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Lærum D, Strand TE, Brustugun OT, Gallefoss F, Falk R, Durheim MT, Fjellbirkeland L. Evaluation of sex inequity in lung-cancer-specific survival. Acta Oncol 2024; 63:343-350. [PMID: 38751329 PMCID: PMC11332543 DOI: 10.2340/1651-226x.2024.27572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/12/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Whether sex is an independent prognostic factor in lung cancer survival is the subject of ongoing debate. Both large national registries and single hospital studies have shown conflicting findings. In this study, we explore the impact of sex on lung-cancer-specific survival in an unselected population that is well-characterized with respect to stage and other covariates. MATERIAL AND METHODS All patients diagnosed with lung cancer at a single hospital serving a whole and defined region in Southern Norway during the 10 years 2007-2016 were included. Follow-up data were available for at least 56 months for all patients. Analyses were adjusted for stage, treatment, performance status, smoking, age, histology, epidermal growth factor receptor/anaplastic lymphoma kinase/immunotherapy treatment and period. Differences in lung-cancer-specific survival by sex were explored using restricted mean survival times (RMST). RESULTS Of the 1,261 patients diagnosed with lung cancer, 596 (47%) were females and 665 (53%) males, with mean ages of 68.5 and 69.5 years, respectively. The observed 5-year lung-cancer-specific survival rate was 27.4% (95% CI 23.7, 31.2) in females and 21.4% (95% CI 18.2, 24.8) in males. However, after adjustment for covariates, no significant differences by sex were observed. The 5-year RMST was 0.9 months shorter (95% CI -2.1, 0.31, p = 0.26) in males compared to females. INTERPRETATION In this cohort, sex was not associated with a difference in lung-cancer-specific survival after adjusting for clinical and biological factors. Imbalance in stage at diagnosis was the main contributor to the observed difference in lung-cancer-specific survival by sex.
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Affiliation(s)
- Dan Lærum
- Department of Internal Medicine, Pulmonary Section, Sorlandet Hospital Kristiansand, Kristiansand, Norway .
| | - Trond-Eirik Strand
- Department of Patient Safety and Quality, Oslo university hospital, Oslo, Norway; UiT The Arctic University of Norway, Department of Community Medicine, Tromsø, Norway
| | - Odd Terje Brustugun
- Section of Oncology, Vestre Viken Hospital Trust, Drammen, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Frode Gallefoss
- Department of Research, Sorlandet Hospital Kristiansand, Kristiansand, Norway; Medical Faculty, University of Bergen, Bergen/Norway
| | - Ragnhild Falk
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Michael T Durheim
- Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway; Department of Respiratory medicine, Division of Cardivascular and Pulmonary Diseases, University of Oslo, Oslo, Norway
| | - Lars Fjellbirkeland
- Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway; Department of Respiratory medicine, Division of Cardivascular and Pulmonary Diseases, University of Oslo, Oslo, Norway
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Trojnar A, Domagała-Kulawik J, Sienkiewicz-Ulita A, Zbytniewski M, Gryszko GM, Cackowski MM, Dziedzic M, Woźnica K, Orłowski TM, Dziedzic DA. Sex differences in clinico-pathologic characteristics and long-term survival among 17,192 surgically treated NSCLC patients: Nationwide population-based propensity score-matching study. Surg Oncol 2022; 45:101873. [DOI: 10.1016/j.suronc.2022.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
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Sponagel J, Devarakonda S, Rubin JB, Luo J, Ippolito JE. De novo serine biosynthesis from glucose predicts sex-specific response to antifolates in non-small cell lung cancer cell lines. iScience 2022; 25:105339. [PMID: 36325067 PMCID: PMC9619300 DOI: 10.1016/j.isci.2022.105339] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 09/16/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022] Open
Abstract
Lung cancer is the leading cause of cancer-related death. Intriguingly, males with non-small cell lung cancer (NSCLC) have a higher mortality rate than females. Here, we investigated the role of serine metabolism as a predictive marker for sensitivity to the antifolate pemetrexed in male and female NSCLC cell lines. Using [13C6] glucose tracing in NSCLC cell lines, we found that a subset of male cells generated significantly more serine from glucose than female cells. Higher serine biosynthesis was further correlated with increased sensitivity to pemetrexed in male cells only. Concordant sex differences in metabolic gene expression were evident in NSCLC and pan-cancer transcriptome datasets, suggesting a potential mechanism with wide-reaching applicability. These data were further validated by integrating antifolate drug cytotoxicity and metabolic pathway transcriptome data from pan-cancer cell lines. Together, these findings highlight the importance of considering sex differences in cancer metabolism to improve treatment for all patients.
