Smoking Status as a Prognostic Factor in Patients with Stage I Pulmonary Adenocarcinoma

Alterations of Ceramides, Acylcarnitines, GlyceroLPLs, and Amines in NSCLC Tissues

Abnormal lipid metabolism plays an important role in cancer development. In this study, nontargeted lipidomic study on 230 tissue specimens from 79 nonsmall cell lung cancer (NSCLC) patients was conducted using ultraperformance liquid chromatography-high-resolution mass spectrometry (UPLC-HRMS). Downregulation of sphingosine and medium-long-chain ceramides and short-medium-chain acylcarnitine, upregulation of long-chain acylcarnitine C20:0, and enhanced histamine methylation were revealed in NSCLC tissues. Compared with paired noncancerous tissues, adenocarcinoma (AC) tissues had significantly decreased levels of sphingosine, medium-long-chain ceramides (Cer d18:1/12:0 and Cer d16:1/14:0, Cer d18:0/16:0, Cer d18:1/16:0, Cer d18:2/16:0, Cer d18:2/18:0), short-medium-chain (C2-C16) acylcarnitines, LPC 20:0 and LPC 22:1, and significantly increased levels of the long-chain acylcarnitine C20:0, LPC 16:0, LPC P-16:0, LPC 20:1, LPC 20:2, glyceroPC, LPE 16:0, and LPE 18:2. In squamous cell carcinoma (SCC) tissues, sphingosine, Cer d18:2/16:0 and Cer d18:2/18:0, and short-medium-chain acylcarnitines had significantly lower levels, while long-chain acylcarnitines (C20:0, and C22:0 or C22:0 M), LPC 20:1, LPC 20:2, and N1,N12-diacetylspermine had significantly higher levels compared to controls. In AC and SCC tissues, the levels of LPG 18:0, LPG 18:1, and LPS 18:1 were significantly decreased, while the levels of ceramide-1-phosphate (C1P) d18:0/3:0 or LPE P-16:0, N1-acetylspermidine, and 1-methylhistamine were significantly increased than controls. Furthermore, an orthogonal partial least-squares-discriminant analysis (OPLS-DA) model based on a 4-lipid panel was established, showing good discrimination ability between cancerous and noncancerous tissues.

Non-Small Cell Lung Cancer Detection and Subtyping by UPLC-HRMS-Based Tissue Metabolomics

Non-small cell lung cancer (NSCLC) is the prevalent histological subtype of lung cancer. In this study, we performed ultraperformance liquid chromatography-high-resolution mass spectrometry (UPLC-HRMS)-based metabolic profiling of 227 tissue samples from 79 lung cancer patients with adenocarcinoma (AC) or squamous cell carcinoma (SCC). Orthogonal partial least squares-discriminant analysis (oPLS-DA) analyses showed that AC, SCC, and NSCLC tumors were discriminated from adjacent noncancerous tissue (ANT) and distant noncancerous tissue (DNT) samples with good accuracies (91.3, 100, and 88.3%), sensitivities (85.7, 100, and 83.9%), and specificities (94.3, 100, and 90.7%), using 12, 4, and 7 discriminant metabolites, respectively. The discriminant panel for AC detection included valine, sphingosine, glutamic acid γ-methyl ester, and lysophosphatidylcholine (LPC) (16:0), levels of which in tumor tissues were significantly altered. Valine, sphingosine, LPC (18:1), and leucine derivatives were used for SCC detection. The discrimination between AC and SCC had 96.8% accuracy, 98.2% sensitivity, and 85.7% specificity using a five-metabolite panel, of which valine and creatine had significant differences. The classification models were further verified with external validation sets, showing a promising prospect for NSCLC tissue detection and subtyping.

Mutational signatures in squamous cell carcinoma of the lung

Background

Tumor mutational burden (TMB) has been identified as one of the predictors for the response to anti-programmed cell death-1 (anti-PD-1) antibody therapy and reported to correlate with smoking history in lung adenocarcinoma. However, in squamous cell carcinoma of the lung, the association between TMB and clinicopathological background factors, such as smoking history, has not been reported, including in our previous study. The mutational signature is a tool to identify the mutagens that are contributing to the mutational spectrum of a tumor by investigating the pattern of DNA changes. Here, we analyzed the mutational signature in lung squamous cell carcinoma to identify mutagens affecting the TMB.

Methods

Seven representative mutational signatures including signature 7 (SI7) [ultraviolet (UV)-related], SI4 (smoking), SI6/15 [mismatch repair (MMR)], SI2/13 [apolipoprotein B mRNA editing enzyme, catalytic polypeptide-like (APOBEC)], and SI5 (clock-like) were analyzed in Japanese patients with lung squamous cell carcinoma (n=67) using data generated by next-generation sequencing consisting of a 415-gene panel. The relationships between signatures and clinico-pathological data including TMB and programmed death-ligand 1 (PD-L1) expression were analyzed.

Results

Although the reconstructed mutational counts were small with targeted sequencing (median: 30.1, range: 13.3–98.7), the distributions of signatures were comparable among samples, with 56 cases containing more than four signatures. The smoking-related SI4 was found in 45 cases and was significantly related with pack-year index (PYI) (P=0.026). The reconstructed mutation counts were highly correlated with SI4 (r=0.51, P<0.0001), whereas the correlation was weak with SI6/15 (MMR-related) and SI2/13 (APOBEC-related). There was no mutational signature related with PD-L1 expression. Some patients exhibited unique signatures; the patient with the highest mutational counts had a MMR signature, and another patient with a prominent UV signature had occupational exposure to UV, as he was employed as a neon sign engineer.

Conclusions

Mutational signatures can predict the cause of lung squamous cell carcinoma. Tobacco smoking is the mutagen most related with TMB.

Advanced pneumonic type of lung adenocarcinoma: survival predictors and treatment efficacy of the tumor

PURPOSE

To retrospectively explore the survival predictors and treatment efficacy of advanced pneumonic-type lung adenocarcinoma (P-ADC).

METHODS

Retrospective analysis of clinical data and survival follow-up was undertaken on 41 patients with advanced P-ADC from January 1, 2009, to April 30, 2019. Analysis on tumor biomarkers such as carcinoembryonic antigen (CEA), neuron-specific enolase (NSE), and the cytokeratin-19-fragment (Cyfra21-1) were undertaken. The patients in this study were divided into three groups based on usage of tyrosine kinase inhibitor (TKI): TKI therapy group (including combination with chemotherapy), non-TKI therapy group (chemotherapy alone), and palliative care group.

RESULTS

More than half of the patients had higher levels of tumor biomarkers and the incidence of NSE was highest (81.8%), followed by CEA (74.4%) and Cyfra21-1 (74.1%). All patients had abnormal findings on chest computed tomography and with adenocarcinoma pathology. The overall survival (OS) time was 10.4 months in TKI group, 8.8 months in the non-TKI group, and 2.1 months in the palliative care group. Patients with higher level of serum Cyfra21-1 had insignificantly shorter survival time compared to those with normal Cyfra21-1 (p = 0.067). TKI therapy and non-TKI therapy provided a better prognosis prediction compared to palliative care. TKI therapy improved prognosis compared to non-TKI therapy. The comprehensive based TKI therapy provided improved OS vs the non-TKI therapy.

