efficacy and safety as well as the psychological impact of lung cancer treatment are common areas of concern for patients, regardless of cultural background or country.

Discussion: Our findings illustrate the value of using qualitative methods with patients to identify preferred treatment characteristics for advanced lung cancer. These could inform a subsequent quantitative preference survey that assesses patient trade-offs regarding treatment options.

Naringenin inhibits migration, invasion, induces apoptosis in human lung cancer cells and arrests tumour progression in vitro

Lung cancer is one of the major cause for high-death rate all over the world, due to increased metastasize and difficulties in diagnosis. Naringenin is naturally occurring flavonoid found in various fruits including tomatoes, citrus fruit and figs. Naringenin is known to have several therapeutic effects including anti-atherogenic, antimicrobial, anti-inflammatory, hepatoprotective, anticancer and anti-mutagenic. The present study was aimed to analyse the naringenin induced anti-proliferative and apoptosis effects in human lung cancer cells. Cells were treated with various concentrations of naringenin (10, 100 & 200 µmol/L) for 48 hours. Cisplatin (20 µg/mL) was used as positive control. Cell viability, apoptosis, migration and mRNA, and protein expression of caspase-3, matrixmetallo proteinases-2 (MMP-2) and MMP-9 were determined. The cell viability was 93.7 ± 7.5, 51.4 ± 4.4 and 32.1 ± 2.1 at 10, 100 and 200 µmol/L of naringenin respectively. Naringenin significantly increased apoptotic cells. The 100 and 200 µmol/L of naringenin significantly suppressed the larger wounds of cultured human cancer cells compared with the untreated lung cancer cells. Naringenin increased d the expression of caspase-3 and reduced the expression of MMP-2 and MMP-9. Taking all these data together, it is suggested that the naringenin was effective against human lung cancer proliferation, migration and metastasis.

Naringenin inhibits migration, invasion, induces apoptosis in human lung cancer cells and arrests tumour progression in vitro

Lung cancer is one of the major cause for high-death rate all over the world, due to increased metastasize and difficulties in diagnosis. Naringenin is naturally occurring flavonoid found in various fruits including tomatoes, citrus fruit and figs. Naringenin is known to have several therapeutic effects including anti-atherogenic, antimicrobial, anti-inflammatory, hepatoprotective, anticancer and anti-mutagenic. The present study was aimed to analyse the naringenin induced anti-proliferative and apoptosis effects in human lung cancer cells. Cells were treated with various concentrations of naringenin (10, 100 & 200 µmol/L) for 48 hours. Cisplatin (20 µg/mL) was used as positive control. Cell viability, apoptosis, migration and mRNA, and protein expression of caspase-3, matrixmetallo proteinases-2 (MMP-2) and MMP-9 were determined. The cell viability was 93.7 ± 7.5, 51.4 ± 4.4 and 32.1 ± 2.1 at 10, 100 and 200 µmol/L of naringenin respectively. Naringenin significantly increased apoptotic cells. The 100 and 200 µmol/L of naringenin significantly suppressed the larger wounds of cultured human cancer cells compared with the untreated lung cancer cells. Naringenin increased d the expression of caspase-3 and reduced the expression of MMP-2 and MMP-9. Taking all these data together, it is suggested that the naringenin was effective against human lung cancer proliferation, migration and metastasis.

Patient Preferences for Lung Cancer Treatment: A Qualitative Study Protocol Among Advanced Lung Cancer Patients

Introduction: Lung cancer is the deadliest and most prevalent cancer worldwide. Lung cancer treatments have different characteristics and are associated with a range of benefits and side effects for patients. Such differences may raise uncertainty among drug developers, regulators, payers, and clinicians regarding the value of these treatment effects to patients. The value of conducting patient preference studies (using qualitative and/or quantitative methods) for benefits and side effects of different treatment options has been recognized by healthcare stakeholders, such as drug developers, regulators, health technology assessment bodies, and clinicians. However, evidence-based guidelines on how and when to conduct and use these studies in drug decision-making are lacking. As part of the Innovative Medicines Initiative PREFER project, we developed a protocol for a qualitative study that aims to understand which treatment characteristics are most important to lung cancer patients and to develop attributes and levels for inclusion in a subsequent quantitative preference survey.