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Affiliation(s)
- Jasmin Sponagel
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Siddhartha Devarakonda
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Joshua B. Rubin
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neuroscience Washington University School of Medicine, St Louis, MO 63110, USA
| | - Jingqin Luo
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO 63110, USA
- Siteman Cancer Center Biostatistics Shared Resource, Washington University School of Medicine, St Louis, MO 63110, USA
| | - Joseph E. Ippolito
- Department of Radiology Washington University School of Medicine, St Louis, MO 63110, USA
- Department of Biochemistry and Molecular Biophysics, Washington University School of Medicine, St Louis, MO 63110, USA
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4
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Wu G, Wang Y, Wan Y. Establishing an 8-gene immune prognostic model based on TP53 status for lung adenocarcinoma. J Clin Lab Anal 2022; 36:e24538. [PMID: 35689561 PMCID: PMC9279974 DOI: 10.1002/jcla.24538] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/27/2022] [Accepted: 05/22/2022] [Indexed: 12/30/2022] Open
Abstract
Background Lung adenocarcinoma (LUAD) results in a majority of cancer burden worldwide. TP53 is the most commonly mutated in LUAD. This study aimed to reveal the relation between TP53 and tumor microenvironment (TME) for improving LUAD treatment. Methods Differentially expressed genes (DEGs) related to immunity were analyzed between TP53‐WT and TP53‐MUT groups. Least absolute shrinkage and selection operator (LASSO) Cox regression was applied to screen prognostic DEGs. Two independent datasets were included to evaluate the robustness of the prognostic model. Results An 8‐gene prognostic model containing ANLN, CCNB1, DLGAP5, FAM83A, GJB2, NAPSA, SFTPB, and SLC2A1 was established based on DEGs. LUAD samples were classified into high‐ and low‐risk groups with differential overall survival in the two datasets. M0 macrophages, M1 macrophages, and activated memory CD4 T cells were more enriched in high‐risk group. Immune checkpoints of PDCD1, LAG3, and CD274 were also high‐expressed in high‐risk group. Conclusion The study improved the understanding of the role of TP53 in the TME modulation. The 8‐gene model had robust performance to predict LUAD prognosis in clinical practice. In addition, the eight prognostic genes may also serve as potential targets for designing therapeutic drugs for LUAD patients.
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Affiliation(s)
- Guodong Wu
- Thoracic Surgery, Shenzhen Second People's Hospital, Shenzhen, China
| | - Youyu Wang
- Thoracic Surgery, Shenzhen Second People's Hospital, Shenzhen, China
| | - Yanhui Wan
- Thoracic Surgery, Shenzhen Second People's Hospital, Shenzhen, China
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5
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Abstract
Cancer is a leading cause of death worldwide. Sex influences cancer in a bewildering variety of ways. In some cancer types, it affects prevalence; in others, genomic profiles, response to treatment, or mortality. In some, sex seems to have little or no influence. How and when sex influences cancer initiation and progression remain a critical gap in our understanding of cancer, with direct relevance to precision medicine. Here, we note several factors that complicate our understanding of sex differences: representativeness of large cohorts, confounding with features such as ancestry, age, obesity, and variability in clinical presentation. We summarize the key resources available to study molecular sex differences and suggest some likely directions for improving our understanding of how patient sex influences cancer behavior.