CONCLUSION

TKI-based therapy could improve the prognosis and OS for advanced P-ADC. This study recommends the analysis of EGFR mutations for all patients with advanced P-ADC.

Cost-effectiveness of a low-dose computed tomography screening programme for lung cancer in New Zealand

OBJECTIVES

The cost-effectiveness of low-dose computed tomography (LDCT) screening for lung cancer is uncertain. This study estimated the health gains, costs (net health system, and including 'unrelated') and cost-effectiveness of biennial LDCT screening among 55-74 years olds with a smoking history of at least 30 pack years, and (if a former smoker) having quit within last 15 years, in New Zealand.

METHODS

We used a macrosimulation stage shift model with New Zealand-specific lung cancer incidence rates and intervention parameters from the National Lung Screening Trial, a health system perspective, and a lifetime horizon for quality-adjusted life-years (QALYs) and costs discounted at 3% per annum. We also examined heterogeneity by gender, ethnicity (Māori (indigenous population) versus non-Māori), age and smoking status.

RESULTS AND CONCLUSION

We estimated 0.067 QALYs gained (95 % uncertainty interval (UI) 0.044 to 0.095) per eligible participant, at a cost of US$2843 ($2067-3797; 2011 $US). The overall incremental cost effectiveness ratio (ICER) was US$44,000 per QALY gained (95 % UI US$27,000 to US$70,000). The ICER was substantially lower for Māori, at US$26,000 per QALY gained (95 % UI US$17,000 to US$39,000). The cost-effectiveness varied by socio-demographics, from US$21,000 for 70-74 year old Māori females to US$60,000 for 55-59 year old non-Māori males. The two scenarios that lowered the ICER the most were halving the screening costs (ICER = US$33,000 per QALY), and improving the sensitivity (from 93.8% to 98%) and specificity (from 73.4% to 95%) of the screening test (ICER = US$23,000 per QALY). Based on a threshold of GDP per capita per QALY gained (i.e. US$30,000), LDCT screening for lung cancer is unlikely to be cost-effective in New Zealand for the proposed target population under our modelling assumptions. However, it is likely to be cost-effective for Māori, a population group which carries a disproportionately high disease burden from lung cancer.

Use of a prognostic risk score that aggregates the FDG-PET/CT SUVmax, tumor size, and histologic group for predicting the prognosis of pStage I lung adenocarcinoma

BACKGROUND

pStage I includes clinicopathologically diverse groups. This study aimed to identify the prognostic factors for pStage I lung adenocarcinoma.

METHODS

We retrospectively reviewed 208 patients with pStage I adenocarcinomas who underwent curative resection in our institute between 2006 and 2013. The maximum standardized uptake value (SUVmax) on [F18]-fluoro-deoxy-D-glucose positron emission tomography-computed tomography (PET/CT) was evaluated. Adenocarcinomas were categorized into the following histologic groups: group 0 (minimally invasive adenocarcinoma and lepidic predominant adenocarcinoma), group 1 (papillary predominant adenocarcinoma), and group 2 (acinar predominant adenocarcinoma and all the remaining subtypes). We assessed the relationship between disease-free survival (DFS) and clinicopathological factors.

RESULTS

Multivariate analysis of DFS demonstrated that SUVmax > 3.0 (p < 0.001), total tumor size > 20 mm (p = 0.016), and histologic groups (p < 0.05) were independent prognostic factors. The prognostic risk score (PRS) was calculated using the following equation: PRS = SUVmax (≤ 3.0: 0 point, > 3.0: 2 points) + total tumor size (≤ 20 mm: 0 point, > 20 mm: 1 point) + histologic group (group 0: 0 point, group 1: 1 point, group 2: 2 points). Patients were divided into the following three risk groups: low-risk (PRS 0-2 points, n = 136), intermediate-risk (PRS 3-4 points, n = 49), and high-risk groups (PRS 5 points, n = 13). The 5-year DFS rates were 93.2%, 50.6%, and 30.8% for the low-, intermediate-, and high-risk groups, respectively (p < 0.001).

CONCLUSIONS

The PRS aggregating the FDG-PET/CT SUVmax, total tumor size, and histologic group predicts the prognosis of pStage I lung adenocarcinoma.

Clinical characteristics and prognosis of nonsurgically treated patients with pneumonic-type adenocarcinoma

Pneumonic-type adenocarcinoma (P-ADC) is a subtype of lung adenocarcinoma with high mortality, which often requires lobectomy surgery. Nonsurgically treated P-ADC patients usually have more advanced or complex conditions, which remain poorly understood and pose a major challenge in clinical management. We aimed to describe the clinical profiles and prognosis of non-surgically treated P-ADC patients. We enrolled 71 patients with pathologically proven P-ADC from a university hospital in China. Clinical and laboratory data were retrieved from medical record. Their median age was 62 years, including 45% men and 35% smokers. Clinical manifestations were dominated by cough, sputum, and dyspnea. Main chest imaging features included nodules, shadow, consolidation, and air bronchogram. Nearly half or more of patients showed higher levels of inflammation and cancer biomarkers including cytokeratin-19-fragment (CYFRA 21-1) and carcinoembryonic antigen (CEA). Majority of patients were classified at the stage IIIB or IV. Palliative care was the most popular treatment option but provided a shorter overall survival compared to tyrosine kinase inhibitor therapy, standard chemotherapy, and sequential therapy while there were no significant differences in the survival among the latter 3 options. Higher serum CEA was associated with longer survival and better prognosis while higher serum CYFRA 21-1 could predict a poor prognosis. Detailed understanding the clinical characteristics and prognostic factors in nonsurgically treated P-ADC may allow the identification of patients with particular risk factors and initiation of early and specific treatment in order to optimize outcomes.

Cost-effectiveness of a low-dose computed tomography screening programme for lung cancer in New Zealand

OBJECTIVES

The cost-effectiveness of low-dose computed tomography (LDCT) screening for lung cancer is uncertain. This study estimated the health gains, costs (net health system, and including 'unrelated') and cost-effectiveness of biennial LDCT screening among 55-74 years olds with a smoking history of at least 30 pack years, and (if a former smoker) having quit within last 15 years, in New Zealand.

METHODS

We used a macrosimulation stage shift model with New Zealand-specific lung cancer incidence rates and intervention parameters from the National Lung Screening Trial, a health system perspective, and a lifetime horizon for quality-adjusted life-years (QALYs) and costs discounted at 3% per annum. We also examined heterogeneity by gender, ethnicity (Māori (indigenous population) versus non-Māori), age and current versus ex-smoking status.

RESULTS AND CONCLUSION

We estimated 0.037 QALYs gained (95% uncertainty interval (UI) 0.024-0.053) per eligible participant, at a cost of US$3606 ($2689-4681). The overall incremental cost effectiveness ratio (ICER) was US$104,000 per QALY gained (95% UI US$59,000-US$175,000). The cost-effectiveness varied moderately by socio-demographics, with the 'best' ICER being US$52,000 for 70-74 year old Māori females and the 'worst' ICER being US$142,000 for 55-59 year old non-Māori females. The ICER varied little by current smoking status, due to higher competing mortality risk limiting QALY gains for current smokers. The two scenarios that lowered the ICER the most were increasing the screening uptake to 100% (ICER = US$50,000 per QALY), and improving the sensitivity (from 93.8%-98%) and specificity (from 73.4%-95%) of the screening test (ICER = US$42,000 per QALY). Based on a threshold of GDP per capita per QALY gained (i.e. US$30,000), LDCT screening for lung cancer is unlikely to be cost-effective in New Zealand for any sociodemographic group.