Methods: The study protocol specifies a four-phased approach: (i) a scoping literature review of published literature, (ii) four focus group discussions with stage III and IV Non-Small Cell Lung Cancer patients, (iii) two nominal group discussions with stage III and IV Non-Small Cell Lung Cancer patients, and (iv) multi-stakeholder discussions involving clinicians and preference experts.

Discussion: This protocol outlines methodological and practical steps as to how qualitative research can be applied to identify and develop attributes and levels for inclusion in patient preference studies aiming to inform decisions across the drug life cycle. The results of this study are intended to inform a subsequent quantitative preference survey that assesses patient trade-offs regarding lung cancer treatment options. This protocol may assist researchers, drug developers, and decision-makers in designing qualitative studies to understand which treatment aspects are most valued by patients in drug development, regulation, and reimbursement.

SARS-COV-2 infection and lung tumor microenvironment

Coronavirus Disease 2019 (COVID-19) is an acute respiratory syndrome, reported at the end of 2019 in China originally and immediately spread affecting over ten million world population to date. This pandemic is more lethal for the older population and those who previously suffered from other ailments such as cardiovascular diseases, respiratory disorders, and other immune system affecting abnormalities including cancers. Lung cancer is an important comorbidity of COVID-19. In this review, we emphasized the impact of lung tumor microenvironment (TME) on the possibility of enhanced severity of infection caused by the SARS-Co-V2. The compromised lung TME is further susceptible to the attack of viruses. The lung cells are also abundant in the virus entry receptors. Several SARS-Co-V2 proteins can modulate the lung TME by disrupting the fragile immune mechanisms contributing to cytokine storming and cellular metabolic variations. We also discussed the impact of medication used for lung cancer in the scenario of this infection. Since other respiratory infections can be a risk factor for lung cancer, COVID-19 recovered patients should be monitored for tumor development, especially if there is genetic susceptibility or it involves exposure to other risk factors.

Time from presentation to pre-diagnostic chest X-ray in patients with symptomatic lung cancer: a cohort study using electronic patient records from English primary care

BACKGROUND

National guidelines in England recommend prompt chest X-ray (within 14 days) in patients presenting in general practice with unexplained symptoms of possible lung cancer, including persistent cough, shortness of breath, or weight loss.

AIM

To examine time to chest X-ray in symptomatic patients in English general practice before lung cancer diagnosis, and explore demographical variation.

DESIGN AND SETTING

Retrospective cohort study using routinely collected general practice, cancer registry, and imaging data from England.

METHOD

Patients with lung cancer who presented symptomatically in general practice in the year pre-diagnosis and who had a pre-diagnostic chest X-ray were included. Time from presentation to chest X-ray (presentation-test interval) was determined and intervals classified based on national guideline recommendations as concordant (≤14 days) or non-concordant (>14 days). Variation in intervals was examined by age, sex, smoking status, and deprivation.

RESULTS

In a cohort of 2102 patients with lung cancer, the median presentation-test interval was 49 (interquartile range [IQR] 5-172) days. Of these, 727 (35%) patients had presentation-test intervals of ≤14 days (median 1 [IQR 0-6] day) and 1375 (65%) had presentation-test intervals of >14 days (median 128 [IQR 52-231] days). Intervals were longer among patients who smoke (equivalent to 63% longer than non-smokers; P<0.001), older patients (equivalent to 7% longer for every 10 years from age 27; P = 0.013), and females (equivalent to 12% longer than males; P = 0.016).

CONCLUSION

In symptomatic primary care patients who underwent chest X-ray before lung cancer diagnosis, only 35% were tested within the timeframe recommended by national guidelines. Patients who smoke, older patients, and females experienced longer intervals. These findings could help guide initiatives aimed at improving timely lung cancer diagnosis.