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Affiliation(s)
- Chenghao Zhu
- Department of Human Genetics, University of California, Los Angeles, CA, USA
- Department of Urology, University of California, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA
- Institute for Precision Health, University of California, Los Angeles, CA, USA
| | - Paul C Boutros
- Department of Human Genetics, University of California, Los Angeles, CA, USA
- Department of Urology, University of California, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA
- Institute for Precision Health, University of California, Los Angeles, CA, USA
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Nagata T, Minami K, Yamamoto M, Hiraki T, Idogawa M, Fujimoto K, Kageyama S, Tabata K, Kawahara K, Ueda K, Ikeda R, Kato Y, Komatsu M, Tanimoto A, Furukawa T, Sato M. BHLHE41/DEC2 Expression Induces Autophagic Cell Death in Lung Cancer Cells and Is Associated with Favorable Prognosis for Patients with Lung Adenocarcinoma. Int J Mol Sci 2021; 22:ijms222111509. [PMID: 34768959 PMCID: PMC8584041 DOI: 10.3390/ijms222111509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/27/2021] [Accepted: 10/04/2021] [Indexed: 12/22/2022] Open
Abstract
Lung cancer constitutes a threat to human health. BHLHE41 plays important roles in circadian rhythm and cell differentiation as a negative regulatory transcription factor. This study investigates the role of BHLHE41 in lung cancer progression. We analyzed BHLHE41 function via in silico and immunohistochemical studies of 177 surgically resected non-small cell lung cancer (NSCLC) samples and 18 early lung squamous cell carcinoma (LUSC) cases. We also examined doxycycline (DOX)-inducible BHLHE41-expressing A549 and H2030 adenocarcinoma cells. BHLHE41 expression was higher in normal lung than in lung adenocarcinoma (LUAD) tissues and was associated with better prognosis for the overall survival (OS) of patients. In total, 15 of 132 LUAD tissues expressed BHLHE41 in normal lung epithelial cells. Staining was mainly observed in adenocarcinoma in situ and the lepidic growth part of invasive cancer tissue. BHLHE41 expression constituted a favorable prognostic factor for OS (p = 0.049) and cause-specific survival (p = 0.042) in patients with LUAD. During early LUSC, 7 of 18 cases expressed BHLHE41, and this expression was inversely correlated with the depth of invasion. DOX suppressed cell proliferation and increased the autophagy protein LC3, while chloroquine enhanced LC3 accumulation and suppressed cell death. In a xenograft model, DOX suppressed tumor growth. Our results indicate that BHLHE41 expression prevents early lung tumor malignant progression by inducing autophagic cell death in NSCLC.
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Affiliation(s)
- Toshiyuki Nagata
- Department of General Thoracic Surgery, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (T.N.); (K.U.); (M.S.)
- Department of Molecular Oncology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.M.); (M.Y.); (K.K.)
| | - Kentaro Minami
- Department of Molecular Oncology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.M.); (M.Y.); (K.K.)
- Department of Pharmacy, University of Miyazaki Hospital, 5200 Kihara Kiyotake cho, Miyazaki 889-1692, Japan;
| | - Masatatsu Yamamoto
- Department of Molecular Oncology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.M.); (M.Y.); (K.K.)
| | - Tsubasa Hiraki
- Department of Pathology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (T.H.); (K.T.); (A.T.)
| | - Masashi Idogawa
- Department of Medical Genome Sciences, Research Institute for Frontier Medicine, Sapporo Medical University, Sapporo 060-8556, Japan;
| | - Katsumi Fujimoto
- Department of Dental and Medical Biochemistry, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (K.F.); (Y.K.)
| | - Shun Kageyama
- Department of Physiology, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo 113-8421, Japan; (S.K.); (M.K.)
| | - Kazuhiro Tabata
- Department of Pathology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (T.H.); (K.T.); (A.T.)
| | - Kohichi Kawahara
- Department of Molecular Oncology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.M.); (M.Y.); (K.K.)
| | - Kazuhiro Ueda
- Department of General Thoracic Surgery, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (T.N.); (K.U.); (M.S.)
| | - Ryuji Ikeda
- Department of Pharmacy, University of Miyazaki Hospital, 5200 Kihara Kiyotake cho, Miyazaki 889-1692, Japan;
| | - Yukio Kato
- Department of Dental and Medical Biochemistry, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (K.F.); (Y.K.)
| | - Masaaki Komatsu
- Department of Physiology, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo 113-8421, Japan; (S.K.); (M.K.)
| | - Akihide Tanimoto
- Department of Pathology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (T.H.); (K.T.); (A.T.)
