Survival after community diagnosis of early-stage non-small cell lung cancer

Factors Associated With Delay in Lung Cancer Diagnosis and Surgery in a Lung Cancer Screening Program

PURPOSE

Delays to biopsy and surgery after lung nodule detection can impact survival from lung cancer. The aim of this study was to identify factors associated with delay in a lung cancer screening (LCS) program.

MATERIALS AND METHODS

We evaluated patients in an LCS program from May 2015 through October 2021 with a malignant lung nodule classified as lung CT screening reporting and data system (Lung-RADS) 4B/4X. A cutoff of more than 30 days between screening computed tomography (CT) and first tissue sampling and a cutoff of more than 60 days between screening CT and surgery were considered delayed. We evaluated the relationship between delays to first tissue sampling and surgery and patient sex, age, race, smoking status, median income by zip code, language, Lung-RADS category, and site of surgery (academic vs community hospital).

RESULTS

A total of 185 lung cancers met the inclusion criteria, of which 150 underwent surgical resection. The median time from LCS CT to first tissue sampling was 42 days, and the median time from CT to surgery was 52 days. 127 (69%) patients experienced a first tissue sampling delay and 60 (40%) had a surgical delay. In multivariable analysis, active smoking status was associated with delay to first tissue sampling (odds ratio: 3.0, CI: 1.4-6.6, P = 0.005). Only performing enhanced diagnostic CT of the chest before surgery was associated with delayed lung cancer surgery (odds ratio: 30, CI: 3.6-252, P = 0.02). There was no statistically significant difference in delays with patients' sex, age, race, language, or Lung-RADS category.

CONCLUSION

Delays to first tissue sampling and surgery in a LCS program were associated with current smoking and performing diagnostic CT before surgery.

Survival analysis and clinicopathological features of patients with stage IA lung adenocarcinoma

Background

With the development of medical technology and change of life habits, early-stage lung adenocarcinoma (LUAD) has become more common. This study aimed to systematically analyzed clinicopathological factors associated to the overall survival (OS) of patients with Stage IA LUAD.

Methods

A total of 5942 Stage IA LUAD patients were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier methods and log-rank tests were used to compare the differences in OS. A nomogram constructed based on the Cox regression was evaluated by Concordance index (C index), calibration curve, decision curve analysis (DCA) and area under curve (AUC). And 136 patients were recruited from Shandong Province Hospital for external validation.

Results

Cox analysis regression indicated that 12 factors, such as Diagnosis to Treatment Interval (DTI) and Income Level, were independent prognostic factors and were included to establish the nomogram. The C-index of our novel model was 0.702, 0.724 and 0.872 in the training, internal and external validation cohorts, respectively. The 3-year and 5-year survival AUCs and calibration curves showed excellent agreement in each cohort. Some new factors in the SEER database, including DTI and Income Level, were firstly confirmed as independent prognostic factors of Stage IA LUAD patients. The distribution of these factors in the T1a, T1b, and T1c subgroups differed and had different effects on survival.

Conclusion

We summarized 12 factors that affect prognosis and constructed a nomogram to predict OS of Stage IA LUAD patients who underwent operation. For the first time, new SEER database parameters, including DTI and Income Level, were proved to be survival-related.

A Comparative Multicenter Cohort Study Evaluating the Long-Term Influence of the Strict Lockdown during the First COVID-19 Wave on Lung Cancer Patients (ARTEMISIA Trial)

The consequences of the strict health restrictions during the first wave of COVID-19 on lung cancer (LC) patients are not known. This cohort study evaluated the impact of the initial lockdown on management of and long-term outcome in LC patients. This exposed-unexposed-type study included two evaluation periods of 6 months each in non-selected patients; one began on the first day of lockdown in 2020, and the other in 2019 during the same calendar period. Various indicators were compared: clinical profiles, management delays and overall survival beyond 2 years. A total of 816 patients from 7 public or private centers were enrolled. The clinical characteristics of the patients in 2020 did not differ from those in 2019, except that the population was older (p = 0.002) with more non-smokers (p = 0.006). Delays for pre-therapeutic medical management were generally reduced after the first imaging in 2020 (1.28 [1.1-1.49]). In the multivariate analysis, being part of the 2020 cohort was correlated with better prognosis (HR = 0.71 [0.5-0.84], p < 0.001). The gain observed in 2020 mainly benefited non-smoking patients, along with ECOG PS 0-2 (p = 0.01), stage 4 (p = 0.003), squamous cell carcinoma (p = 0.03) and receiving systemic therapy (p = 0.03). In conclusion, the first lockdown did not exert any deleterious impact on LC patients.

Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer

INTRODUCTION

There is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer.

METHODS

We identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival.

RESULTS

In multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14).

CONCLUSIONS

Expeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.

Impact of time-to-treatment on survival for early-stage non-small cell lung cancer in The Netherlands-a nationwide observational cohort study

Background

Varied outcomes on the relation between time-to-treatment and survival in early-stage non-small cell lung cancer (NSCLC) patients are reported. We examined this relation in a large multicentric retrospective cohort study and identified factors associated with extended time-to-treatment.

Methods

We included 9,536 patients with clinical stage I-II NSCLC, diagnosed and treated in 2014-2019, from the Netherlands Cancer Registry that includes nation-wide data. Time-to-treatment was defined as the number of days between first outpatient visit for suspected lung cancer and start of treatment. The effect of extended time-to-treatment beyond the first quartile and survival was studied with Cox proportional hazard regression. Analyses were stratified for stage and type of therapy. Time-to-treatment was adjusted for multiple covariates including performance status and socioeconomic status. Factors associated with treatment delay were identified by multilevel logistic regression.

Results

Median time-to-treatment was 47 days [interquartile range (IQR): 34-65] for stage I and 46 days (IQR: 34-62) for stage II. The first quartile extended to 33 days for both stages. Risk of death increased significantly with extended time-to-treatment for surgical treatment of clinical stage II patients [adjusted hazard ratio (aHR) >33 days: 1.36, 95% confidence intervals (CI): 1.09-1.70], but not in stage II patients treated with radiotherapy or in stage I patients. Causes of prolonged time-to-treatment were multifactorial including diagnostic tests, such as endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS).

Conclusions

Clinical stage II patients benefit from fast initiation of surgical treatment. Surprisingly this appears to be accounted for by patients who are clinically stage II but pathologically stage I. Further study is needed on characterizing these patients and the significance of lymph node- or distant micrometastasis in guiding time-to-treatment and treatment strategy.

Delays to surgery and worse outcomes: The compounding effects of social determinants of health in non-small cell lung cancer

Objective

To quantify the compounding effects of social determinants of health on time to surgery (T2S) and clinical outcomes.

Methods

The National Cancer Database was queried for treatment-naïve patients with cT1-4N0-1M0 non-small cell lung cancer undergoing (bi)lobectomy or pneumonectomy between 2006 and 2016 with 1 to 180 days T2S, the number of days between diagnosis and surgery; surgical delays were defined as statistically significant increased T2S compared with a reference cohort. Social determinants of health factors prognostic for surgical delays were identified using multivariable regression. The 30-/90-day mortality and 5-year survival estimates were calculated using logistic and Cox regressions, respectively.