Lead DEAD/H box helicase biomarkers with the therapeutic potential identified by integrated bioinformatic approaches in lung cancer

DEAD/H box helicases are implicated in lung cancer but have not been systematically investigated for their clinical significance and function. In this study, we aimed to evaluate the potential of DEAD/H box helicases as prognostic biomarkers and therapeutic targets in lung cancer by integrated bioinformatic analysis of multivariate large-scale databases. Survival and differential expression analysis of these helicases enabled us to identify four biomarkers with the most significant alterations. These were found to be the negative prognostic factors DDX11, DDX55 and DDX56, and positive prognostic factor DDX5. Pathway enrichment analysis indicates that MYC signalling is negatively associated with expression levels of the DDX5 gene while positively associated with that of DDX11, DDX55 and DDX56. High expression levels of the DDX5 gene is associated with low mutation levels of TP53 and MUC16, the two most frequently mutated genes in lung cancer. In contrast, high expression levels of DDX11, DDX55 and DDX56 genes are associated with high levels of TP53 and MUC16 mutation. The tumour-infiltrated CD8 + T and B cells positively correlate with levels of DDX5 gene expression, while negatively correlate with that of the other three DEAD box helicases, respectively. Moreover, the DDX5-associated miRNA profile is distinguished from the miRNA profiles of DDX11, DDX55 and DDX56, although each DDX has a different miRNA signature. The identification of these four DDX helicases as biomarkers will be valuable for prognostic prediction and targeted therapeutic development in lung cancer.

One-Year Quality of Life Trends in Early-Stage Lung Cancer Patients After Lobectomy

Objective: Quality of Life (QoL) is an important predictor of patient's recovery and survival in lung cancer patients. The aim of the present study is to identify 1-year trends of lung cancer patients' QoL after robot-assisted or traditional lobectomy and investigate whether clinical (e.g., pre-surgery QoL, type of surgery, and perioperative complications) and sociodemographic variables (e.g., age) may predict these trends.

Methods: An Italian sample of 176 lung cancer patients undergoing lobectomy completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire—Core 30 (QLQ-C30) at the pre-hospitalization (t0), 30 days (t1), 4 months (t2), 8 months (t3), and 12 months (t4) after surgery. Sociodemographic and clinical characteristics (age, gender, perioperative complications, and type of surgery) were also collected. The individual change over time of the 15 dimensions of the EORTC QLQ-C30 and the effects of pre-surgery scores of QoL dimensions, type of surgery, perioperative complications, and age on patients' QoL after surgery were studied with the individual growth curve (IGC) models.

Results: Patients had a good recovery after lobectomy: functioning subscales improved over time, while most of the symptoms became less severe over the care process. Perioperative complications, type of surgery, pre-surgery status, and age significantly affected these trends, thus becoming predictors of patients' QoL.

Conclusion: This study highlights different 1-year trends of lung cancer patients' QoL. The measurement of pre- and post-surgery QoL and its clinical and sociodemographic covariables would be necessary to better investigate patients' care process and implement personalized medicine in lung cancer hospital divisions.

Current Novel Advances in Bronchoscopy

Screening for lung cancer has changed substantially in the past decade since The National Lung Screening Trial. The resultant increased discovery of incidental pulmonary nodules has led to a growth in the number of lesions requiring tissue diagnosis. Bronchoscopy is one main modality used to sample lesions, but peripheral lesions remain challenging for bronchoscopic biopsy. Alternatives have included transthoracic biopsy or operative biopsy, which are more invasive and have a higher morbidity than bronchoscopy. In hopes of developing less invasive diagnostic techniques, technologies have come to assist the bronchoscopist in reaching the outer edges of the lung. Navigational bronchoscopy is able to virtually map the lung and direct the biopsy needle where the scope cannot reach. Robotic bronchoscopy platforms have been developed to provide stability and smaller optics to drive deeper into the bronchial tree. While these new systems have not yet proven better outcomes, they may reduce the need for invasive procedures and be valuable armamentarium in diagnosing and treating lung nodules, especially in the periphery.