- Center for the Research of Advanced Diagnosis and Therapy of Cancer, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
| | - Tatsuhiko Furukawa
- Department of Molecular Oncology, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.M.); (M.Y.); (K.K.)
- Center for the Research of Advanced Diagnosis and Therapy of Cancer, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
- Correspondence: ; Tel.: +81-99-275-5490
| | - Masami Sato
- Department of General Thoracic Surgery, Graduate School Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (T.N.); (K.U.); (M.S.)
- Center for the Research of Advanced Diagnosis and Therapy of Cancer, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
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Sachs E, Sartipy U, Jackson V. Sex and Survival After Surgery for Lung Cancer: A Swedish Nationwide Cohort. Chest 2021; 159:2029-2039. [PMID: 33217414 PMCID: PMC8129733 DOI: 10.1016/j.chest.2020.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Prior reports on a possible female survival advantage in both surgical and nonsurgical cohorts of patients with lung cancer are conflicting. Previously reported differences in survival after lung cancer surgery could be the result of insufficient control for disparities in risk factor profiles in men and women. RESEARCH QUESTION Do women who undergo pulmonary resections for lung cancer have a better prognosis than men when taking a wide range of prognostic factors into account? STUDY DESIGN AND METHODS We performed a nationwide population-based observational cohort study analyzing sex-specific survival after pulmonary resections for lung cancer. We identified 6356 patients from the Swedish National Quality Register for General Thoracic Surgery and performed individual-level record linkage to other national health-data registers to acquire detailed information regarding comorbidity, socioeconomic status, and vital status. Inverse probability of treatment weighting was used to account for differences in baseline characteristics. The association between female sex and all-cause mortality was assessed with Cox regression models, and flexible parametric survival models were used to estimate the absolute survival differences with 95% CIs. We also estimated the difference in restricted mean survival time. RESULTS We observed a lower risk of death in women compared with men (hazard ratio, 0.73; 95% CI, 0.67-0.79). The absolute survival difference at 1, 5, and 10 years was 3.0% (95% CI, 2.2%-3.8%), 10% (95% CI, 7.0%-12%), and 12% (95% CI, 8.5%-15%), respectively. The restricted mean survival time difference at 10 years was 0.84 year (95% CI, 0.61-1.07 years). The findings were consistent across several subgroups. INTERPRETATION Women who underwent pulmonary resections for lung cancer had a significantly better prognosis than men. The survival advantage was evident regardless of age, common comorbidities, socioeconomic status, lifestyle factors, physical performance, type and extent of surgery, tumor characteristics, and stage of disease. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03567538; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Erik Sachs
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Veronica Jackson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Casal-Mouriño A, Ruano-Ravina A, Lorenzo-González M, Rodríguez-Martínez Á, Giraldo-Osorio A, Varela-Lema L, Pereiro-Brea T, Barros-Dios JM, Valdés-Cuadrado L, Pérez-Ríos M. Epidemiology of stage III lung cancer: frequency, diagnostic characteristics, and survival. Transl Lung Cancer Res 2021; 10:506-518. [PMID: 33569332 PMCID: PMC7867742 DOI: 10.21037/tlcr.2020.03.40] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/04/2020] [Indexed: 12/24/2022]
Abstract
Stage III non-small cell lung cancer (NSCLC) includes a highly heterogeneous group of patients with differences in the extent and localization of disease. Many aspects of stage III disease are controversial. The data supporting treatment approaches are often subject to a number of limitations, due to the heterogeneous patient populations involved in the trials. Furthermore, the definition of stage III disease has changed over time, and early studies were frequently inadequately powered to detect small differences in therapeutic outcome, were not randomized, or had a limited follow-up times. Major improvements in therapy, including the use of more active chemotherapy agents and refinements in radiation and surgical techniques, also limit the interpretation of earlier clinical trials. Lastly, improvements in pretreatment staging have led to reclassification of patients with relatively minimal metastatic disease as stage IV rather than stage III, leading to an apparent increase in the overall survival of both stage III and IV patients. Median overall stage III NSCLC survival ranges from 9 to 34 months. Higher survival rates are observed in younger Caucasian women with good performance status, adenocarcinoma, mutations, stage IIIA, and in patients with multidisciplinary-team-based diagnoses.