Results

In total, 110,005 patients met inclusionary criteria. Multivariable analysis identified race, insurance, and facility type as factors with significant 3-way interaction: T2S of one depended on the others. Income and education also contributed to delays. Privately insured (private) non-Hispanic White patients at academic medical centers (AMCs) were the reference with T2S of 44.1 days. At AMCs, private Black patients had significant delays to surgery (54.7 days; P < .0001), as did Medicaid and uninsured Black patients (58.5 days; P < .0001, 59.4 days; P < .0001, respectively). The 15-day surgical delays were associated with statistically significant 5% increased 30-day mortality odds (confidence interval [CI], 1.03-1.08), 6% increased 90-day mortality odds (CI, 1.04-1.08), and 4% decrease in hazard of death at 5 years (CI, 1.04-1.05).

Conclusions

In treatment-naïve patients with cT1-4N0-1M0 non-small cell lung cancer, Black race, Medicaid, uninsured status, and AMCs generate compounding surgical delays with increased 30-/90-day mortality and decreased 5-year survival. Thoracic surgeons can leverage these facility and demographic-specific insights to standardize time to surgery and begin mitigating underlying disparities.

Association of Surgical Timing with Outcomes in Early Stage Lung Cancer

BACKGROUND

Optimal time to surgery for lung cancer is not well established. We aimed to assess whether time to surgery correlates with outcomes.

METHODS

We assessed patients 18-84 years old who were diagnosed with stage I/II lung cancer at our integrated healthcare system from 2009 to 2019. Time to surgery was defined to start with disease confirmation (imaging or biopsy) prior to the surgery scheduling date. Outcomes of unplanned return to care within 30 days of lung cancer surgery, all-cause mortality, and disease recurrence were compared based on time to surgery before and after 2, 4, and 12 weeks.

RESULTS

Of 2861 included patients, 70% were over 65 years old and 61% were female. Time to surgery occurred in 1-2 weeks for 6%, 3-4 weeks for 31%, 5-12 weeks for 58%, and 13-26 weeks for 5% of patients. Patients with time to surgery > 4 (vs. ≤ 4) weeks had greater risk of both death (hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.00-1.39) and recurrence (HR 1.33, 95% CI 1.10-1.62). Associations were not statistically significant when dichotomizing time to surgery at 2 or 12 weeks for death (2 week HR 1.23, 95% CI 0.93-1.64; 12 week HR 1.35, 95% CI 0.97-1.88) and recurrence (2 week HR 1.54, 95% CI 0.85-2.80; 12 week HR 2.28, 95% CI 0.80-6.46).

CONCLUSIONS

Early stage lung cancer patients with time to surgery within 4 weeks experienced lower rates of recurrence. Optimal time to surgical resection may be shorter than previously reported.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Timely Curative Treatment and Overall Mortality Among Veterans With Stage I NSCLC

Introduction

Early stage lung cancer (LC) outcomes depend on the receipt of timely therapy. We aimed to determine the proportions of Veterans with stage I NSCLC in the age group eligible for LC screening (LCS) receiving timely curative treatment (≤12 wk after diagnosis), the factors associated with timely treatment and modality, and the factors associated with overall mortality.

Methods

Retrospective cohort study in Veterans aged 55 to 80 years when diagnosed with stage I NSCLC during 2011 to 2015. We used multivariate logistic regression models to determine factors associated with receiving timely therapy and receiving surgery versus stereotactic body radiation therapy (SBRT). We used multivariate Cox proportional hazards regression analysis to determine factors associated with overall mortality.

Results

We identified 4796 Veterans with stage I NSCLC; the cohort was predominantly older, White males, current or former smokers, and living in urban areas. Overall, 84% underwent surgery and 16% underwent SBRT. The median time to treatment was 63 days (61 d for surgery; 71 d for SBRT), with 30% treated more than 12 weeks. Unmarried Veterans with higher social deprivation index were less likely to receive timely therapy. Black race, female sex, and never smoking were associated with lower overall mortality. Older Veterans receiving treatment >12 wk, with higher comorbidity index, and squamous cell carcinoma had higher overall mortality.

Conclusions

A total of 30% of the Veterans with stage I NSCLC in the age group eligible for LCS received curative treatment more than 12 weeks after diagnosis, which was associated with higher overall mortality. Delays in LC treatment could decrease the mortality benefits of LCS among the Veterans.

Comparing modalities for risk assessment in patients with pulmonary lesions and nondiagnostic bronchoscopy for suspected lung cancer

BACKGROUND

Bronchoscopy is commonly utilized for non-surgical sampling of indeterminant pulmonary lesions, but nondiagnostic procedures are common. Accurate assessment of the risk of malignancy is essential for decision making in these patients, yet we lack tools that perform well across this heterogeneous group of patients. We sought to evaluate the accuracy of three previously validated risk models and physician-assessed risk (PAR) in patients with a newly identified lung lesion undergoing bronchoscopy for suspected lung cancer where the result is nondiagnostic.

METHODS

We performed an analysis of prospective data collected for the Percepta Bronchial Genomic Classifier Multicenter Registry. PAR and three previously validated risk models (Mayo Clinic, Veteran's Affairs, and Brock) were used to determine the probability of lung cancer (low, intermediate, or high) in 375 patients with pulmonary lesions who underwent bronchoscopy for possible lung cancer with nondiagnostic pathology. Results were compared to the actual adjudicated prevalence of malignancy in each pre-test risk group, determined with a minimum of 12 months follow up after bronchoscopy.

RESULTS

PAR and the risk models performed poorly overall in the assessment of risk in this patient population. PAR most closely matched the observed prevalence of malignancy in patients at 12 months after bronchoscopy, but all modalities had a low area under the curve, and in all clinical models more than half of all the lesions labeled as high risk were truly or likely benign. The studied risk model calculators overestimate the risk of malignancy compared to PAR, particularly in the subset in older patients, irregularly bordered nodules, and masses > 3 cm. Overall, the risk models perform only slightly better when confined to lung nodules < 3 cm in this population.

CONCLUSION

The currently available tools for the assessment of risk of malignancy perform suboptimally in patients with nondiagnostic findings following a bronchoscopic evaluation for lung cancer. More accurate and objective tools for risk assessment are needed.

TRIAL REGISTRATION

not applicable.

Improved survival of non-small cell lung cancer patients after introducing patient navigation: A retrospective cohort study with propensity score weighted historic control

OnkoNetwork is a patient navigation program established in the Moritz Kaposi General Hospital to improve the timeliness and completeness of cancer investigations and treatment. The H2020 SELFIE consortium selected OnkoNetwork as a promising integrated care initiative in Hungary and conducted a multicriteria decision analysis based on health, patient experience, and cost outcomes. In this paper, a more detailed analysis of clinical impacts is provided in the largest subgroup, non-small cell lung cancer (NSCLC) patients. A retrospective cohort study was conducted, enrolling new cancer suspect patients with subsequently confirmed NSCLC in two annual periods, before and after OnkoNetwork implementation (control and intervention cohorts, respectively). To control for selection bias and confounding, baseline balance was improved via propensity score weighting. Overall survival was analyzed in univariate and multivariate weighted Cox regression models and the effect was further characterized in a counterfactual analysis. Our analysis included 123 intervention and 173 control NSCLC patients from early to advanced stage, with significant between-cohort baseline differences. The propensity score-based weighting resulted in good baseline balance. A large survival benefit was observed in the intervention cohort, and intervention was an independent predictor of longer survival in a multivariate analysis when all baseline characteristics were included (HR = 0.63, p = 0.039). When post-baseline variables were included in the model, belonging to the intervention cohort was not an independent predictor of survival, but the survival benefit was explained by slightly better stage distribution and ECOG status at treatment initiation, together with trends for broader use of PET-CT and higher resectability rate. In conclusion, patient navigation is a valuable tool to improve cancer outcomes by facilitating more timely and complete cancer diagnostics. Contradictory evidence in the literature may be explained by common sources of bias, including the wait-time paradox and adjustment to intermediate outcomes.