Lung cancer in never smokers from the Princess Margaret Cancer Centre

Introduction

Lung cancer in never smokers represents a distinct epidemiological, clinical, and molecular entity.

Results

Most 712 never smoking lung cancer patients were female (72%) with a median age at diagnosis of 62.2 years (18–94). Caucasians (46%), East Asians (42%), adenocarcinoma histology (87%) and presentation with metastatic disease at diagnosis (59%) were common. Of 515 patients with available archival tissue, the most common identified single mutations were EGFR (52.2%), followed by ALK (7.5%), KRAS (2.3%), TP53 (1.3%), ERBB2 (1%), BRAF (0.4%), PIK3CA (0.4%), SMAD4 (0.4%), CTNNB1 (0.2%), AKT1 (0.2%), and NRAS (0.2%); 8% tumors had multiple mutations, while 25.8% had none identified. Median overall survival (mOS) was 42.2 months (mo) for the entire cohort. Patients with mutations in their tumors had significantly better mOS (69.5 mo) when compared to those without (31.0 mo) (HR = 0.59; 95% CI: 0.44–0.79; p < 0.001). Earlier stage (p < 0.001), adenocarcinoma histology (p = 0.012), good performance status (p < 0.001) and use of targeted therapy (p < 0.001) were each independently associated with longer survival. Patients with ALK-translocation-positive tumours have significantly longer OS compared to those without any mutations (p = 0.0029) and to those with other and null mutations (p = 0.022).

Conclusions

Lung cancer in never smokers represents a distinct clinical and molecular entity characterized by a high incidence of targetable mutations and long survival.

Methods

We analyzed retrospectively the data from electronic patient records of never smokers diagnosed with lung cancer treated at the Princess Margaret Cancer Centre (Toronto) between 1988–2015 to characterize demographic and clinical features, pathology, molecular profile (using hotspot or targeted sequencing panels), treatment and survival.

Prognostic Effect of Age on Survival of Patients with Stage I Adenocarcinoma of the Lung

Aims and Background

It is still unclear whether age is an independent prognostic factor in patients with stage I NSCLC.

Methods

Five hundred and sixty-nine patients with stage I adenocarinoma who underwent surgical resection as first treatment were included. The effect on overall survival of age, gender, smoking habits, Charlson comorbidity index score (CCIS), type of surgery, tumor size and lymphatic or blood vessel invasion was analyzed.

Results

When the patients were divided into four groups according to quartiles of age, distributions of gender, smoking habit, CCIS, histology, blood vessel invasion and adjuvant chemotherapy were significantly different among the four groups. Age, gender, smoking habit, CCIS, tumor size and lymphatic and blood vessel invasion were significantly associated with overall survival of the patients in Kaplan-Meier analysis (logrank, P <0.001, P <0.001, P = 0.029, P <0.001, P = 0.001, P = 0.001 and P = 0.007, respectively). Moreover, the highest quartile of age (over 68 years old) was a prominent determinant for a worse prognosis after adjustment for the confounding variables using a Cox proportional hazard model (adjusted hazard ratio = 2.735, 95% confidence interval = 1.623–4.608, P <0.001).

Conclusions

The findings suggest that age is an important determinant of overall survival in patients with stage I adenocarcinoma. Therefore, age should be considered in classifying the patients into groups of higher or lower risk for death as well as in designing clinical trials.

Impact of Concurrent Genomic Alterations Detected by Comprehensive Genomic Sequencing on Clinical Outcomes in East-Asian Patients with EGFR-Mutated Lung Adenocarcinoma

Next-generation sequencing (NGS) has enabled comprehensive detection of genomic alterations in lung cancer. Ethnic differences may play a critical role in the efficacy of targeted therapies. The aim of this study was to identify and compare genomic alterations of lung adenocarcinoma between Japanese patients and the Cancer Genome Atlas (TCGA), which majority of patients are from the US. We also aimed to examine prognostic impact of additional genomic alterations in patients harboring EGFR mutations. Genomic alterations were determined in Japanese patients with lung adenocarcinoma (N = 100) using NGS-based sequencing of 415 known cancer genes, and correlated with clinical outcome. EGFR active mutations, i.e., those involving exon 19 deletion or an L858R point mutation, were seen in 43% of patients. Some differences in driver gene mutation prevalence were observed between the Japanese cohort described in the present study and the TCGA. Japanese cohort had significantly more genomic alterations in cell cycle pathway, i.e., CDKN2B and RB1 than TCGA. Concurrent mutations, in genes such as CDKN2B or RB1, were associated with worse clinical outcome in patients with EGFR active mutations. Our data support the utility of comprehensive sequencing to detect concurrent genomic variations that may affect clinical outcomes in this disease.

Development and validation of a preoperative prognostic index independent of TNM stage in resected non-small cell lung cancer

BACKGROUND

Previously reported prognostic tools for patients with resected non-small cell lung cancer (NSCLC) include factors found postoperatively, but not preoperatively. However, it would be important to predict patient prognosis before NSCLC resection. To suggest a novel preoperative prognostic tool, we evaluated the relationship of preoperative prognostic factors with the survival of patients with resected NSCLC.

METHODS

We retrospectively reviewed the data of two independent cohorts of patients with completely resected NSCLC. To develop the prognostic index in one cohort, the overall survival (OS) was evaluated using the Cox proportional hazards model. We assessed the disease-free survival (DFS) and OS of three risk groups defined according to the prognostic index. Then, the prognostic index was validated in the other cohort.

RESULTS

Seven independent risk factors for OS were selected: age ≥ 70 years, ever-smokers, vital capacity <80%, neutrophil-to-lymphocyte ratio ≥ 2.1, cytokeratin 19 fragment >normal limit, non-usual interstitial pneumonia (UIP) pattern, and UIP pattern. Three risk groups were defined: low-risk (36.9%), intermediate-risk (54.0%), and high-risk (9.1%). In the derivation cohort, the 5-year DFS rate was 77.8%, 58.8%, and 22.6% (P < 0.001), and the 5-year OS rate was 95.2%, 70.4%, and 28.9% (P < 0.001), respectively. Multivariate analyses showed that the prognostic index predicted DFS and OS, independent of pathological stage and tumor histology, in both derivation and validation cohorts.

CONCLUSIONS

We developed and validated a simple preoperative prognostic index composed of seven variables, which may help clinicians predict prognosis before surgery in patients with NSCLC.

Refraining from smoking shortly before lobectomy has no influence on the risk of pulmonary complications: a case-control study on a matched population

Objectives

Whether or not smoking increases the risk of postoperative pulmonary complications (PPCs) in lung resection patients remains controversial. The objective of this study was to evaluate whether active smoking at the time of surgery increases the risk of PPCs compared to abstention shortly before the procedure.

Methods

We conducted a case-control study on 378 patients who underwent non-extended lobectomy in our institution. Cases were active smokers at the time of surgery, and controls were patients who quit smoking at any time up to 16 weeks before surgery. All patients received the same perioperative care, including chest physiotherapy. The occurrence of PPCs was the considered outcome. PPCs were defined as pneumonia (American Thoracic Society criteria, 2004) or atelectasis requiring bronchoscopy. Cases and controls were matched according to age, body mass index, forced expiratory volume in the first second of expiration (FEV1%), FEV1/forced vital capacity, type of approach and diagnosis of non-small-cell lung cancer. We calculated the odds ratio (OR) with 95% confidence interval (CI) for PPCs.

