Evaluation of a 'Watch and Wait' Approach for Chemotherapy in Patients with Newly Diagnosed Advanced Non-small Cell Lung Cancer from a Diverse Community Population

AIMS

Systemic therapy in advanced non-small cell lung cancer (NSCLC) is the standard of care. The time of treatment administration has not been examined in the metastatic setting. A 'watch and wait' approach for the initiation of chemotherapy is sometimes used in clinical practice, either because of patient preference, presumed indolent disease behaviour, upfront radiotherapy or other interventions. We propose to evaluate the effect of a watch and wait approach on systemic treatment deliverability and patients' outcomes in a population-based study.

MATERIALS AND METHODS

A retrospective analysis of stage IIIB/IV NSCLC patients referred to medical oncology at the British Columbia Cancer Agency in 2009 was conducted. We defined the following: immediate chemotherapy (ICT) - chemotherapy ≤ 8 weeks from medical oncology consult; watch and wait chemotherapy (WWC) - initial observation with chemotherapy > 8 weeks from medical oncology consultation; watch and wait missed (WWM) - watch and wait patients who did not receive chemotherapy; best supportive care (BSC) - patients deemed chemotherapy ineligible. Statistical methods included Kaplan-Meier analysis, Log-rank tests and Cox proportional hazards modelling.

RESULTS

In total, 744 patients were seen by medical oncology; 355 (48%) received ICT, 173 (23%) watch and wait and 216 (29%) BSC. Of the 173 patients on a watch and wait approach, 42% missed an opportunity for chemotherapy due to poor performance status (50%), death (49%) and comorbidity (1%). The median overall survival was as follows: watch and wait 11.5 months, ICT 12.8 months and BSC 4.3 months (P < 0.0001). Controlling for confounding factors (age, gender, performance status), overall survival was longer in WWC (hazard ratio 0.73, confidence interval 0.81-1.07, P = 0.023) and lower in WWM (hazard ratio 1.68, 95% confidence interval 1.27-2.22, P < 0.0001), compared with ICT.

CONCLUSIONS

A significant proportion of watch and wait patients never receive systemic therapy, predominantly due to a decline in performance status. Patients in the ICT group were younger, had a better performance status and had non-squamous histology compared with the watch and wait group. The overall survival was longer in the patients who received ICT versus watch and wait. The watch and wait strategy is associated with a high risk of missing the opportunity for any chemotherapy and should be judiciously implemented only in carefully selected patients.

Histologic classification of non-small-cell lung cancer over time: reducing the rates of not-otherwise-specified

BACKGROUND

The importance of histologic classification in selecting the appropriate systemic therapy for non-small-cell lung cancer (nsclc) came to attention in 2007. In British Columbia, that information was communicated through international and national meetings, our centralized cancer care program, and to the medical community at large in multidisciplinary forums. We examined the effects of those education programs on the categorization of nsclc and associated systemic treatment practices.

METHODS

The BC Cancer Agency provides cancer care to 4.6 million residents of British Columbia. A retrospective review of all stage iiib and ivnsclc patients referred in 2007 and 2011 collected baseline characteristics, treatment, and outcomes. Histology was classified using the International Classification of Diseases for Oncology, 3rd edition, for the Canadian Cancer Registry.

RESULTS

In 2007, 671 patients were referred, and 170 received chemotherapy; in 2011, the relevant figures were 680 and 197 respectively. Baseline characteristics in the cohorts were not statistically significantly different in 2007 and 2011. Histologic classifications in 2007 were 41% nonsquamous, 13% squamous, and 46% not otherwise specified (nos); in 2011, they were 63%, 17%, and 20% respectively. Exposure to pemetrexed in any line of therapy in 2007 was 22% for nonsquamous, 17% for squamous, and 10% for nos; in 2011, exposure was 39%, 3%, and 37% respectively. Exposure to epidermal growth factor receptor tyrosine kinase inhibitor (egfrtki) in 2007 was 36%, 22%, and 33%; in 2011, it was 64%, 60%, and 63%. Median overall survival duration, 2007 versus 2011, was 3.25 months versus 3.57 months with best supportive care, and 11.31 months versus 11.54 months with chemotherapy.

CONCLUSIONS

The specificity of nsclc histologic categorization improved in 2011 compared with 2007, with a reduction of 26 percentage points in the rate of nos disease. The proportion of patients treated with chemotherapy over time remained the same, but the use of pemetrexed and egfrtki increased. The increased accuracy in histologic classification resulted in more appropriate utilization of systemic drugs.

Development of an electronic emergency department-based geo-information injury surveillance system in Hong Kong

OBJECTIVES

To describe the experience in the development of an electronic emergency department (ED)-based injury surveillance (IS) system in Hong Kong using data-mining and geo-spatial information technology (IT) for a Safe Community setup.