Association between time-to-treatment and outcomes in non-small cell lung cancer: a systematic review

BACKGROUND

National targets for timely diagnosis and management of a potential cancer are driven in part by the perceived risk of disease progression during avoidable delays. However, it is unclear to what extent time-to-treatment impacts prognosis for patients with non-small cell lung cancer, with previous reviews reporting mixed or apparently paradoxical associations. This systematic review focuses on potential confounders in order to identify particular patient groups which may benefit most from timely delivery of care.

METHODS

Medline, EMBASE and Cochrane databases were searched for publications between January 2012 and October 2020, correlating timeliness in secondary care pathways to patient outcomes. The protocol is registered with PROSPERO (the International Prospective Register of Systematic Reviews; ID 99239). Prespecified factors (demographics, performance status, histology, stage and treatment) are examined through narrative synthesis.

RESULTS

Thirty-seven articles were included. All but two were observational. Timely care was generally associated with a worse prognosis in those with advanced stage disease (6/8 studies) but with better outcomes for patients with early-stage disease treated surgically (9/12 studies). In one study, patients with squamous cell carcinoma referred for stereotactic ablative radiotherapy benefited more from timely care, compared with patients with adenocarcinoma. One randomised controlled trial supported timeliness as being advantageous in those with stage I-IIIA disease.

CONCLUSION

There are limitations to the available evidence, but observed trends suggest timeliness to be of particular importance in surgical candidates. In more advanced disease, survival trends are likely outweighed by symptom burden, performance status or clinical urgency dictating timeliness of treatment.

Effect of an Antiracism Intervention on Racial Disparities in Time to Lung Cancer Surgery

PURPOSE

Timely lung cancer surgery is a metric of high-quality cancer care and improves survival for early-stage non-small-cell lung cancer. Historically, Black patients experience longer delays to surgery than White patients and have lower survival rates. Antiracism interventions have shown benefits in reducing racial disparities in lung cancer treatment.

METHODS

We conducted a secondary analysis of Accountability for Cancer Care through Undoing Racism and Equity, an antiracism prospective pragmatic trial, at five cancer centers to assess the impact on overall timeliness of lung cancer surgery and racial disparities in timely surgery. The intervention consisted of (1) a real-time warning system to identify unmet care milestones, (2) race-specific feedback on lung cancer treatment rates, and (3) patient navigation. The primary outcome was surgery within 8 weeks of diagnosis. Risk ratios (RRs) and 95% CIs were estimated using log-binomial regression and adjusted for clinical and demographic factors.

RESULTS

A total of 2,363 patients with stage I and II non-small-cell lung cancer were included in the analyses: intervention (n = 263), retrospective control (n = 1,798), and concurrent control (n = 302). 87.1% of Black patients and 85.4% of White patients in the intervention group (P = .13) received surgery within 8 weeks of diagnosis compared with 58.7% of Black patients and 75.0% of White patients in the retrospective group (P < .01) and 64.9% of Black patients and 73.2% of White patients (P = .29) in the concurrent group. Black patients in the intervention group were more likely to receive timely surgery than Black patients in the retrospective group (RR 1.43; 95% CI, 1.26 to 1.64). White patients in the intervention group also had timelier surgery than White patients in the retrospective group (RR 1.10; 95% CI, 1.02 to 1.18).

CONCLUSION

Accountability for Cancer Care through Undoing Racism and Equity is associated with timelier lung cancer surgery and reduction of the racial gap in timely surgery.

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.

Clinical impact of delays in the management of lung cancer patients in the last decade: systematic review

INTRODUCTION

Due to the importance of lung cancer early treatment because of its severity and extent worldwide a systematic literature review was conducted about the impact of delays in waiting times on the disease prognosis.

MATERIALS AND METHODS

We conducted a systematic search of observational studies (2010-2020) including adult patients diagnosed with lung cancer and reporting healthcare timelines and their clinical consequences.

RESULTS

We included 38 articles containing data on waiting times and prognosis; only 31 articles linked this forecast to a specific waiting time. We identified 41 healthcare time intervals and found medians of 6-121 days from diagnosis to treatment and 4-19.5 days from primary care to specialist visit: 37.5% of the intervals indicated better prognosis with longer waiting times.

CONCLUSIONS

All articles emphasized that waiting times must be reduced to achieve good management and prognosis of lung cancer. Further prospective studies are needed on the relationship between waiting times and prognosis of lung cancer.

Percepta Genomic Sequencing Classifier and decision-making in patients with high-risk lung nodules: a decision impact study

BACKGROUND

Incidental and screening-identified lung nodules are common, and a bronchoscopic evaluation is frequently nondiagnostic. The Percepta Genomic Sequencing Classifier (GSC) is a genomic classifier developed in current and former smokers which can be used for further risk stratification in these patients. Percepta GSC has the capability of up-classifying patients with a pre-bronchoscopy risk that is high (> 60%) to "very high risk" with a positive predictive value of 91.5%. This prospective, randomized decision impact survey was designed to test the hypothesis that an up-classification of risk of malignancy from high to very high will increase the rate of referral for surgical or ablative therapy without additional intervening procedures while increasing physician confidence.

METHODS

Data were collected from 37 cases from the Percepta GSC validation cohort in which the pre-bronchoscopy risk of malignancy was high (> 60%), the bronchoscopy was nondiagnostic, and the patient was up-classified to very high risk by Percepta GSC. The cases were randomly presented to U.S pulmonologists in three formats: a pre-post cohort where each case is presented initially without and then with a GSG result, and two independent cohorts where each case is presented either with or without with a GSC result. Physicians were surveyed with respect to subsequent management steps and confidence in that decision.

RESULTS

One hundred and one survey takers provided a total of 1341 evaluations of the 37 patient cases across the three different cohorts. The rate of recommendation for surgical resection was significantly higher in the independent cohort with a GSC result compared to the independent cohort without a GSC result (45% vs. 17%, p < 0.001) In the pre-post cross-over cohort, the rate increased from 17 to 56% (p < 0.001) following the review of the GSC result. A GSC up-classification from high to very high risk of malignancy increased Pulmonologists' confidence in decision-making following a nondiagnostic bronchoscopy.

CONCLUSIONS

Use of the Percepta GSC classifier will allow more patients with early lung cancer to proceed more rapidly to potentially curative therapy while decreasing unnecessary intervening diagnostic procedures following a nondiagnostic bronchoscopy.

[Rapid outpatient diagnostic pathways for lung cancer: Evaluation after one year]

INTRODUCTION

The introduction of coordinated care pathways for lung cancer diagnosis and treatment is a complex process. The purpose of the French Cancer Plan 2014-2019 was to improve referral to treatment waiting times in people with suspected malignancy. The aim of this study was to assess a rapid outpatient diagnostic program for lung cancer established in 2016.