Results

The overall prevalence of PPCs was 4.7% (18/378); 5.3% (13 out of 244) in the active smokers group and 3.7% (5 out of 134) in the ex-smokers group. After matching, two sets of 134 patients each were compared. The prevalence was 4.5% (6/134) in active and 3.7% (5/134) in ex-smokers (OR 1.21 95% CI: 0.29-5.13, P  =   0.76).

Conclusions

In this population of patients strictly matched according to risk criteria for PPCs, smoking at the time of surgery was not identified as a risk variable. Therefore, the practice of postponing surgery until tobacco abstention has been achieved does not seem to be justified.

[Prognostic factors of advanced stage non-small-cell lung cancer]

INTRODUCTION

Primary lung cancer is the leading cause of cancer death in men in the world. Although the introduction of new drugs, new therapeutic strategies and despite therapeutic advances, the prognosis is relatively improved during the last years.

AIM

To evaluate the prognosis of patients with locally advanced or metastatic non-small-cell lung cancer (NSCLC) and to identify prognostic factors at these stages.

METHODS

A retrospective study, including 140 cases of locally advanced or metastatic NSCLC diagnosed in our department between 2003 and 2013.

RESULTS

The average age was 61±10 years (35 to 90 years). Sex ratio was 18. The delays management were 80±25 days for presentation, 45±20 days for the diagnostic, while the treatment delay was 8±2.33 days. The cancer was at stage IIIA in 14%, IIIB in 27% and IV in 59%. Six months and one-year survival was between 50 and 74% and between 9 and 25%, respectively. Better survival was observed in patients with NSCLC on stage III, having better performance status, having comorbid conditions, with prolonged delays management, a short therapeutic delay and patients who received specific antitumor treatment.

CONCLUSION

The prognostic factors in locally advanced and metastatic NSCLC in our patients were: stage of cancer, performance status, comorbid conditions, delay of management and specific antitumoral treatment. These factors should be considered in the management of patients with advanced NSCLC.

Impact of sex on prognostic host factors in surgical patients with lung cancer

BACKGROUND

Lung cancer has markedly poorer survival in men. Recognized important prognostic factors are divided into host, tumour and environmental factors. Traditional staging systems that use only tumour factors to predict prognosis are of limited accuracy. By examining sex-based patterns of disease-specific survival in non-small cell lung cancer patients, we determined the effect of sex on the prognostic value of additional host factors.

METHODS

Two cohorts of patients treated surgically with curative intent between 2000 and 2009 were utilized. The primary cohort was from Melbourne, Australia, with an independent validation set from the American Surveillance, Epidemiology and End Results (SEER) database. Univariate and multivariate analyses of validated host-related prognostic factors were performed in both cohorts to investigate the differences in survival between men and women.

RESULTS

The Melbourne cohort had 605 patients (61% men) and SEER cohort comprised 55 681 patients (51% men). Disease-specific 5-year survival showed men had statistically significant poorer survival in both cohorts (P < 0.001); Melbourne men at 53.2% compared with women at 68.3%, and SEER 53.3% men and 62.0% women were alive at 5 years. Being male was independently prognostic for disease-specific mortality in the Melbourne cohort after adjustment for ethnicity, smoking history, performance status, age, pathological stage and histology (hazard ratio = 1.54, 95% confidence interval: 1.10-2.16, P = 0.012).

CONCLUSIONS

Sex differences in non-small cell lung cancer are important irrespective of age, ethnicity, smoking, performance status and tumour, node and metastasis stage. Epidemiological findings such as these should be translated into research and clinical paradigms to determine the factors that influence the survival disadvantage experienced by men.

Lung cancer in women, a different disease: survival differences by sex in Turkey

PURPOSE

In this study, we aimed to evaluate the effects of sex-based non-small cell lung cancer (NSCLC) varieties on survival rates.

MATERIALS AND METHODS

A retrospective study was performed in patients with NSCLC who were diagnosed by histological methods between the years 2000 and 2010. A chi-square test was used to compare variables. Overall survival (OS) was estimated by the Kaplan-Meier method.

RESULTS

Of the 844 patients, 117 (13.9%) were women and 727 (86.1%) were men. Adenocarcinoma was more common in women than in men (p<0.0001). There were more women non-smokers than men (p<0.0001). There was no statistically significant difference in ECOG PS, weight loss>10%, stage, LDH, albumin and treatment between women and men. Women younger than 65 years (17.0 vs 12.0 months; p=0.03), who had adenocarcinoma histology (15.0 vs 10.0 months; p=0.006) and who had a hemoglobin level≥12 g/dL (18.0 vs 12.0 months; p=0.01) were found to have a better median OS rate than men. Median OS rates were found to be 13.0 months in females and 12.0 months in males (p=0.14). Among metastatic patients, the median OS was 11.0 months in females and 8.0 months in males (p=0.005). Among stage IIIB and stage IV patients who had first line platinum-based chemotherapy, the median OS was 17.0 months in women and 11.0 months in men (p=0.002). The response rate of chemotherapy was higher in women than in men (p=0.03).

CONCLUSIONS

In our study, we found that survival duration is longer and chemotherapy response is better in women with NSCLC who do not have anemia or comorbidities and who are mostly non-smokers with adenocarcinomas. Further studies regarding the causes of these differences may provide clarity on this subject.

The impact of low-dose carcinogens and environmental disruptors on tissue invasion and metastasis

The purpose of this review is to stimulate new ideas regarding low-dose environmental mixtures and carcinogens and their potential to promote invasion and metastasis. Whereas a number of chapters in this review are devoted to the role of low-dose environmental mixtures and carcinogens in the promotion of invasion and metastasis in specific tumors such as breast and prostate, the overarching theme is the role of low-dose carcinogens in the progression of cancer stem cells. It is becoming clearer that cancer stem cells in a tumor are the ones that assume invasive properties and colonize distant organs. Therefore, low-dose contaminants that trigger epithelial-mesenchymal transition, for example, in these cells are of particular interest in this review. This we hope will lead to the collaboration between scientists who have dedicated their professional life to the study of carcinogens and those whose interests are exclusively in the arena of tissue invasion and metastasis.

Prognostic Factors in Non-Small Cell Lung Cancer Less Than 3 Centimeters: Actuarial Analysis, Accumulative Incidence and Risk Groups

INTRODUCTION

In TNM classification, factors determining the tumor (T) component in non-small cell lung cancer have scarcely changed over time and are still based solely on anatomical features. Our objective was to study the influence of these and other morphopathological factors on survival.

METHODS

A total of 263 patients undergoing lung resection due to stage I non-small cell lung cancer ≤3cm in diameter were studied. A survival analysis and competing-risk estimate study was made on the basis of clinical, surgical and pathological variables using actuarial analysis and accumulative incidence methods, respectively. A risk model was then generated from the results.