METHODS

This paper described the phased development of an emergency department-based IS system based on World Health Organization (WHO) injury surveillance Guideline to support safety promotion and injury prevention in a Safe Community in Hong Kong starting 2002.

RESULTS

The initial ED data-based only collected data on name, sex, age, address, eight general categories of injury types (traffic, domestic, common assault, indecent assault, batter, industrial, self-harm and sports) and disposal from ED. Phase 1--manual data collection on International Classification of External Causes of Injury pre-event data; Phase 2--manual form was converted to electronic format using web-based data mining technology with built in data quality monitoring mechanism; Phase 3--integration of injury surveillance-data with in-patient hospital information; and Phase 4--geo-spatial information and body mapping were introduced to geo-code exact place of injury in an electronic map and site of injury on body map.

CONCLUSION

It was feasible to develop a geo-spatial IS system at busy ED to collect valuable information for safety promotion and injury prevention at Safe Community setting. The keys for successful development and implementation involves engagement of all stakeholders at design and implementation of the system with injury prevention as ultimate goal, detail workflow planning at front end, support from the management, building on exiting system and appropriate utilisation of modern technology.

Does Chiari osteotomy compromise subsequent total hip arthroplasty?

We compared 28 total hip arthroplasties done in dysplastic hips after previous Chiari osteotomy (group I) with a well-matched control group of 50 primary procedures (group II) done during the same period at an average follow-up of 5 years (range, 25-199 months). Group I required significantly less acetabular augmentation, had significantly shorter operative times, had less intraoperative blood loss, and had fewer complications than group II. There was no significant difference between the 2 groups in terms of clinical or radiographic outcome. Total hip arthroplasty after a successful Chiari osteotomy leads to medium-term results similar to those of other dysplastic hips. In our experience, less bone grafting was required, better coverage of the cup by host-bone was obtained, and the center of motion of the hip was more anatomic. Chiari osteotomy may delay the need for total hip arthroplasty, may facilitate acetabular reconstruction, and does not seem to compromise the medium-term clinical or radiographic outcome.

Insufficiency fracture of acetabulum: a case report

Most stress fractures of the hip joint occur on the femoral side. A review of the English literature showed that only eight cases of stress fracture of the acetabulum had been reported. Another insufficiency fracture of the acetabulum in an osteoporotic bone is reported.

Diffuse pigmented villonodular synovitis of the shoulder: a case report

Pigmented villonodular synovitis (PVNS) of the shoulder is an uncommon disorder with unknown etiology. It is characterized by synovial proliferation and hemosiderin deposition into the synovial tissues of the affected joints. PVNS affects mainly the knee joint and shoulder involvement is rare. There are only 12 cases of shoulder involvement reported in the English-language literature. A case of PVNS of the shoulder with simultaneous rotator cuff tear is presented and the literature is reviewed.

Two to five year follow-up of Harris-Galante cementless total hip arthroplasty

One hundred and forty-nine hips (125 patients) underwent cementless Harris-Galante primary total hip arthroplasty from September 1987 to June 1990 at the Taichung Veterans General Hospital. Seventy hips (61 patients) have been followed up for at least 2 years (range, 26-55 months, mean 36 months). The primary diagnoses included osteoarthritis (42.9%) and avascular necrosis (57.1%). All the hips were evaluated using Harris hip score and Mayo Clinic hip score. The average Harris hip score was 36.5 points (23-73) preoperatively, and 95 points (80-100) postoperatively. When evaluated by the Harris hip score, 94.3% were excellent, and 5.7% had good results; and 90% were excellent, 10% had good results when evaluated by Mayo Clinic hip score. No fair or poor results were noted by either evaluating system. Fifty-seven femoral components (81.4%) appeared to have stable bone ingrowth fixation, ten components (14.3%) had stable fibrous ingrowth, and three (4.3%) were unstable. Fifty-five hips (78.6%) showed radiolucent lines around the femoral component in follow-up roentgenogram; most were at the non-porous, fiber-mesh part. It seemed that there was no correlation between these radiolucent lines and clinical outcome, according to this short-term study.

Button batteries as foreign bodies in the nasal cavities

Two cases of foreign bodies (button batteries) in the nasal cavities were reported. The first patient was a 6-year-old girl who put a button battery into her left nostril and ulceration of the septum and inferior turbinate was found. The other patient was a 3-year-old boy, the alkaline battery caused neither septal perforation nor stenosis of the nasal meatus. All button batteries as foreign bodies in the nasal cavities should be removed immediately to prevent severe local tissue damage, resulting in late sequels, such as septal perforation or stenosis of the nasal meatus.