METHOD

This retrospective study was carried out in the Pulmonology Department at Tenon Hospital, Paris, France between May 2016 and May 2017.

RESULTS

During this period, 118 patients (60%) of patients in the pathway were diagnosed with lung cancer. The median waiting time to first consultation (D1) was 4 (2-7) days. The median waiting time between diagnosis and treatment decision (D4) was 4 (0-8) days. The median waiting time to the first treatment (D5) was 10 (4-15) days for chemotherapy and 27 (16-34) days for surgery. The median waiting time between the first abnormal chest X-ray and the first treatment (D6) was 49 days (34-70).

CONCLUSION

Referral to treatment waiting times was consistent with international recommendations. Coordinating nurses improved care pathways in lung cancer patients.

Diagnosis-to-surgery interval and survival for different histologies of stage I-IIA lung cancer

Background

Guidelines on timeliness of lung cancer surgery are inconsistent. Lung cancer histologic subtypes have different prognosis and treatment. It is important to understand the consequences of delayed surgery for each lung cancer histologic subtype. This study aimed to examine the association between diagnosis-to-surgery time interval and survival for early stage lung cancer and selected histologic subtypes.

Methods

Patients diagnosed with stage I–IIA lung cancer between 2004 and 2015 receiving definitive surgery and being followed up until Dec. 31, 2018, were identified from Surveillance, Epidemiology, and End Results database. Histologic subtypes included adenocarcinoma, squamous or epidermoid carcinoma, bronchioloalveolar carcinoma, large cell carcinoma, adenosquamous carcinoma, carcinoid carcinoma, and small cell carcinoma. Diagnosis-to-surgery interval was treated as multi-categorical variables (<1, 1–2, 2–3, and ≥3 months) and binary variables (≥1 vs. <1 month, ≥2 vs. <2 months, and ≥3 vs. <3 months). Outcomes included cancer-specific and overall survival. Covariates included age at diagnosis, sex, race, marital status, tumor size, grade, surgery type, chemotherapy, radiotherapy, and study period. Kaplan-Meier survival curves and Cox proportional hazards regression models were applied to examine the survival differences.

Results

With a median follow-up time of 51 months, a total of 40,612 patients were analyzed, including 40.1% adenocarcinoma and 24.5% squamous or epidermoid carcinoma. The proportion of patients receiving surgery <1, 1–2, 2–3, and ≥3 months from diagnosis were 34.2%, 33.9%, 19.8%, and 12.1%, respectively. Delayed surgery was associated with worse cancer-specific and overall survival for all lung cancers, adenocarcinoma, squamous or epidermoid, bronchioloalveolar, and large cell carcinoma (20–40% increased risk). Dose-dependent effects (longer delay, worse survival) were observed in all lung cancers, adenocarcinoma, and squamous and epidermoid carcinoma. No significant association between surgery delay and survival was observed in adenosquamous, carcinoid, and small cell carcinoma.

Conclusions

Our findings support the guidelines of undertaking surgery within 1 month from diagnosis in patients with stage I–IIA lung cancer. The observed dose-dependent effects emphasize the clinical importance of early surgery. Future studies with larger sample size of less frequent histologic subtypes are warranted to provide more evidence for histology-specific lung cancer treatment guidelines.

Impact of Delays in Lung Cancer Treatment on Survival

Timely care is an important dimension of health care quality, but the impact of delays in care on lung cancer outcomes is unclear. Quantifying the impact of delays in cancer treatment on survival is necessary to inform resource allocation, quality improvement initiatives, and lung cancer guidelines. Review of the available literature demonstrated significant heterogeneity between studies in terms of the impact of delay. Frequently paradoxical results were reported, with delay being associated with improved survival in patients with advanced disease. However, significant methodologic flaws were identified in many studies, which probably is the reason for the paradoxical results. The most significant methodologic limitations identified were incorrectly controlling for final pathologic stage (a mediator in the causal chain from delay to survival), failure to control for confounding by acuity of cancer presentation, and failure to consider effect measure modification. The effect of delay on survival probably varies by stage. The impact of delays is lowest for subcentimeter nodules, probably highest in stage II disease, and low in patients who are only eligible for palliative care. Precise quantification of the impact of delay is not currently possible. Given the available evidence, quality metrics for the timeliness of lung cancer care should focus on local barriers to care. These metrics should be carefully designed to take into account clinical-radiographic stage at initial presentation.

The Impact of Extended Delayed Surgery for Indolent Lung Cancer or Part-solid Ground Glass Nodules

BACKGROUND

During the COVID-19 pandemic, patients with lung cancer may experience treatment delays. The objective of this study was to evaluate the impact of extended treatment delays on survival among patients with stage I typical bronchopulmonary carcinoid (BC), lepidic predominant adenocarcinoma (LPA) or invasive adenocarcinoma with a lepidic component (ADL).

METHODS

Using National Cancer Data Base data (2004-2015), multivariable Cox regression analysis with penalized smoothing splines was performed to examine the association between treatment delay and all-cause mortality for stage I BC, LPA and ADL. Propensity score-matched analyses compared the overall survival in patients who received "early" versus "delayed" surgery (i.e. 0-30 versus 90-120 days following diagnosis) across the different histologic subtypes.

RESULTS

During the study period, patients with stage I BC (n=4,947), LPA (n=5,340) and ADL (n=6,816) underwent surgery. Cox regression analysis of these cohorts showed a gradual steady increase in the hazard ratio the longer treatment is delayed. However, in propensity score-matched analyses which created cohorts of patients who underwent early and delayed surgery that were well-balanced in patient characteristics, no significant differences in 5-year survival were found between early and delayed surgery for stage I BC (87% [95% CI:77-93] vs 89% [95% CI:80-94]), stage I LPA (73% [95% CI:64-80] vs 77% [95% CI:68-83]) and stage I ADL (71% [95% CI:64-76] vs 69% [95% CI:60-76]).

CONCLUSIONS

During the COVID-19 pandemic, for early-stage indolent lung tumors and part-solid ground glass lung nodules, a delay of surgery by 3-4 months following diagnosis can be considered.

Analysis of Delayed Surgical Treatment and Oncologic Outcomes in Clinical Stage I Non-Small Cell Lung Cancer

IMPORTANCE

The association between delayed surgical treatment and oncologic outcomes in patients with non-small cell lung cancer (NSCLC) is poorly understood given that prior studies have used imprecise definitions for the date of cancer diagnosis.

OBJECTIVE

To use a uniform method to quantify surgical treatment delay and to examine its association with several oncologic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted using a novel data set from the Veterans Health Administration (VHA) system. Included patients had clinical stage I NSCLC and were undergoing resection from 2006 to 2016 within the VHA system. Time to surgical treatment (TTS) was defined as the time between preoperative diagnostic computed tomography imaging and surgical treatment. We evaluated the association between TTS and several delay-associated outcomes using restricted cubic spline functions. Data analyses were performed in November 2021.

EXPOSURE

Wait time between cancer diagnosis and surgical treatment (ie, TTS).

MAIN OUTCOMES AND MEASURES

Several delay-associated oncologic outcomes, including pathologic upstaging, resection with positive margins, and recurrence, were assessed. We also assessed overall survival.