RESULTS

Survival at 5 and 10 years was 79.8 and 74.3%, respectively. The best prognostic factors were presence of symptoms, smoking habit and FEV1>60%, number of resected nodes>7, squamous histology, absence of vascular invasion, absence of visceral pleural invasion and presence of invasion more proximal than the lobar bronchus. All these were statistically significant according to the actuarial method. The factor "age<50 years" was close to the margin of statistical significance. Pleural invasion and vascular invasion were entered in the multivariate analysis. The competing-risk analysis showed a probability of death due to cancer of 14.3 and 35.1% at 5 and 10 years, respectively. Significant variables in the univariate and multivariate analyses were similar, with the exception of FEV1>60%.

CONCLUSIONS

Pleural invasion and vascular invasion determine survival or risk of death due to non-small cell lung cancer ≤3cm and can be used for generating a predictive risk model.

Effect of smoking on survival from non-small cell lung cancer: a retrospective Veterans' Affairs Central Cancer Registry (VACCR) cohort analysis

Although a well-established risk factor for lung cancer, the impact of smoking on the survival of non-small cell lung cancer (NSCLC) is not well known. We performed a retrospective analysis of the Veteran's Affairs Comprehensive Cancer Registry of NSCLC patients. Smoking status was categorized as never smoker, past smoker and current smoker based on self-reported history. Multivariate analysis was performed to evaluate the impact of smoking on overall survival (OS) from NSCLC. The study population (n = 61,440) comprised predominantly of males (98 %) and Caucasians (81 %). The median age at diagnosis was 68 years (range 22-108 years). Current smokers were diagnosed with NSCLC at a younger age (65 years) compared to never smokers (71 years) and past smokers (72 years) (p < 0.001). On multivariate analysis, current smokers (n = 34,613) [Hazard ratio (HR) 1.059; 95 % confidence interval (CI) 1.012-1.108], but not past smokers (n = 23,864) (HR 1.008; 95 % CI 0.962-1.056), had worse OS for Stage III and IV NSCLC, compared to never smokers (n = 2,963). Smoking status was not prognostic in stages I and II NSCLC. Current smokers were diagnosed with NSCLC at a younger age than never smokers. Although current smoking was associated with worse prognosis, especially in stages III and IV, the impact of smoking status on OS was modest.

[Mortality in early-stage, surgically resected non-small cell lung cancer less than 3 cm of size: Competing risk analysis]

BACKGROUND AND OBJECTIVE

Survival studies of non-small cell lung cancer (NSCLC) are usually based on the Kaplan-Meier method. However, other factors not covered by this method may modify the observation of the event of interest. There are models of cumulative incidence (CI), that take into account these competing risks, enabling more accurate survival estimates and evaluation of the risk of death from other causes. We aimed to evaluate these models in resected early-stage NSCLC patients.

PATIENTS AND METHOD

This study included 263 patients with resected NSCLC whose diameter was ≤ 3 cm without node involvement (N0). Demographic, clinical, morphopathological and surgical variables, TNM classification and long-term evolution were analysed. To analyse CI, death by another cause was considered to be competitive event. For the univariate analysis, Gray's method was used, while Fine and Gray's method was employed for the multivariate analysis.

RESULTS

Mortality by NSCLC was 19.4% at 5 years and 14.3% by another cause. Both curves crossed at 6.3 years, and probability of death by another cause became greater from this point. In multivariate analysis, cancer mortality was conditioned by visceral pleural invasion (VPI) (P=.001) and vascular invasion (P=.020), with age>50 years (P=.034), smoking (P=.009) and the Charlson index ≥ 2 (P=.000) being by no cancer.

CONCLUSIONS

By the method of CI, VPI and vascular invasion conditioned cancer death in NSCLC >3 cm, while non-tumor causes of long-term death were determined.

Smoking is a perioperative risk factor and prognostic factor for lung cancer surgery

OBJECTIVE

The aim of this study was to investigate the smoking status of lung cancer patients and to confirm the risk of smoking for patients undergoing lung cancer surgery.

METHODS

We conducted a retrospective study of patients undergoing lung cancer surgery. Between May 2004 and March 2013, 716 patients underwent lung cancer surgery at our institution. Based on smoking status, the patients were classified into 3 groups: nonsmoker, past smoker, and current smoker. Based on exclusion criteria, a final total of 670 patients were investigated for the association between smoking status and postoperative complications. In addition, we explored the effect of smoking on survival after surgery.

RESULTS

There were 254 non-smokers, 246 past smokers, and 170 current smokers. The percent of female patients, adenocarcinoma, and stage IA cancer was highest in the nonsmokers. Respiratory function was significantly impaired in past and current smokers. Respiratory and cardiac complications were found less frequently in non-smokers (11.4%) followed by 17.1% of past smokers and 21.2% of current smokers (p = 0.0226). Univariate analysis showed that smoking was a significantly poor prognostic factor for overall survival. The 5-year survival rates for non-smokers, past, and current smokers were 81.4, 65.4, and 68.8%, respectively (p = 0.0003).

CONCLUSIONS

Smokers with lung cancer tended to have advanced lung cancer, impaired pulmonary function, and high morbidity after lung cancer surgery. Although multivariate analysis did not show that smoking was associated with poor outcome, non-smokers had significantly better overall survival, even for patients with stage IA lung cancers.

Impact of smoking on mortality of patients with non-small cell lung cancer

BACKGROUND

Cigarette smoking is one of the major causes of lung cancer. However, the correlation between smoking status and the survival of patients with lung cancer is uncertain. The present study aimed to evaluate the impact of smoking status on the mortality of patients with non-small cell lung cancer (NSCLC).

METHODS

The medical records of 313 patients newly diagnosed with NSCLC between January 2005 and January 2006 were reviewed. Eligible patients were divided into ever-smokers (221 patients) and never-smokers (92 patients), and the overall survival and clinical characteristics of the two groups were compared. Predictors of survival were analyzed using Cox's proportional hazards regression.

RESULTS

In ever-smokers, the mean age was higher, and male gender and squamous histology were predominant compared to never-smokers. The median survival time was longer in never-smokers (21.1 vs. 41.9 months, ever-smokers vs. never-smokers, respectively; P = 0.027). Overall survival estimates at 12, 24, and 60 months were 62.9 versus 82.6%, 43.4 versus 65.2%, and 31.2 versus 42.4%, in each group. Advanced age, advanced disease stage (stages III and IV), and coexistence of interstitial lung disease were analyzed as independent risk factors for shorter survival. Although ever-smoking was not an independent risk factor, current smoking was a risk factor for higher mortality.

CONCLUSIONS

The overall mortality of ever-smokers was higher than that of never-smokers in patients with newly diagnosed NSCLC, and current smoking was an independent risk factor for a poorer prognosis.

Tobacco Smoking and Lung Cancer: Perception-changing facts

Tobacco smoking remains the most established cause of lung carcinogenesis and other disease processes. Over the last 50 years, tobacco refinement and the introduction of filters have brought a change in histology, and now adenocarcinoma has become the most prevalent subtype. Over the last decade, smoking also has emerged as a strong prognostic and predictive patient characteristic along with other variables. This article briefly reviews scientific facts about tobacco, and the process and molecular pathways involved in lung carcinogenesis in smokers and never-smokers. The evidence from randomised trials about tobacco smoking's impact on lung cancer outcomes is also reviewed.