A Multidisciplinary Lung Cancer Program: Does It Reduce Delay Between Diagnosis and Treatment?

INTRODUCTION

Lung cancer is the leading cause of cancer death in the USA, claiming more than 140,000 deaths annually. Delays in diagnosis and treatment can lead to missed opportunities for both curative and life prolonging therapies. This study aimed to evaluate duration of time to diagnosis and first treatment, as well as investigate reasons for delays in care.

METHODS

This retrospective study included all lung cancer cases diagnosed by Stony Brook's Lung Cancer Evaluation Center (LCEC) between 2013 and 2019. Demographic, radiologic, pathologic and clinical variables were investigated, including cancer staging, histology, and medical and family histories. Evaluations included the determination of median time from initial encounter to diagnosis, median time from diagnosis to start of treatment and an exploration of the factors that influence possible causes for delays in care.

RESULTS

The LCEC's comprehensive multidisciplinary lung nodule program yielded a median length of time from CT to PET of 11 days, PET to procedure of 13 days, procedure to treatment consult of 9 days, and from consult to treatment of 9 days. LCEC patients experienced an overall median of 44 days from initial presentation to first treatment compared to the national ideal of 62 days, thereby representing a 29% reduction in time from first CT to onset of treatment.

CONCLUSION

Delays in lung cancer diagnosis and treatment can negatively impact patient morbidity and mortality. This study suggests that a coordinated multidisciplinary lung cancer program may reduce delays in care, thereby improving patient outcomes.

Ex vivo culture of circulating tumour cells derived from non-small cell lung cancer

Background

Tumour tissue-based information is limited. Liquid biopsy can provide valuable real-time information through circulating tumour cells (CTCs). Profiling and expanding CTCs may provide avenues to study transient metastatic disease.

Methods

Seventy non-small cell lung cancer (NSCLC) patients were recruited. CTCs were enriched using the spiral microfluidic chip and a RosetteSep™ using bloods from NSCLC patients. CTC cultures were carried out using the Clevers media under hypoxic conditions. CTCs were characterized using immunofluorescence and mutation-specific antibodies for samples with known mutation profiles. Exome sequencing was used to characterized CTC cultures.

Results

CTCs (>2 cells) were detected in 38/70 (54.3%) of patients ranging from 0 to 385 CTCs per 7.5 mL blood. In 4/5 patients where primary tumours harboured an EGFR exon 19 deletion, this EGFR mutation was also captured in CTCs. ALK translocation was confirmed on CTCs from a patient harbouring an ALK-rearrangement in the primary tumour. Short term CTC cultures were successfully generated in 9/70 NSCLC patients. Whole exome sequencing (WES) confirmed the presence of somatic mutations in the CTC cultures with mutational signatures consistent with NSCLC.

Conclusions

We were able to detect CTCs in >50% of NSCLC patients. NSCLC patients with >2 CTCs had a poor prognosis. The short-term CTC culture success rate was 12.9%. Further optimization of this culture methodology may provide a means by which to expand CTCs derived from NSCLC patient’s bloods. CTC cultures allow for expansion of cells to a critical mass, allowing for functional characterization of CTCs with the goal of drug sensitivity testing and the creation of CTC cell lines.

Magnetic Iron Nanocubes Effectively Capture Epithelial and Mesenchymal Cancer Cells

Current methods for capturing circulating tumor cells (CTCs) are based on the overexpression of cytokeratin (CK) or epithelial cell-adhesion molecule (EpCAM) on cancer cells. However, during the process of metastasis, tumor cells undergo epithelial-to-mesenchymal transition (EMT) that can lead to the loss of CK/EpCAM expression. Therefore, it is vital to develop a capturing technique independent of CK/EpCAM expression on the cancer cell. To develop this technique, it is important to identify common secondary oncogenic markers overexpressed on tumor cells before and after EMT. We analyzed the biomarker expression levels in tumor cells, before and after EMT, and found two common proteins-human epidermal growth factor receptor 2 (Her2) and epidermal growth factor receptor (EGFR) whose levels remained unaffected. So, we synthesized immunomagnetic iron nanocubes covalently conjugated with antibodies of Her2 or EGFR to capture cancer cells irrespective of the EMT status. The nanocubes showed high specificity (6-9-fold) in isolating the cancer cells of interest from a mixture of cells spiked in serum. We characterized the captured cells for identifying their EMT status. Thus, we believe the results presented here would help in the development of novel strategies for capturing both primary and metastatic cancer cells from patients' blood to develop an effective treatment plan.