RESULTS

Among 9904 patients who underwent surgical treatment for clinical stage I NSCLC, 9539 (96.3%) were men, 4972 individuals (50.5%) were currently smoking, and the mean (SD) age was 67.7 (7.9) years. The mean (SD) TTS was 70.1 (38.6) days. TTS was not associated with increased risk of pathologic upstaging or positive margins. Recurrence was detected in 4158 patients (42.0%) with median (interquartile range) follow-up of 6.15 (2.51-11.51) years. Factors associated with increased risk of recurrence included younger age (hazard ratio [HR] for every 1-year increase in age, 0.992; 95% CI, 0.987-0.997; P = .003), higher Charlson Comorbidity Index score (HR for every 1-unit increase in composite score, 1.055; 95% CI, 1.037-1.073; P < .001), segmentectomy (HR vs lobectomy, 1.352; 95% CI, 1.179-1.551; P < .001) or wedge resection (HR vs lobectomy, 1.282; 95% CI, 1.179-1.394; P < .001), larger tumor size (eg, 31-40 mm vs <10 mm; HR, 1.209; 95% CI, 1.051-1.390; P = .008), higher tumor grade (eg, II vs I; HR, 1.210; 95% CI, 1.085-1.349; P < .001), lower number of lymph nodes examined (eg, ≥10 vs <10; HR, 0.866; 95% CI, 0.803-0.933; P < .001), higher pathologic stage (III vs I; HR, 1.571; 95% CI, 1.351-1.837; P < .001), and longer TTS, with increasing risk after 12 weeks. For each week of surgical delay beyond 12 weeks, the hazard for recurrence increased by 0.4% (HR, 1.004; 95% CI, 1.001-1.006; P = .002). Factors associated with delayed surgical treatment included African American race (odds ratio [OR] vs White race, 1.267; 95% CI, 1.112-1.444; P < .001), higher area deprivation index [ADI] score (OR for every 1 unit increase in ADI score, 1.005; 95% CI, 1.002-1.007; P = .002), lower hospital case load (OR for every 1-unit increase in case load, 0.998; 95% CI, 0.998-0.999; P = .001), and year of diagnosis, with less recent procedures more likely to have delay (OR for each additional year, 0.900; 95% CI, 0.884-0.915; P < .001). Patients with surgical treatment within 12 weeks of diagnosis had significantly better overall survival than those with procedures delayed more than 12 weeks (HR, 1.132; 95% CI, 1.064-1.204; P < .001).

CONCLUSIONS AND RELEVANCE

Using a more precise definition for TTS, this study found that surgical procedures delayed more than 12 weeks were associated with increased risk of recurrence and worse survival. These findings suggest that patients with clinical stage I NSCLC should undergo expeditious treatment within that time frame.

Estimating the Impact of Extended Delay to Surgery for Stage I Non-small-cell Lung Cancer on Survival

OBJECTIVE

The purpose of this study is to evaluate the impact of extended delay to surgery for stage I NSCLC.

SUMMARY OF BACKGROUND DATA

During the COVID-19 pandemic, patients with NSCLC may experience delays in care, and some national guidelines recommend delays in surgery by >3 months for early NSCLC.

METHODS

Using data from the National Lung Screening Trial, a multi-center randomized trial, and the National Cancer Data Base, a multi-institutional oncology registry, the impact of "early" versus "delayed" surgery (surgery received 0-30 vs 90-120 days after diagnosis) for stage I lung adenocarcinoma and squamous cell carcinoma (SCC) was assessed using multivariable Cox regression analysis with penalized smoothing spline functions and propensity score-matched analyses.

RESULTS

In Cox regression analysis of the National Lung Screening Trial (n = 452) and National Cancer Data Base (n = 80,086) cohorts, an increase in the hazard ratio was seen the longer surgery was delayed. In propensity score-matched analysis, no significant differences in survival were found between early and delayed surgery for stage IA1 adenocarcinoma and IA1-IA3 SCC (all P > 0.13). For stage IA2-IB adenocarcinoma and IB SCC, delayed surgery was associated with worse survival (all P < 0.004).

CONCLUSIONS

The mortality risk associated with an extended delay to surgery differs across patient subgroups, and difficult decisions to delay care during the COVID-19 pandemic should take substage and histologic subtype into consideration.

Mortality due to cancer treatment delay: systematic review and meta-analysis

OBJECTIVE

To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Published studies in Medline from 1 January 2000 to 10 April 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models.

RESULTS

The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings.

CONCLUSIONS

Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.

Time to surgery in thoracic cancers and prioritization during COVID-19: a systematic review

Background

Coronavirus disease 2019 (COVID-19) has overwhelmed hospital resources worldwide, requiring widespread cancellation of non-emergency operations, including lung and esophageal cancer operations. In the United States, while hospitals begin to increase surgical volume and tackle the backlog of cases, the specter of a “second wave,” with a potential vaccine months to years away, highlights the ongoing need to triage cases based upon the risk of surgical delay. We synthesize the available literature on time to surgery and its impact on outcomes along with a critical appraisal of the released triage guidelines in the United States.

Methods

We performed a systematic literature review using PubMed according to preferred reporting items for systematic reviews and meta-analyses guidelines evaluating relevant literature from the past 15 years.

Results

Out of 679 screened abstracts, 12 studies investigating time to surgery in lung cancer were included. In stage I–II lung cancer, delayed resection beyond 6 to 8 weeks is consistently associated with lower survival. No identified evidence justifies a 2 cm cutoff for immediate versus delayed surgery. For stage IIIa lung cancer, time to surgery greater than 6 weeks after neoadjuvant therapy is similarly associated with worse survival. For esophageal cancer, 254 abstracts were screened and 23 studies were included. Minimal literature addresses primary esophagectomy, but time to surgery over 8 weeks is associated with lower survival. In the neoadjuvant setting, longer time to surgery is associated with increased pathologic complete response, but also decreased survival. The optimal window for esophagectomy following neoadjuvant therapy is 6 to 8 weeks.

Conclusions

In the setting of the COVID-19 pandemic, timely resection of lung and esophageal cancer should be prioritized whenever possible based upon local resources and disease-burden.

The Use of Bronchoscopy During the Coronavirus Disease 2019 Pandemic: CHEST/AABIP Guideline and Expert Panel Report

BACKGROUND

The coronavirus disease 2019 (COVID-19) has swept the globe and is causing significant morbidity and mortality. Given that the virus is transmitted via droplets, open airway procedures such as bronchoscopy pose a significant risk to health-care workers (HCWs). The goal of this guideline was to examine the current evidence on the role of bronchoscopy during the COVID-19 pandemic and the optimal protection of patients and HCWs.

STUDY DESIGN AND METHODS

A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that addressed specific topics on bronchoscopy related to COVID-19 infection and transmission. MEDLINE (via PubMed) was systematically searched for relevant literature and references were screened for inclusion. Validated evaluation tools were used to assess the quality of studies and to grade the level of evidence to support each recommendation. When evidence did not exist, suggestions were developed based on consensus using the modified Delphi process.

RESULTS

The systematic review and critical analysis of the literature based on six PICO questions resulted in six statements: one evidence-based graded recommendation and 5 ungraded consensus-based statements.

INTERPRETATION

The evidence on the role of bronchoscopy during the COVID-19 pandemic is sparse. To maximize protection of patients and HCWs, bronchoscopy should be used sparingly in the evaluation and management of patients with suspected or confirmed COVID-19 infections. In an area where community transmission of COVID-19 infection is present, bronchoscopy should be deferred for nonurgent indications, and if necessary to perform, HCWs should wear personal protective equipment while performing the procedure even on asymptomatic patients.