The influence of smoking intensity on the clinicopathologic features and survival of patients with surgically treated non-small cell lung cancer

BACKGROUND

Smoking is a well-known carcinogen for lung cancer. However, whether smoking affects the biological behavior of lung cancer remains uncertain. This study aimed to investigate the influences of smoking intensity on the clinicopathologic characteristics of and survival in non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed 2238 consecutive patients who underwent surgical resection for NSCLC between 1990 and 2010. Smoking intensity was defined as pack-years (PY). The patients were divided into three groups according to the median value of smoking intensity (40 PY): group A (never smokers), group B (smoking intensity less than 40 PY) and group C (smoking intensity more than 40 PY).

RESULTS

There were 1629 (72.8%) male patients, and the mean age was 61.71 ± 13.17 years. Adenocarcinoma was reported in 1058 (47.3%) patients. The median follow-up period was 30.7 months (range: 0.0-261.7 months). The 5-year overall survivals for groups A, B and C were 60.1%, 51.6% and 43.2%, respectively (p < 0.001). In subset analysis by histology, the 5-year overall survival was significantly different according to smoking intensity in adenocarcinoma (p < 0.001), but there was no difference in the non-adenocarcinoma. In adenocarcinoma, the incidences of vascular invasion (p = 0.028), pleural invasion (p = 0.013) and poor differentiation (p < 0.001) were higher and tumor sizes (p < 0.001) were greater in group C than others. On multivariate analysis, smoking intensity was an adverse risk factor for overall survival in surgically treated adenocarcinoma patients (hazard ratio = 1.008, p = 0.028).

CONCLUSION

Smoking intensity was an adverse prognostic factor after surgical resection of adenocarcinoma. Heavy smoking was correlated with poor pathologic characteristics in adenocarcinoma.

Aurora-B overexpression is correlated with aneuploidy and poor prognosis in non-small cell lung cancer

Aurora-B is a key regulator of mitosis, and the overexpression has been detected in a variety of solid tumors. The Aurora-B overexpression has been suggested to correlate with clinical aggressiveness and aneuploidy in vitro, however, the frequency of overexpression of Aurora-B protein, the association with clinicopathologic parameters and aneuploidy remain poorly defined in non-small-cell lung cancer (NSCLC). Using 157 surgical specimens of human NSCLC, we here show that overexpression of Aurora-B proteins are significantly correlated with aneuploidy and poor outcomes in NSCLC. We examined immunohistochemical protein expression of Aurora-B, and DNA ploidy by laser scanning cytometry in 157 NSCLC cases. Aurora-B overexpression was found in 83 cases (53%) of NSCLC, and was significantly correlated with vascular invasion (p=0.012), poor differentiation (p<0.001), larger tumor size (p=0.010) and lymph node metastasis (p=0.05) and poor prognosis (p=0.011). Aneuploidy was found in 87 cases (57%), and was significantly correlated with Aurora-B overexpression (p=0.0065). Logistic multivariate analysis revealed overexpression of Aurora-B protein to be significant risk factors for aneuploidy compared with other factors. These results indicate that Aurora-B overexpression may contribute to malignant potential and increased aneuploidy in NSCLC. Thus, Aurora-B may serve as a new therapeutic target in against patients with NSCLC, although further studies will be necessary.

Clinico-pathological features and management of lung cancer patients with atherosclerotic vascular diseases

PURPOSE

Increased numbers of patients with both lung cancer and atherosclerotic vascular disease (AVD) may be expected in the future. The aim of this study was to report the incidence of lung cancer in patients with AVD and to discuss patient characteristics and management.

METHOD

A total of 638 patients who underwent AVD treatment were investigated.

RESULTS

Lung cancer was observed in 17 (2.7%) of 638 patients studied. The proportion of smoking history was significantly higher in patients with lung cancer (p = 0.0091).The pack-year index in patients with lung cancer was significantly higher than that in patients without lung cancer (p = 0.0073). Although 4 of 6 (66.7%) patients with concomitant lung cancer and AVD had stage I or II lung cancer, 5 of 7 (71.4%) patients with lung cancer diagnosed after AVD treatment had stage III or IV lung cancer. In patients with lung cancer found after AVD treatment, only 1 of 7 patients underwent surgical resections. The time until lung cancer was 12 to 198 months with a mean of62.5 months after AVD treatment. In concomitant cases, priority was given to AVD treatment in all 5 cases, and there were no serious events after the postoperative course.

CONCLUSIONS

Both patients with a smoking history and heavy smokers were at high risk for lung cancer, and most lung cancers found after AVD treatment were in the advanced stages and had poor prognoses. Therefore, we recommend careful and routine follow-up for screening lung cancer after AVD treatment.

Chapter 6: Lung cancer in never smokers: epidemiology and risk prediction models

In this chapter we review the epidemiology of lung cancer incidence and mortality among never smokers/nonsmokers and describe the never smoker lung cancer risk models used by the Cancer Intervention and Surveillance Network (CISNET) modelers. Our review focuses on those influences likely to have measurable population impact on never smoker risk, such as secondhand smoke, even though the individual-level impact may be small. Occupational exposures may also contribute importantly to the population attributable risk of lung cancer. We examine the following risk factors in this chapter: age, environmental tobacco smoke, cooking fumes, ionizing radiation including radon gas, inherited genetic susceptibility, selected occupational exposures, preexisting lung disease, and oncogenic viruses. We also compare the prevalence of never smokers between the three CISNET smoking scenarios and present the corresponding lung cancer mortality estimates among never smokers as predicted by a typical CISNET model.

Prognostic factors for survival in a Chinese population presenting with advanced non-small cell lung cancer with an emphasis on smoking status: A regional, single-institution, retrospective analysis of 4552 patients

BACKGROUND

Lung cancer ranks as the top of cancer-related mortality in the world. Approximately 85-90% of all lung cancer cases are non-small cell lung cancer (NSCLC). For advanced NSCLC patients, the five-year survival rate is less than 5%. Previous studies have attempted to determine prognostic factors, such as smoking status, gender, ethnicity, age, and histological type. However, the results are controversial and conflict. In this study, we investigated prognostic factors in a Chinese population presenting with advanced NSCLC.

METHODS

Medical records of patients with advanced NSCLC (AJCC Stage IIIB/IV) who received treatment at our institution were reviewed. Kaplan-Meier method and Cox Proportional Hazards model were performed in both univariate and multivariate analyses.

RESULTS

A total of 4552 patients were entered. Among them, 1320 (29.0%) were female, 2408 non-smokers (52.9%), and all had Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) = 0/1. Univariate analysis suggested that female gender (P < 0.001), adenocarcinoma histology (P < 0.001), age <70 (P < 0.001), and non-smoker status (P < 0.001) were associated with better survival. However, multivariate analysis demonstrated that age (hazard ratio [HR]= 1.173, 95% confidence interval [CI]: 1.085-1.268, P < 0.001), smoking status (vs. non-smokers, HR = 1.212, 95% CI: 1.123-1.308, P < 0.001), and histological type (non-adenocarcinoma vs. adenocarcinoma, HR = 1.104, 95% CI: 1.031-1.181, P = 0.004), but not gender, were independent prognostic factors.

CONCLUSIONS

Smoking status, age, and histological type are independent prognostic factors in Chinese NSCLC patients presenting with advanced disease. Non-smoking status is associated with better overall survival in Chinese NSCLC patients.