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Affiliation(s)
- Ana Casal-Mouriño
- Department of Pneumology, Santiago de Compostela University Clinical Teaching Hospital, Galicia, Spain
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
| | - Alberto Ruano-Ravina
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología and Salud Pública/CIBERESP), Madrid, Spain
| | - María Lorenzo-González
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Population Screening Unit, Galician Regional Health Authority, Santiago de Compostela, Spain
| | - Ángeles Rodríguez-Martínez
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Department of Oncology, Pontevedra University Hospital Complex, Pontevedra, Spain
| | - Alexandra Giraldo-Osorio
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Research Group for Health Promotion and Disease Prevention, Department of Public Health, University of Caldas, Manizales, Colombia
| | - Leonor Varela-Lema
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Scientific-Technical Advisory Unit, Galician Health Technology Assessment Agency, Health Knowledge Management Agency (Unidade de Asesoramento Científico-técnico/avalia-t, Axencia de Coñecemento en Saúde/ACIS), Galician Regional Health Authority, Galicia, Spain
| | - Tara Pereiro-Brea
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Department of Pneumology, A Coruña University Teaching Hospital Complex, A Coruña, Spain
| | - Juan Miguel Barros-Dios
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
| | - Luis Valdés-Cuadrado
- Department of Pneumology, Santiago de Compostela University Clinical Teaching Hospital, Galicia, Spain
- Interdisciplinary Group of Research in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Mónica Pérez-Ríos
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, A Coruña, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología and Salud Pública/CIBERESP), Madrid, Spain
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Zheng Y, Huang Y, Bi G, Chen Z, Lu T, Xu S, Zhan C, Wang Q. Enlarged Mediastinal Lymph Nodes in Computed Tomography are a Valuable Prognostic Factor in Non-Small Cell Lung Cancer Patients with Pathologically Negative Lymph Nodes. Cancer Manag Res 2020; 12:10875-10886. [PMID: 33149692 PMCID: PMC7605607 DOI: 10.2147/cmar.s271365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background Most non-small cell lung cancer patients with enlarged mediastinal lymph nodes (LN) in preoperative computer tomography (CT) images are diagnosed with N0 in the pathological examination after surgery. However, these patients seem to have worse survival than those without enlarged mediastinal LN in our clinical practice. This study aimed to investigate whether the size of mediastinal LN is correlated with the prognosis in pathological N0 patients, which could help us to predict the prognoses further. Methods The retrospective cohort study involved 758 N0 patients with a thin layer CT scan. We have measured the size of mediastinal LN, including long diameter, short diameter, and volume on CT image, and classified patients by X-tile. Next, we explored the risk factors of enlarged LN by univariate and multivariate logistic analysis. Then, we have compared the 5-year cancer-specific survival by Kaplan-Meier and log-rank method. Multivariate Cox analysis was utilized to further survival analysis. Finally, we have constructed the prediction model by nomogram. Results A total of 150 N0 patients (19.8%) had mediastinal LN enlargement in our study. After multivariate logistic analysis, we found the LN enlargement was significantly correlated with age (p=0.001), pathology (p < 0.001) and tumor recurrence (p < 0.001). The patients with LN enlargement had a worse 5-year cancer-specific survival (75.3% vs 92.8%, p < 0.001) after Kaplan-Meier analysis. Patients with a larger volume had increased risk of tumor-associated death when compared with the normal group (p < 0.001) by multivariate Cox analyses. Conclusion N0 patients with larger mediastinal LN had a worse 5-year cancer-specific survival and a higher risk of recurrence. The volume of LN was the most valuable prognostic factor in N0 patients.
