Major stressful events and risk of developing head/neck and pancreatic cancer

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Background: Major stressful life events have been shown to be associated with an increased risk of lung cancer, breast cancer and the development of various chronic illnesses. The stress response generated by our body results in a variety of physiological and metabolic changes which can affect the immune system, endocrine system and metabolism which has been shown to be associated with tumor progression. There is an indication that stress may need to be considered as a risk factor for malignancies. Methods: This is a matched case control study. The objective of this study was to determine if major stressful life events are associated with the incidence of head, neck, and pancreatic cancer (HNPC). Cases (CA) were HNPC patients diagnosed within the previous 12 months. Controls (CO) were patients without a prior history of malignancy and were matched with the cases by age and smoking status. Basic demographic data and medical information were collected from the patient’s medical records. Data on major stressful life events were collected using the modified Holmes-Rahe stress scale, and the following variables: death of a spouse, death of a child/immediate family member, serious personal illness, divorce/separation, loss of a job, caring for ill family member, financial difficulties, relocation, stress at work, detention/incarceration and retirement. A total sample of 300 was needed (100 cases, 200 controls) to achieve at least 80% power to detect odds ratios (OR) of 2.00 or higher at 5% level of significance. Results: From January 2018 to August 2021, 278 patients were enrolled (CA = 77, CO = 201) matched for mean age (years) (CA = 63, CO = 64), median smoking exposure (years) (CA = 36, CO = 38). About 65% of patients in CA group and 49% of CO group were male and 54% and 46% of the CA and CO groups respectively were of white race. In a multivariable logistic regression analysis after controlling for potential confounding variables (including sex, age, race, education, marital status, smoking history), there was no difference in lifetime incidence of major stressful event between the cases and controls. However, patients with HNPC were significantly more likely to report a major stressful life event within past 5 years when compared to CO [OR = 2.59 (1.24, 5.44), p = 0.012]. Conclusions: Patients with head, neck and pancreatic cancers are significantly associated with having a major stressful life event within 5 years of their diagnosis. This study highlights the potential need to recognize stressful life events as risk factors for developing malignancies and consider incorporating early rehabilitative efforts for major life stressful events.

Evaluation of advanced lung cancer inflammation as potential prognostic markers in patients with colorectal cancer

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Background: The Advanced Lung cancer Inflammation (ALI) prognostic index evaluates the degree of systemic inflammation in cancer patients and has been validated in small cell lung and esophageal cancer. The “sidedness” of the colon primary has prognostic implications with left sided tumors having longer survival rates than right sided. Our hypothesis is that right sided colorectal cancers (CRC) will have a lower ALI. Methods: We conducted a retrospective review of newly diagnosed CRC patients who were seen and evaluated at a tertiary Cancer Center from 1/1/2005 to 12/31/2015. ALI is calculated as ALI = BMI x (serum albumin/NLR). NLR is the neutrophil to lymphocyte ratio. Logistic regression models were used to determine the association between primary colon cancer location and ALI. Results: A total of 279 patients were included in this study. 53% of patients were male and mean age was 63.4 years (SD 13.7). 52% of cancers were located on the right side. Using an ordered logistic regression, ALI was predictive of higher stage disease (p = 0.04). In those patients with stage III (n = 64) or IV (n = 136) disease, the likelihood of a low ALI was significantly higher for right-sided colon cancers (OR 2.12, 95%CI:1.18-7.76). Conclusions: The Advanced Lung Cancer Inflammation index appears to be related to both CRC stage and primary cancer location. Ongoing studies are needed to determine the relationship between ALI and CRC survival.