Female gender is an independent prognostic factor in non-small-cell lung cancer: a meta-analysis

PURPOSE

It is not clear whether women with non-small-cell lung cancer (NSCLC) live significantly longer than men. Thus, we conducted a meta-analysis of published studies to quantitatively compare NSCLC survival data between genders.

MATERIALS AND METHODS

A MEDLINE Web search for computer-archived bibliographic data regarding overall survival differences between genders was performed. DerSimonian-Laird random effects analysis was used to estimate the pooled hazard ratio (HR).

RESULTS

We selected 39 articles as appropriate data sources, involving 86 800 patients including 32 701 women and 54 099 men. Combined HRs for women vs. men in studies using univariate and multivariate analyses respectively were 0.79 (p <0.0001) and 0.78 (p <0.0001). Pooled HRs for 3 study subgroups having (1) fewer than 30% stage I cases, (2) fewer than 50% adenocarcinoma cases, and (3) statistical adjustment for smoking status all indicated the survival advantage of women.

CONCLUSION

This meta-analysis of published data concerning NSCLC patients indicated significantly better survival for women.

Non-small cell lung cancer in never smokers as a representative 'non-smoking-associated lung cancer': epidemiology and clinical features

Recent interest in lung cancer without a history of tobacco smoking has led to the classification of a distinct disease entity of 'non-smoking-associated lung cancer'. In this review article, we have made an overview of the recent literature concerning both the epidemiology and clinical features of lung cancer in never smokers, and have brought 'non-smoking-associated lung cancer' into relief. The etiology of lung cancer in never smokers remains indefinite although many putative risk factors have been described including secondhand smoking, occupational exposures, pre-existing lung diseases, diet, estrogen exposure, etc. Non-small cell lung cancer (NSCLC) in never smokers is clinically characterized by an increased incidence in females and a higher occurrence of adenocarcinoma in comparison to NSCLC in ever smokers in both surgical patients and non-resectable advanced-stage patients. Furthermore, the prognosis of never-smoking NSCLC is better than that of smoking-related NSCLC in both surgical patients and non-resectable advanced-stage patients. Recently recognized novel gene mutations such as EGFR (epidermal growth factor receptor) mutations are largely limited to never smokers or light smokers, and the expression of this gene is responsible for the clinical efficacy of gefitinib, an epidermal growth factor receptor-tyrosine kinase inhibitor. NSCLC with the EML4 (echinoderm microtubule-associated protein-like 4)-ALK (anaplastic lymphoma kinase) fusion gene is also more likely to occur in never smokers and in those with adenocarcinoma histology, and is expected to benefit from ALK inhibitors. In consideration of the future increase in never-smoking NSCLC or 'non-smoking-associated lung cancer', both clinical trials and investigations are needed.

Smoking reduces survival in young females with lung adenocarcinoma after curative resection

The aim of this study was to investigate effects of smoking on the overall survival of young female lung adenocarcinoma patients after curative resection. A total of 282 surgically treated young females (younger than 40) with histologically confirmed primary lung adenocarcinoma were studied retrospectively. Overall survivals (OS) and related prognostic factors were analyzed. The 5-year OS of current-smokers and non-smokers were 20 and 36.6%, respectively (P = 0.03). As for patients with stage I disease, the 5-year OS of current-smokers and non-smokers were 50 and 68.8%, respectively, (P = 0.02). Smoking (RR = 3.15, CI 1.726-8.786) was identified as an independent prognostic factor. Current-smokers (21.4 vs. 14.5%, P = 0.03) and non-smokers (37.9 vs. 28.8%, P = 0.02) all benefited from adjuvant chemotherapy. Among young female patients with adenocarcinoma, current-smokers have a lower survival rate than non-smokers, especially patients with stage I disease.

Non-small cell lung cancer in never smokers: a clinical entity to be identified

OBJECTIVES

It has been recognized that patients with non-small cell lung cancer who are lifelong never-smokers constitute a distinct clinical entity. The aim of this study was to assess clinical risk factors for survival among never-smokers with non-small cell lung cancer.

METHODS

All consecutive non-small cell lung cancer patients diagnosed (n = 285) between May 2005 and May 2009 were included. The clinical characteristics of never-smokers and ever-smokers (former and current) were compared using chi-squared or Student's t tests. Survival curves were calculated using the Kaplan-Meier method, and log-rank tests were used for survival comparisons. A Cox proportional hazards regression analysis was evaluated by adjusting for age (continuous variable), gender (female vs. male), smoking status (never- vs. ever-smoker), the Karnofsky Performance Status Scale (continuous variable), histological type (adenocarcinoma vs. non-adenocarcinoma), AJCC staging (early vs. advanced staging), and treatment (chemotherapy and/or radiotherapy vs. the best treatment support).

RESULTS

Of the 285 non-small cell lung cancer patients, 56 patients were never-smokers. Univariate analyses indicated that the never-smoker patients were more likely to be female (68% vs. 32%) and have adenocarcinoma (70% vs. 51%). Overall median survival was 15.7 months (95% CI: 13.2 to 18.2). The never-smoker patients had a better survival rate than their counterpart, the ever-smokers. Never-smoker status, higher Karnofsky Performance Status, early staging, and treatment were independent and favorable prognostic factors for survival after adjusting for age, gender, and adenocarcinoma in multivariate analysis.

CONCLUSIONS

Epidemiological differences exist between never- and ever-smokers with lung cancer. Overall survival among never-smokers was found to be higher and independent of gender and histological type.

[The International Association for the Study of Lung Cancer Staging Project. Prognostic factors and pathologic TNM stage in surgically managed non-small cell lung cancer]

目的

本研究的目的是在国际肺癌研究协会国际分期数据库中采用外科治疗的Ⅰ-ⅢA期非小细胞肺癌病例中，评价除肿瘤原发灶、病理淋巴结和转移（TNM）分期外，细胞类型、年龄和性别的影响。

材料和方法

从提交至分期数据库的67 725例非小细胞肺癌（NSCLC）病例中，筛选出9 137例采用外科治疗的病例，这些病例的病理分期、年龄、性别和特殊组织细胞类型等信息均可获得。在亚组中分析记录行为状态和吸烟史。检验方法采用Cox比例风险回归和递归分割及合并（RPA）分析。

结果

病理TNM分期、年龄以及性别均为生存的独立预后因素。尽管细支气管肺泡癌（BAC）亚型间存在潜在的异质性，其相对于其它细胞类型仍具有生存优势。修正比较提示罹患鳞癌相对于非BAC腺癌及大细胞癌具有微弱的生存优势，尽管此优势仅限于男性患者。RPA结果提示TNM分期为首要因素，年龄是各分期分组的预后因素。在RPA分析中未发现细胞类型具有预后价值。依据RPA的结果形成预后分组，诸分组的预后价值得到北美监视、流行病学、结局结果注册机构的认可。在资料可得的亚组中，行为状态和吸烟史均为预后因素。在回归模型中，吸烟状态的纳入未影响其它变量的效果。

结论

年龄和性别已被证实为外科切除的非小细胞肺癌的重要预后因素。细胞类型的重要性次之，尽管归类于BAC的少部分病例相对于其它组织学类型具有生存优势，且鳞癌相对于非BAC腺癌具有微弱的生存优势。在未修正分析中，分期、年龄、性别和细胞类型间的不平衡可能会导致有关细胞类型的误导结果。在该分析中，病理TNM分类是最重要的预后因素。

Long-term survival outcomes by smoking status in surgical and nonsurgical patients with non-small cell lung cancer: comparing never smokers and current smokers

BACKGROUND

Survival outcomes of never smokers with non-small cell lung cancer (NSCLC) who undergo surgery are poorly characterized. This investigation compared surgical outcomes of never and current smokers with NSCLC.