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Affiliation(s)
- Yuansheng Zheng
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
| | - Yiwei Huang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
| | - Guoshu Bi
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
| | - Zhencong Chen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
| | - Tao Lu
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
| | - Songtao Xu
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China.,Department of Thoracic Surgery, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen City, Fujian Province, People's Republic of China
| | - Cheng Zhan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
| | - Qun Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai City, People's Republic of China
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10
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Integrated analysis of long non-coding RNAs and mRNA profiles reveals potential sex-dependent biomarkers of bevacizumab/erlotinib response in advanced lung cancer. PLoS One 2020; 15:e0240633. [PMID: 33075110 PMCID: PMC7571718 DOI: 10.1371/journal.pone.0240633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/25/2020] [Indexed: 11/19/2022] Open
Abstract
Background While lung cancer patient outcomes are well-recognized to vary as a function of patient sex, there has been insufficient research regarding the relationship between patient sex and EGFR(Epidermal growth factor receptor) response efficacy. The present study therefore sought to identify novel sex-related biomarkers of bevacizumab/erlotinib (BE) responses in non-small cell lung cancer (NSCLC) patients. Methods The exon array data in the Gene Expression Omnibus (GEO) dataset were analyzed in order to identify patterns of mRNA and lncRNA expression associated with BE resistance in NSCLC. These differentially expressed (DE) lncRNAs and mRNAs were identified via DE Analysis Filtering. These DE mRNAs were then assessed for their potential functional roles via pathway enrichment analyses, with overlapping functions possibly associated with the BE resistance. The mRNAs in these overlapping groups were then assessed for their correlations with patient survival, and lncRNA-mRNA co-expression networks were generated for each patient subset. A protein-protein interaction (PPI) network was also generated based upon these DE mRNAs. Results In females we identified 172 DE lncRNAs and 1766 DE mRNAs associated with BE responses, while in males we identified 78 DE lncRNAs and 485 DE mRNAs associated with such responses. Based on the overlap between these two datasets, we identified a total of 37 GO functions and 18 pathways associated with BE responses. Co-expression and PPI networks suggested that the key lncRNAs and mRNAs associated with these BE response mechanisms weredifferent in the male and female patients. Conclusions This work is the first to conduct a global profiling of the relationship between lncRNA and mRNA expression patterns, patient sex, and BE responses in individuals suffering from NSCLC. Together these results suggest that the integrative lncRNA-mRNA expression analyses may offer invaluable new therapeutic insights that can guide the tailored treatment of lung cancer in order to ensure optimal BE responses.
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Lung cancer LDCT screening and mortality reduction - evidence, pitfalls and future perspectives. Nat Rev Clin Oncol 2020; 18:135-151. [PMID: 33046839 DOI: 10.1038/s41571-020-00432-6] [Citation(s) in RCA: 220] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 12/17/2022]
Abstract
In the past decade, the introduction of molecularly targeted agents and immune-checkpoint inhibitors has led to improved survival outcomes for patients with advanced-stage lung cancer; however, this disease remains the leading cause of cancer-related mortality worldwide. Two large randomized controlled trials of low-dose CT (LDCT)-based lung cancer screening in high-risk populations - the US National Lung Screening Trial (NLST) and NELSON - have provided evidence of a statistically significant mortality reduction in patients. LDCT-based screening programmes for individuals at a high risk of lung cancer have already been implemented in the USA. Furthermore, implementation programmes are currently underway in the UK following the success of the UK Lung Cancer Screening (UKLS) trial, which included the Liverpool Health Lung Project, Manchester Lung Health Check, the Lung Screen Uptake Trial, the West London Lung Cancer Screening pilot and the Yorkshire Lung Screening trial. In this Review, we focus on the current evidence on LDCT-based lung cancer screening and discuss the clinical developments in high-risk populations worldwide; additionally, we address aspects such as cost-effectiveness. We present a framework to define the scope of future implementation research on lung cancer screening programmes referred to as Screening Planning and Implementation RAtionale for Lung cancer (SPIRAL).