Major stressful life events and risk of developing lung cancer

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Background: Lung cancer is the leading cause of cancer-related mortality linked with smoking, though only 6-18% of heavy smokers die of lung cancer. We hypothesized that major stressful life events are a risk factor for developing lung cancer. Methods: In our matched case-control study, cases (CA) were lung cancer patients diagnosed within past 12 months. Controls (CO) were patients without a prior history of malignancy. CA and CO were matched for age, gender and smoking status. Smokers had at least 10 packs/years history of smoking. Data was collected using standardized research questionnaire on 11 major stressful life events using Holmes and Rahe stress scale. The primary endpoint was odds of having a major stressful life event. A sample of 360 patients (120 CA and 240 CO), was needed to achieve 80% power to detect an odds ratio (OR) of 2.00 using Chi-Square test with a P = 0.05 significance. The study was IRB approved at each institution. Results: Between May 2015 and December 2016, 324 patients were enrolled (23 were excluded due to prior cancer history or incomplete information). 301 (CA = 102; CO = 199) were included in the final analysis. The two groups were well matched in median age (CA = 64.4 years; CO = 63.9years), gender (CA-Male = 48%; CO-Male = 49.2%) and smoking status (ever smoker, CA = 86%; CO = 85%). There was no difference in lifetime stressful life event between CA and CO (95% vs 93.9% P = 0.68%). However, CA were significantly more likely to have had a major stressful life event within the past 5 years than controls (CA = 77.4% vs CO = 65.8%, P = 0.03, (OR = 1.78). Serious life-threatening illness of an immediate family member (P = 0.04) and retirement (P = 0.07) within the past 5 years were noticeably more common among CA. Holmes-Rahe stress score in the last 5 years was higher in men (86.3 vs 63.3, P = 0.07) and those > 65 years old (82.4 vs 57.2,P = 0.04) as compared with CO and in those with squamous histology than with adenocarcinoma (115.6 vs 63.4, P = 0.005). Conclusions: Patients with lung cancer (CA) were significantly more likely to have had a major stressful life event within the past 5 years than the matched controls (CO), especially in older men with squamous histology. Major stressful life events should be considered a risk factor for developing lung cancer.

Cachexia Index in Advanced Non-Small-Cell Lung Cancer Patients

INTRODUCTION

Cancer cachexia affects many advanced non-small-cell lung cancer (NSCLC) patients. Cachexia index (CXI) was developed to assess the degree of cachexia in these patients.

METHODS

Patients with metastatic NSCLC diagnosed between January 1, 2000, and June 30, 2011, at our institution were retrospectively studied. Abdominal computed tomography scans done within 1 month of diagnosis were reviewed to estimate skeletal muscle area (SMA) and skeletal muscle index (SMI) at the L3 level. CXI was developed as follows: [Formula: see text] where SMI is the skeletal muscle index, Alb is the serum albumin, and NLR is the neutrophil-to-lymphocyte ratio. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Survival among various factors was calculated using the log-rank test. Multivariate Cox regression was used to perform survival analysis in order to estimate the effects of various factors.

RESULTS

Patients were divided into two groups around the median into stage I cachexia (CXI ≥35, n = 56) and stage II cachexia (CXI <35, n = 56). Groups did not differ in age, gender, ethnicity, or histology of cancer. Patients with stage II cachexia had significantly worse PFS (2.45 vs 5.43 months, P < 0.0001) and OS (3.45 vs 8.8 months, P = 0.0001) than those with stage I cachexia. On multivariate analysis adjusting for gender, race, and histology, patients with stage II cachexia were found to have worse PFS (hazard ratio [HR] 1.94, 95% confidence interval [CI] 1.27-2.95) and OS (HR 1.53, 95% CI 1.0009-2.34).

CONCLUSION

The CXI is a novel index for estimating cachexia that also correlates with prognosis in both men and women with advanced NSCLC.