METHODS

This investigation was a single-institution retrospective study of never and current smokers with NSCLC from 1975 to 2004. From an analytic cohort of 4,546 patients with NSCLC, we identified 724 never smokers and 3,822 current smokers. Overall, 1,142 patients underwent surgery with curative intent. For survival analysis by smoking status, hazard ratios (HRs) were estimated using Cox proportional hazard modeling and then further adjusted by other covariates.

RESULTS

Never smokers were significantly more likely than current smokers to be women (P < .01), older (P < .01), and to have adenocarcinoma (P < .01) and bronchioloalveolar carcinoma (P < .01). No statistically significant differences existed in stage distribution at presentation for the analytic cohort (P = .35) or for the subgroup undergoing surgery (P = .24). The strongest risk factors of mortality among patients with NSCLC who underwent surgery were advanced stage (adjusted hazard ratio, 3.43; 95% CI, 2.32-5.07; P < .01) and elevated American Society of Anesthesiologists classification (adjusted hazard ratio, 2.18; 95% CI, 1.40-3.40; P < .01). The minor trend toward an elevated risk of death on univariate analysis for current vs never smokers in the surgically treated group (hazard ratio, 1.20; 95% CI, 0.98-1.46; P = .07) was completely eliminated when the model was adjusted for covariates (P = .97).

CONCLUSIONS

Our findings suggest that smoking status at time of lung cancer diagnosis has little impact on the long-term survival of patients with NSCLC, especially after curative surgery. Despite different etiologies between lung cancer in never and current smokers the prognosis is equally dismal.

Lung cancer in never smokers: molecular profiles and therapeutic implications

The majority of lung cancers are caused by long term exposure to the several classes of carcinogens present in tobacco smoke. Although a significant fraction of lung cancers in never smokers may also be attributable to tobacco, many such cancers arise in the absence of detectable tobacco exposure, and may follow a very different cellular and molecular pathway of malignant transformation. Recent studies summarized here suggest that lung cancers arising in never smokers have a distinct natural history, profile of oncogenic mutations, and response to targeted therapy. The majority of molecular analyses of lung cancer have focused on genetic profiling of pathways responsible for metabolism of primary tobacco carcinogens. Limited research has been conducted evaluating familial aggregation and genetic linkage of lung cancer, particularly among never smokers in whom such associations might be expected to be strongest. Data emerging over the past several years show that lung cancers in never smokers are much more likely to carry activating mutations of the epidermal growth factor receptor (EGFR), a key oncogenic factor and direct therapeutic target of several newer anticancer drugs. EGFR mutant lung cancers may represent a distinct class of lung cancers, enriched in the never-smoking population, and less clearly linked to direct tobacco carcinogenesis. These insights followed initial testing and demonstration of efficacy of EGFR-targeted drugs. Focused analysis of molecular carcinogenesis in lung cancers in never smokers is needed, and may provide additional biologic insight with therapeutic implications for lung cancers in both ever smokers and never smokers.

Pack-years of cigarette smoking as a prognostic factor in patients with stage IIIB/IV nonsmall cell lung cancer

BACKGROUND

This study was undertaken to characterize the relation between the survival of patients with stage IIIB/IV nonsmall cell lung cancer (NSCLC) and pack-years of cigarette smoking (graded according to the American Joint Committee on Cancer staging system).

METHODS

Data were analyzed from patients with stage IIIB/IV NSCLC who had completed a prospective smoking questionnaire. The impact of pack-years of cigarette smoking, age, sex, Karnofsky performance status (KPS), and the presence of weight loss >5% was evaluated on overall survival using univariate and multivariate analyses.

RESULTS

Smoking history and clinical data were available for 2010 patients with stage IIIB/IV NSCLC (1004 women and 1006 men). Approximately 70% of patients (1409 patients) had smoked >15 pack-years, 13% (270) were former and current smokers who had smoked < or = 15 pack-years, and 16% (331) were never-smokers (<100 lifetime cigarettes). Never-smokers had a longer median survival compared with former or current smokers (17.8 months vs 11.3 months; log-rank P < .001). Among smokers, patients with a < or = 15 pack-year history of smoking had a longer median survival than patients who had smoked >15 pack-years (14.6 months vs 10.8 months; log-rank P = .03). As the number of pack-years increased, the median overall survival decreased (log-rank P < .001). Multivariate analysis indicated that a history of smoking was an independent prognostic factor (hazard ratio, 1.36; P < .001).

CONCLUSIONS

More cigarette smoking, measured in pack-years, was associated with decreased survival after a diagnosis of stage IIIB/IV NSCLC. Trials assessing survival in patients with stage IIIB/IV NSCLC should report a detailed cigarette smoking history for all patients.

Impact and interactions between smoking and traditional prognostic factors in lung cancer progression

BACKGROUND

Cigarette smoking is a well-known risk factor of lung carcinogenesis. The clinical impact of smoking on lung cancer metastases and survival remains unclear. We sought to investigate the effect of smoking intensity on lung cancer treatment failure (represented by overall survival), and the interactions between smoking and clinicopathological factors in lung cancer progression.

METHODS

Clinical information was obtained from four non-small cell lung cancer patient cohorts (n=347). Twenty patients were excluded from the analysis because their smoking history was not available. The distribution of smoking intensity on patient age (> or =60 years or <60 years), gender, tumor differentiation (poor, moderate and well differentiated), and clinical stage (1, 2, or 3) was assessed with Kruskal-Wallis rank sum tests. The effect of smoking on cause-specific lung cancer mortality was estimated by using Cox proportional hazard models and Kaplan-Meier analysis. The interactions between clinicopathological factors and smoking intensity with regard to lung cancer overall survival were evaluated with analysis of variance (ANOVA) for Cox modeling.

RESULTS

Greater smoking intensity at diagnosis was found in older patients (> or =60 years; p=0.022), male (p=1.35e-7), poorly differentiated tumors (p=8.51e-5), patients with tumor stage 2 (p=0.031), and squamous cell lung cancer patients (p=2.2e-16). Patients who smoked more than 61 packs/year had an increased risk for lung cancer recurrence (hazard ratio=1.41, 95% CI: [1.03, 1.94], log-rank p=0.032) and shorter overall survival period (log-rank p=0.033, Kaplan-Meier analysis) than those who smoked less than 61 packs/year. ANOVA analysis showed that smoking intensity (p=0.03) and tumor stage (p=1.2e-6) are the only significant prognostic factors of lung cancer, whereas patient age, gender, and tumor differentiation were not significant in lung cancer prognostication. There were significant interactions between smoking and clinical stage (p=0.02) as well as patient age and tumor differentiation (p=0.03) in lung cancer progression.

CONCLUSION

Smoking intensity at diagnosis is an independent, significant prognostic factor of non-small cell lung cancer. This factor could be used in patient selection for chemoprevention of tumor metastases and relapse. Additionally, the information may be used for clinically relevant tobacco prevention and intervention messages.