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12
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Denman AR, Groves-Kirkby CJ, Crockett RGM. Cost-effectiveness of radon remediation programmes in the UK in the 2020s. JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2020; 222:106351. [PMID: 32892905 DOI: 10.1016/j.jenvrad.2020.106351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 06/11/2023]
Abstract
Radon, a gaseous radioactive decay product of naturally-occurring uranium is widely distributed in the environment in rocks and soils and, in certain circumstances, can accumulate in the built environment. Initial studies confirmed a direct link between exposure to both radon gas and its short-lived radioactive progeny, and increased lung-cancer incidence, and demonstrated that radon levels in domestic housing can be sufficiently high to expose occupants to increased risk of lung-cancer. Subsequent studies worldwide have shown that it is cost-effective to detect and reduce domestic radon levels in order to reduce this risk. Recent advances in the early detection of lung-cancer, coupled with the development of improved treatment procedures, have progressively improved survival from the disease, with the numbers surviving at 5 years doubling over recent years, during which period the real costs of lung cancer treatment have risen by around 30%. In the meantime, however, in addition to radon and tobacco-smoke, other airborne pollutants have been identified as risk-factors for lung-cancer. This paper reviews both these actual developments and anticipated future trends, and concludes that since these advances in diagnosis and treatment of lung-cancer have had only a modest effect on cost-effectiveness, it is still important to conduct radon monitoring and remediation programmes. While the general increase in life-expectancy improves the cost-effectiveness of radon remediation programmes significantly, reducing tobacco-smoking incidence reduces that cost-effectiveness but with the overall benefit of reducing radon-related lung-cancers. The challenge remains of encouraging affected householders to remediate their homes to reduce radon levels.
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Affiliation(s)
- Antony R Denman
- Faculty of Arts, Science and Technology, The University of Northampton, University Drive, Northampton, NN1 5PH, UK.
| | - Christopher J Groves-Kirkby
- Faculty of Arts, Science and Technology, The University of Northampton, University Drive, Northampton, NN1 5PH, UK.
| | - Robin G M Crockett
- Faculty of Arts, Science and Technology, The University of Northampton, University Drive, Northampton, NN1 5PH, UK.
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13
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Abstract
Lung cancer is the first cause of death from malignant disease. The distressing epidemiological data show the increasing female to male incidence ratio for this tumor. A high incidence of lung cancer in never smokers with importance of environmental agents makes a problem among women. Adenocarcinoma (ADC) is noted in women with increasing rate and ethnic background impacts female lung cancer with differences in the incidence of genetic aberrations. The conception of different hormonal status is taken into consideration as potential explanation of variant cancer biology and clinical manifestation in women and men. The impact of 17-β-estradiol, estrogen receptors, aromatase expression, pituitary sex hormones receptors in carcinogenesis with relation between estrogens and genetic aberrations are investigated. The response to newest therapies among female is also different than in men. This overview summarizes currently available evidence on the specificity of female lung cancer and presents the direction of necessary studies.