SUV max of the most intense lesion on fdgpet/CT scan at baseline as a potential prognostic factor in stage IV (NSCLC): A retrospective review

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Background: Lung cancer is the leading cause of mortality in United States and worldwide. Stage IV lung cancer has poor prognosis with 5-year survival of 2%. Limited numbers of factors are known to predict survival in stage IV NSCLC (Non Small Cell Lung Cancer) including stage at diagnosis, Performance Status (PS), genomic expression profile. Earlier studies have found SUV max (Maximum Standardized Uptake Value) of primary lung tumor on FDGPET/CT (Fluoro Deoxy Glucose –Positron Emission Tomography/Computed Tomography) correlates with tumor doubling time and survival. However prior studies included stage I-IV NSCLC patients and SUVmax of primary lung tumor. Hence we performed this study with only clinical stage IVNSCLC who underwent FDGPET/CT scan at baseline to determine whether SUVmax value of most intense lesion has any prognostic significance. Methods: Retrospective review identified 46 patients (September 2004- September 2011) that were diagnosed with stage IV NSCLC at our institution. SUVmax of most intense lesion on FDG PET/CT scan was determined utilizing an automated program on a dedicated PET/CT workstation by a single nuclear medicine specialist. Cox regression analysis and Log-rank test were used to analyze data. Results: Descriptive statistics: Median age 61.6 (43.8-77.8), Females 17 (36%), African Americans 26 (56%), Performance status 0-1=36 (80%), number of metastatic sites 1-2=30 (65%), Adenocarcinoma 32 (70%), Chemotherapy 31 (61%), SUV max- primary (65%), other sites (35%). The patient population was subdivided into two groups using the median SUVmax of 17.8. The median survival of patients having SUV max ≤17.8 and SUVmax > 17.8 was 13.4 months and 4.5 months respectively (P =0.0269). Multivariate analysis indicated PS (HR=2.8), any chemotherapy (HR=2.56) and SUV max ≤ 17.8 (HR=1.98, P=0.04) predicted survival. Conclusions: SUV max of the most intense lesion at the time of presentation predicts worse outcome in stage IVNSCLC and needs to be validated in a prospective study. PETCT may be able to predict the areas that harbor resistant clones of cells, described in previous studies as tumor heterogeneity, which may confer prognostic significance.

Cisplatin (CDDP) and radiation versus cetuximab (Cx) and radiation in locally advanced head and neck squamous cell cancer (SCHNC): A retrospective review

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Background: SCHNC is a common malignancy and approximately 60% of patients present with locally advanced disease. There is paucity of data directly comparing Cx and CDDP with concurrent radiation in locally advanced SCHNC. We retrospectively reviewed charts of patients treated with CDDP and/or Cx along with radiation in locally advanced SCHNC comparing efficacy and outcomes in an academic cancer center. Methods: Ninety-five patients with locally advanced SCHNC were treated with concurrent CDDP (100 mg/m2 day 1, 22, 43) or Cx (400mg/m2 on day -7 and 250mg/m2 weekly) at our institution between January 2006 and June 2011. Forty-four patients were treated with CDDP (group A), 24 with Cx (group B) and 27 were initially started on CDDP but were switched to Cx secondary to toxicity (group C). All patients received concurrent radiation treatments (66-70 Gy, 2.0 Gy/fraction). The selection of CDDP versus Cx was largely based on ECOG performance status (PS) and baseline renal function of the patients. Chi-square test, analysis of variance, and log-rank test was used for analysis. The three groups had similar baseline characteristics except for mean age of 61, 56 and 55 years in group A, B and C respectively; T4 tumors consisted of 44%, 75% and 41% in groups A, B and C respectively. Groups A, B and C had a combined ECOG 0 and I (PS) of 93%, 75% and 92%. Patients with ECOG III PS were excluded. Results: Oropharynx was the most common treated site (38%) followed by Larynx (35%). Complete response (CR) was seen in 77%, 17% and 67% in groups A, B and C respectively (P<0.001). Median progression free survival (PFS) was 16.6, 4.3 and 22.8 in groups A, B and C respectively (P<0.001) and median overall survival (OS) was >35, 11.6 and >32 months in groups A, B and C respectively (P<0.0001). Conclusions: Concurrent CDDP with radiation leads to better response rate PFS and OS as opposed to Cx though many patients treated with CDDP could not complete treatment due to toxicity. Randomized trial comparing the two should be considered.