Impact of time-to-treatment on overall survival of non-small cell lung cancer patients-an analysis of the national cancer database

Background

The association between time-to-treatment and outcomes for lung cancer has not been conclusively established. In this study, we evaluated the effect of time-to-treatment on the overall 5-year survival of patients with non-small cell lung cancer (NSCLC) with cancer stage at diagnosis.

Methods

We analyzed data in the National Cancer Data Base for adult patients newly diagnosed with NSCLC in 2003–2011 (N=693,554). Extended Cox regression with counting process was used to model the effect of time-to-treatment on survival, adjusted for demographic and clinical factors. Multivariable analyses were performed separately for the groups with different stages at diagnosis. Time-to-treatment was defined as the interval between diagnosis and treatment initiation, with the categories of (I) 0 day, (II) 1 day–4 weeks, (III) 4.1–6.0 weeks, and (IV) >6 weeks (the 1 day–4 weeks group was considered the reference group).

Results

Compared to treatment initiated between 1 day and 4 weeks after diagnosis, time-to-treatment at 4.1–6.0 weeks was associated with a lower risk of death for patients with early-stage cancer [adjusted HR (aHR), 0.84 (95% CI, 0.82–0.85)], with locally advanced cancer [aHR, 0.82 (95% CI, 0.80–0.83)], and with metastatic cancer [aHR, 0.75 (95% CI, 0.74–0.76)]. Similarly, a lower risk of death was associated with time-to-treatment longer than 6 weeks for patients with any cancer stage at diagnosis. However, a subset analysis for early-stage patients who received surgery only showed that extended time-to-surgery was associated a higher risk of death [aHR _{4.1-6.0 weeks}, 1.06 (95% CI, 1.03–1.09); aHR_{>6 weeks} 1.17 (95% CI, 1.14–1.20)].

Conclusions

The findings show that, although time-to-treatment should not be compromised, it is imperative to ensure that patients receive optimal pre-treatment assessments rather than rushing the treatment. Future research should focus on examining clinical characteristics to determine an optimal time-to-treatment to achieve the best possible survival for NSCLC patients.

Delayed surgery after histologic or radiologic-diagnosed clinical stage I lung adenocarcinoma

Background

The impact of delayed surgery on clinical outcomes after histologic or radiologic diagnosis of clinical stage I adenocarcinoma remains controversial. We evaluated the effects of delayed surgery on outcomes of patients with early-stage lung cancer.

Methods

Associations between time intervals of “histologic diagnosis-to-surgery” (HDS), “radiologic diagnosis-to-surgery” (RDS), and overall survival in clinical stage I adenocarcinoma were assessed using multivariable Cox proportional hazard analysis.

Results

A total of 561 consecutive patients with preoperative histologic confirmation of stage I lung cancer between 2006 and 2016 were included. Median time to HDS and RDS were 20 (2–267) and 58 (38–2,983) days. Higher Charlson comorbidity score, receiving brain magnetic resonance imaging screening, and video-assisted thoracoscopic surgery approach were significantly associated with increased risk of late HDS (>21 days). Smaller tumor size and non-radiologic solid-dominant pattern were significantly associated with increased risk of late RDS (>60 days). In the overall cohort, worse 5-year overall survival was associated with late HDS compared to early HDS (75.9% vs. 85.5%, P=0.003). No significant differences were found in later late vs. early RDS (83.7% vs. 83.3%, P=0.570). In 286 propensity-score matched patients, late HDS [adjusted hazard ratio (aHR) =2.031, P=0.038], higher Charlson comorbidity score (aHR=1.610, P=0.023), larger tumor size (aHR=2.164, P=0.031), without brain magnetic resonance imaging screening (aHR=2.051, P=0.045), and tumor with angiolymphatic invasion (aHR=4.638, P=0.001) were significantly associated with lower overall survival.

Conclusions

In patients with stage I lung adenocarcinoma, delayed surgery after a histologic diagnosis is an independent predictor of overall survival after adjusting for clinical risk factors, suggesting meaningful differences in clinical outcomes between timely vs. delayed surgeries.

Diagnostic Yield of the Virtual Bronchoscopic Navigation System Guided Sampling of Peripheral Lung Lesions using Ultrathin Bronchoscope and Protected Bronchial Brush

OBJECTIVES

The use of an ultrathin bronchoscope (UB) to diagnose peripheral pulmonary lesions is described. A virtual bronchoscopic navigation system was used to direct the ultrathin scope to the nodule. One of the constraints of this technique was the inability to confirm the target lesion position during biopsy by using a conventional linear endobronchial ultrasound probe, since the probe does not fit into a 1.2 mm working channel of this bronchoscope. The aim of the study was to review our institutional experience with the use of a UB for sampling peripheral pulmonary lesions using the transbronchial brush guided by virtual bronchoscopy. We describe a technique wherein we attempt to brush all the visible bronchial sub-segments once the bronchoscope has reached close to the nodule.

MATERIALS AND METHODS

In total, 52 patients underwent the procedure between 2010 and 2017. A multiplanar computed tomography (CT) scan of the chest was obtained and subsequently uploaded to the Lung Point Virtual bronchoscopy navigation software. The UB was parked close to the lesion. All visible airway branches were then brushed using a protected bronchial brush. The data were retrospectively abstracted from the electronic medical records using standardized forms.

RESULTS

A total of 52 lesions (40 solid, 8 part-solid, 3 cavitary, and 1 ground-glass) were sampled using a transbronchial brush (median, 2; range, 1-8). Twenty-four lesions were under 2 cm in size. The overall success rates were 67.3%. The average diameter of nodules was 2.7±1.01 cm; 65% lesions were in the outer-third of the lungs. The cancer-specific sensitivity was 72.5%. The presence of bronchus sign; location of the lesion; and the characteristics, size, and stage of cancer did not have any impact on the diagnostic yield.

CONCLUSION

Virtual bronchoscopy-guided ultrathin bronchoscopy with bronchial brushing is safe and has a diagnostic yield comparable to other described techniques for evaluating peripheral pulmonary nodules.

Up-regulation of long noncoding RNA uc.338 predicts poor survival in non-small cell lung cancer

BACKGROUND

Long noncoding RNA ultraconserved element 338 (uc.338) is a long non-coding RNA reported to function as a promoter in non-small cell lung cancer (NSCLC). However, the function and potential mechanism of uc.338 in NSCLC is still unclear.

OBJECTIVE

The aim of the present study was to assess the effect of uc.338 on the prognosis of patients with NSCLC.

METHODS

The expression levels of uc.338 in NSCLC tissues and matched normal lung tissues were examined by real-time quantitative PCR. Then the association between uc.338 levels with clinical variables as well as survival time was investigated.

RESULTS

We found that uc.338 expression levels were significantly upregulated in NSCLC compared with the matched noncancerous lung tissues (P< 0.01). In addition, increased uc.338 expression was significantly associated with TNM stage (P< 0.003), lymph node metastasis (P< 0.006) and distant metastasis (P< 0.002). More importantly, Kaplan-Meier survival analysis demonstrated that higher uc.338 expression levels were associated with a shorter overall survival (P< 0.0016) and disease-free survival (p< 0.0001) in NSCLC patients. Finally, univariate and multivariate Cox regression analyses revealed that uc.338 was an independent risk factor for overall survival and disease-free survival.