The Malignant Role of Exosomes as Nanocarriers of Rare RNA Species

Nowadays, advancements in the oncology sector regarding diagnosis methods allow us to specifically detect an increased number of cancer patients, some of them in incipient stages. However, one of the main issues consists of the invasive character of most of the diagnosis protocols or complex medical procedures associated with it, that impedes part of the patients to undergo routine checkups. Therefore, in order to increase the number of cancer cases diagnosed in incipient stages, other minimally invasive alternatives must be considered. The current review paper presents the value of rare RNA species isolated from circulatory exosomes as biomarkers of diagnosis, prognosis or even therapeutic intervention. Rare RNAs are most of the time overlooked in current research in favor of the more abundant RNA species like microRNAs. However, their high degree of stability, low variability and, for most of them, conservation across species could shift the interest toward these types of RNAs. Moreover, due to their low abundance, the variation interval in terms of the number of sequences with differential expression between samples from healthy individuals and cancer patients is significantly diminished and probably easier to interpret in a clinical context.

Promoting Clinical Conversations about Lung Cancer Screening: Exploring the Role of Perceived Online Social Support

The perceived availability of online social support may contribute to patient-provider conversations about lung cancer screening. This study examines how the perceived availability of instrumental and emotional online social support is associated with patient-provider communication about lung cancer screening among adults who meet U.S. Preventive Services Taskforce (USPSTF) eligibility criteria and live with a COPD diagnosis. In April 2018, 575 adults completed an online survey after being recruited from a large southeastern academic medical center's broad research registry and website listing. Nearly half of the participants were 55-to-80 years old (41%), a current or former smoker who had quit smoking within the past 15 years (42%), and reported a smoking prevalence of 30 pack years or more (PPY; 41%). Results demonstrate that having a COPD diagnosis, identifying as male, and being a current or former tobacco smoker resulted in greater odds of having a clinical conversation about lung cancer screening. Conversely, meeting the 30 PPY smoking and 55-to-80 age thresholds lowered the odds of having these conversations. A high degree of instrumental and emotional online social support was associated with a greater incidence of annual patient-provider conversations about screening. This combination of perceived online social support was especially useful for patients with COPD.

Identification of lncRNA biomarkers for lung cancer through integrative cross-platform data analyses

This study was designed to identify lncRNA biomarker candidates using lung cancer data from RNA-Seq and microarray platforms separately.

Lung cancer datasets were obtained from the Gene Expression Omnibus (GEO, n = 287) and The Cancer Genome Atlas (TCGA, n = 216) repositories, only common lncRNAs were used. Differentially expressed (DE) lncRNAs in tumors with respect to normal were selected from the Affymetrix and TCGA datasets. A training model consisting of the top 20 DE Affymetrix lncRNAs was used for validation in the TCGA and Agilent datasets. A second similar training model was generated using the TCGA dataset.

First, a model using the top 20 DE lncRNAs from Affymetrix for training and validated using TCGA and Agilent, achieved high prediction accuracy for both training (98.5% AUC for Affymetrix) and validation (99.2% AUC for TCGA and 92.8% AUC for Agilent). A similar model using the top 20 DE lncRNAs from TCGA for training and validated using Affymetrix and Agilent, also achieved high prediction accuracy for both training (97.7% AUC for TCGA) and validation (96.5% AUC for Affymetrix and 80.9% AUC for Agilent). Eight lncRNAs were found to be overlapped from these two lists.