CONCLUSIONS

Our results show that uc.338 may play an important role in tumorigenesis and progression and could serve as a potential independent prognostic biomarker for patients with NSCLC.

The Population Burden of Cancer: Research Driven by the Catchment Area of a Cancer Center

Cancer centers, particularly those supported by the National Cancer Institute, are charged with reducing the cancer burden in their catchment area. However, methods to define both the catchment area and the cancer burden are diverse and range in complexity often based on data availability, staff resources, or confusion about what is required. This article presents a review of the current literature identifying 4 studies that have defined various aspects of the cancer burden in a defined geographical area and highlights examples of how some cancer centers and other health institutions have defined their catchment area and characterized the cancer burden within it. We then present a detailed case study of an approach applied by the University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center to define its catchment area and its population cancer burden. We cite examples of how the Cancer Center research portfolio addresses the defined cancer burden. Our case study outlines a systematic approach to using publicly available data, such as cancer registry data, that are accessible by all cancer centers. By identifying gaps and formulating future research directions based on the needs of the population within the catchment area, epidemiologic studies and other types of cancer research can be directed to the population served. This review can help guide cancer centers in developing an approach to defining their own catchment area as mandated and applying research findings to this defined population.

Impact of Timing of Lobectomy on Survival for Clinical Stage IA Lung Squamous Cell Carcinoma

BACKGROUND

Because the relationship between the timing of surgery following diagnosis of lung cancer and survival has not been precisely described, guidelines on what constitutes a clinically meaningful delay of resection of early-stage lung cancer do not exist. This study tested the hypothesis that increasing the time between diagnosis and lobectomy for stage IA squamous cell carcinoma (SCC) would be associated with worse survival.

METHODS

The association between timing of lobectomy and survival for patients with clinical stage IA SCC in the National Cancer Data Base (2006-2011) was assessed using multivariable Cox proportional hazards analysis and restricted cubic spline (RCS) functions.

RESULTS

The 5-year overall survival of 4,984 patients who met study inclusion criteria was 58.3% (95% CI, 56.3-60.2). Surgery was performed within 30 days of diagnosis in 1,811 (36%) patients, whereas the median time to surgery was 38 days (interquartile range, 23, 58). In multivariable analysis, patients who had surgery 38 days or more after diagnosis had significantly worse 5-year survival than patients who had surgery earlier (hazard ratio, 1.13 [95% CI, 1.02-1.25]; P = .022). Multivariable RCS analysis demonstrated the hazard ratio associated with time to surgery increased steadily the longer resection was delayed; the threshold time associated with statistically significant worse survival was ∼90 days or greater.

CONCLUSIONS

Longer intervals between diagnosis of early-stage lung SCC and surgery are associated with worse survival. Although factors other than the timing of treatment may contribute to this finding, these results suggest that efforts to minimize delays beyond those needed to perform a complete preoperative evaluation may improve survival.

Value of neutrophil-to-lymphocyte ratio for predicting lung cancer prognosis: A meta-analysis of 7,219 patients

Current evidence suggests that the neutrophil-to-lymphocyte ratio (NLR) may be a biomarker for poor prognosis in lung cancer, although this association remains controversial. Therefore, a meta-analysis was performed to evaluate the association between NLR and lung cancer outcome. A systematic literature search was performed through the PubMed, Embase and Cochrane Library databases (until July 30, 2016), to identify studies evaluating the association between NLR and overall survival (OS) and/or progression-free survival (PFS) among patients with lung cancer. Based on the results of this search, data from 18 studies involving 7,219 patients with lung cancer were evaluated. The pooled hazard ratio (HR) suggested that elevated pretreatment NLR predicted poor OS [HR=1.46, 95% confidence interval (CI): 1.30-1.64] and poor PFS (HR=1.42, 95% CI: 1.15-1.75) among patients with lung cancer. Subgroup analysis revealed that the prognostic value of NLR for predicting poor OS increased among patients who underwent surgery (HR=1.50, 95% CI: 1.21-1.84) or patients with early-stage disease (HR=1.64, 95% CI: 1.37-1.97). An NLR cut-off value of ≥4 significantly predicted poor OS (HR=1.56, 95% CI: 1.31-1.85) and PFS (HR=1.54, 95% CI: 1.13-1.82), particularly in the cases of small-cell lung cancer. Thus, the results of the present meta-analysis suggested that an elevated pretreatment NLR (e.g., ≥4) may be considered as a biomarker for poor prognosis in patients with lung cancer.

Timeliness of Treatment Initiation and Associated Survival Following Diagnosis of Non-Small-Cell Lung Cancer in South Carolina

OBJECTIVES

Non-small-cell lung cancer (NSCLC) patient survival depends on a number of factors, including early diagnosis and initiation of treatment. Standard treatment options for patients with NSCLC include surgery, radiation therapy, and chemotherapy. The objective of this study was to evaluate the impact that the initiation of timely treatment has on patient survival among a cohort of privately insured patients with NSCLC in South Carolina.

METHODS

Data for the study were retrospectively obtained from the South Carolina Central Cancer Registry and the state health plan Blue Cross and Blue Shield claims. Patients were diagnosed as having NSCLC between January 1, 2005 and December 31, 2010, were aged 18 years or older, and were covered under the state health plan for at least 1 year before diagnosis. The final study sample included 746 patients. Kaplan-Meier curves and Cox proportional hazard modeling were conducted to examine factors associated with survival, stratified by stage at diagnosis.

RESULTS

The majority in the study cohort (80%) received timely (≤6 weeks) rather than untimely (>6 weeks) care (20%). The mean survival time for patients receiving timely treatment by stage was 36.9, 27.1, and 12.4 months for localized, regional, and distant metastasis, respectively. The mean survival time for patients receiving untimely care by stage was 39.4, 33.8, and 25.2 months for localized, regional, and distant metastasis, respectively. Among patients with NSCLC in the distant metastasis stage, those receiving timely treatment experienced significantly decreased survival (hazard ratio 2.2) in comparison to those receiving untimely care.

CONCLUSIONS

Initiation of treatment within 6 weeks is not associated with greater survival time across all stages of cancer (localized, regional, and distant metastasis). Additional research is needed to examine the impact of other treatment quality metrics on the survival of patients with NSCLC, different time thresholds for treatment initiation that may be more meaningful to survival among patients with NSCLC, and timely care among patients with NSCLC in other geographic areas and populations.

Navigation bronchoscopy for diagnosis and small nodule location

Lung cancer continues to be the most common cause of cancer death. Screening programs for high risk patients with the use of low-dose computed tomography (CT) has led to the identification of small lung lesions that were difficult to identify using previous imaging modalities. Electromagnetic navigational bronchoscopy (ENB) is a novel technique that has shown to be of great utility during the evaluation of small, peripheral lesions, that would otherwise be challenging to evaluate with conventional bronchoscopy. The diagnostic yield of navigational bronchoscopy however is highly variable, with reports ranging from 59% to 94%. This variability suggests that well-defined selection criteria and standardized protocols for the use of ENB are lacking. Despite this variability, we believe that this technique is a useful tool evaluating small peripheral lung lesions when patients are properly selected.

Quality Measures in Clinical Stage I Non-Small Cell Lung Cancer: Improved Performance Is Associated With Improved Survival

BACKGROUND

National organizations have recommended quality measures for operations in early-stage non-small cell lung cancer (NSCLC). The outcomes of adherence to these guidelines are unknown.

METHODS

Information about patients who underwent an operation for clinical stage I NSCLC was abstracted from the National Cancer Database. After reviewing current guidelines, the following quality measures were selected: anatomic resection, operation within 8 weeks of diagnosis, achievement of negative surgical margins, and sampling of 10 or more lymph nodes. Multivariate models identified variables independently associated with receiving quality measures and a Cox model created to evaluate overall survival.

RESULTS

Between 2004 and 2013, 133,026 of 133,366 (99.7%), 126,598 of 133,366 (94.9%), 91,472 of 133,366 (68.6%), and 30,041 of 133,366 (22.5%) patients met one, two, three, or four measures. Income of at least $38,000/year (odds ratio [OR] 1.20, 95% CI: 1.15 to 1.24), insurance type (private insurance: OR 1.22, 95% CI: 1.09 to 1.36; Medicare: OR 1.16, 95% CI:1.04 to 1.30), centers with at least 38 cases/year (OR 1.18, 95% CI: 1.14 to 1.22), academic institutions (OR 1.31, 95% CI: 1.27 to 1.35), and clinical stage IB patients (OR 1.50, 95% CI: 1.40 to 1.60) were more likely to meet all four measures; whereas increasing age (OR 0.99, 95% CI: 0.99 to 0.99), women (OR 0.93, 95% CI: 0.91 to 0.96), non-Caucasian race (OR 0.83, 95% CI: 0.79 to 0.87), and increasing Charlson/Deyo comorbidity score (1: OR 0.90, 95% CI: 0.87 to 0.93; ≥2: OR 0.82, 95% CI: 0.79 to 0.86) were associated with lower likelihood. Pathologic upstaging (hazard ratio [HR] 1.84, 95% CI: 1.78 to 1.89) and meeting all four measures (HR 0.39, 95% CI: 0.31 to 0.48) were most powerfully associated with overall survival.

CONCLUSIONS

National adherence to quality measures in stage I NSCLC resection is suboptimal. Guideline compliance is strongly associated with survival, and vigorous efforts should be instituted by national societies to improve adherence.

Early lung cancer detection, mucosal, and alveolar imaging

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer deaths worldwide. Early detection is essential for long-term survival. Screening of high-risk individuals with low-dose computed tomography screening has proven to increase survival. However, current radiological imaging techniques have poor specificity for lung cancer detection and poor sensitivity for detection of mucosal or alveolar preinvasive malignant lesions. Bronchoscopy allows imaging and sampling of early lung cancer, with the highest safety profile and high diagnostic accuracy.

RECENT FINDINGS

Available technologies, such as autofluorescence bronchoscopy, narrow band imaging, and radial ultrasound bronchoscopy can significantly increase the yield and diagnostic accuracy of bronchoscopy for early cancer detection in the central airways. Newer technologies such as optical coherence tomography, confocal bronchoscopy, and Raman spectroscopy may significantly increase the diagnostic yield of both central and parenchymal early cancer lesions.

SUMMARY

Although some of these technologies are still investigational and are not readily available in most centers, they may identify early mucosal and alveolar cancer lesions accurately in the least invasive manner to provide appropriate therapy and prolong patient survival from lung cancer.

Effects of Delayed Surgical Resection on Short-Term and Long-Term Outcomes in Clinical Stage I Non-Small Cell Lung Cancer

BACKGROUND

Conflicting evidence currently exists regarding the causes and effects of delay of care in non-small cell lung cancer (NSCLC). We hypothesized that delayed surgery in early-stage NSCLC is associated with worse short-term and long-term outcomes.

METHODS

Treatment data of clinical stage I NSCLC patients undergoing surgical resection were obtained from the National Cancer Data Base (NCDB). Treatment delay was defined as resection 8 weeks or more after diagnosis. Propensity score matching for patient and tumor characteristics was performed to create comparable groups of patients receiving early (less than 8 weeks from diagnosis) and delayed surgery. Multivariable regression models were fitted to evaluate variables influencing delay of surgery.

RESULTS

From 1998 to 2010, 39,995 patients with clinical stage I NSCLC received early surgery, while 15,658 patients received delayed surgery. Of these, 27,022 propensity-matched patients were identified. Those with a delay in care were more likely to be pathologically upstaged (18.3% stage 2 or higher versus 16.6%, p < 0.001), have an increased 30-day mortality (2.9% vs 2.4%, p = 0.01), and have decreased median survival (57.7 ± 1.0 months versus 69.2 ± 1.3 months, p < 0.001). Delay in surgery was associated with increasing age, non-white race, treatment at an academic center, urban location, income less than $35,000, and increasing Charlson comorbidity score (p < 0.0001 for all). Delayed patients were more likely to receive a sublobar resection (17.2% vs 13.1%, p < 0.001).

CONCLUSIONS

Patients receiving delayed resection for clinical stage I NSCLC have higher comorbidity scores that may affect ability to perform lobectomy and result in higher perioperative mortality. However, delay in resection is independently associated with increased rates of upstaging and decreased median survival. Strategies to minimize delay while medically optimizing higher risk patients are needed.

Rule discovery and distance separation to detect reliable miRNA biomarkers for the diagnosis of lung squamous cell carcinoma

Background

Altered expression profiles of microRNAs (miRNAs) are linked to many diseases including lung cancer. miRNA expression profiling is reproducible and miRNAs are very stable. These characteristics of miRNAs make them ideal biomarker candidates.

Method

This work is aimed to detect 2-and 3-miRNA groups, together with specific expression ranges of these miRNAs, to form simple linear discriminant rules for biomarker identification and biological interpretation. Our method is based on a novel committee of decision trees to derive 2-and 3-miRNA 100%-frequency rules. This method is applied to a data set of lung miRNA expression profiles of 61 squamous cell carcinoma (SCC) samples and 10 normal tissue samples. A distance separation technique is used to select the most reliable rules which are then evaluated on a large independent data set.

Results

We obtained four 2-miRNA and three 3-miRNA top-ranked rules. One important rule is that: If the expression level of miR-98 is above 7.356 and the expression level of miR-205 is below 9.601 (log2 quantile normalized MirVan miRNA Bioarray signals), then the sample is normal rather than cancerous with specificity and sensitivity both 100%. The classification performance of our best miRNA rules remarkably outperformed that by randomly selected miRNA rules. Our data analysis also showed that miR-98 and miR-205 have two common predicted target genes FZD3 and RPS6KA3, which are actually genes associated with carcinoma according to the Online Mendelian Inheritance in Man (OMIM) database. We also found that most of the chromosomal loci of these miRNAs have a high frequency of genomic alteration in lung cancer. On the independent data set (with balanced controls), the three miRNAs miR-126, miR-205 and miR-182 from our best rule can separate the two classes of samples at the accuracy of 84.49%, sensitivity of 91.40% and specificity of 77.14%.

Conclusion

Our results indicate that rule discovery followed by distance separation is a powerful computational method to identify reliable miRNA biomarkers. The visualization of the rules and the clear separation between the normal and cancer samples by our rules will help biology experts for their analysis and biological interpretation.