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Affiliation(s)
- Joanna Domagala-Kulawik
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Anna Trojnar
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
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CORR Insights®: Patterns of Change Over Time in Knee Bone Shape Are Associated with Sex. Clin Orthop Relat Res 2020; 478:1503-1505. [PMID: 32452930 PMCID: PMC7310454 DOI: 10.1097/corr.0000000000001307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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15
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Freudenstein D, Litchfield C, Caramia F, Wright G, Solomon BJ, Ball D, Keam SP, Neeson P, Haupt Y, Haupt S. TP53 Status, Patient Sex, and the Immune Response as Determinants of Lung Cancer Patient Survival. Cancers (Basel) 2020; 12:cancers12061535. [PMID: 32545367 PMCID: PMC7352604 DOI: 10.3390/cancers12061535] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 12/19/2022] Open
Abstract
Lung cancer poses the greatest cancer-related death risk and males have poorer outcomes than females, for unknown reasons. Patient sex is not a biological variable considered in lung cancer standard of care. Correlating patient genetics with outcomes is predicted to open avenues for improved management. Using a bioinformatics approach across non-small cell lung cancer (NSCLC) subtypes, we identified where patient sex, mutation of the major tumor suppressor gene, Tumour protein P53 (TP53), and immune signatures stratified outcomes in lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC), among datasets of The Cancer Genome Atlas (TCGA). We exposed sex and TP53 gene mutations as prognostic for LUAD survival. Longest survival in LUAD occurred among females with wild-type (wt) TP53 genes, high levels of immune infiltration and enrichment for pathway signatures of Interferon Gamma (INF-γ), Tumour Necrosis Factor (TNF) and macrophages-monocytes. In contrast, poor survival in men with LUAD and wt TP53 genes corresponded with enrichment of Transforming Growth Factor Beta 1 (TGFB1, hereafter TGF-β) and wound healing signatures. In LUAD with wt TP53 genes, elevated gene expression of immune checkpoint CD274 (hereafter: PD-L1) and also protein 53 (p53) negative-regulators of the Mouse Double Minute (MDM)-family predict novel avenues for combined immunotherapies. LUSC is dominated by male smokers with TP53 gene mutations, while a minor population of TCGA LC patients with wt TP53 genes unexpectedly had the poorest survival, suggestive of a separate etiology. We conclude that advanced approaches to LUAD and LUSC therapy lie in the consideration of patient sex, TP53 gene mutation status and immune signatures.
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Affiliation(s)
- Donald Freudenstein
- Tumor Suppression Laboratory, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia; (D.F.); (C.L.); (F.C.); (S.P.K.); (Y.H.)
| | - Cassandra Litchfield
- Tumor Suppression Laboratory, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia; (D.F.); (C.L.); (F.C.); (S.P.K.); (Y.H.)
| | - Franco Caramia
- Tumor Suppression Laboratory, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia; (D.F.); (C.L.); (F.C.); (S.P.K.); (Y.H.)
| | - Gavin Wright
- Department of Surgery, St Vincent’s Hospital, The University of Melbourne, Fitzroy, VIC 3065, Australia;
| | - Benjamin J. Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia;
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia; (D.B.); (P.N.)
| | - David Ball
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia; (D.B.); (P.N.)
- Department of Radiation Oncology Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia
| | - Simon P. Keam
- Tumor Suppression Laboratory, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia; (D.F.); (C.L.); (F.C.); (S.P.K.); (Y.H.)
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia; (D.B.); (P.N.)
- Cancer Immunology Research, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia
| | - Paul Neeson
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia; (D.B.); (P.N.)
- Cancer Immunology Research, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia
| | - Ygal Haupt
- Tumor Suppression Laboratory, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia; (D.F.); (C.L.); (F.C.); (S.P.K.); (Y.H.)
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia; (D.B.); (P.N.)
- Department of Clinical Pathology, University of Melbourne, Parkville, VIC 3010, Australia
- Department of Biochemistry and Molecular Biology, Monash University, Melbourne, VIC 3004, Australia
| | - Sue Haupt
- Tumor Suppression Laboratory, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, 3000, Australia; (D.F.); (C.L.); (F.C.); (S.P.K.); (Y.H.)
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia; (D.B.); (P.N.)
- Department of Clinical Pathology, University of Melbourne, Parkville, VIC 3010, Australia
- Correspondence:
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Educational level, management and outcomes in small-cell lung cancer (SCLC): A population-based cohort study. Lung Cancer 2020; 139:111-117. [DOI: 10.1016/j.lungcan.2019.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 12/27/2022]
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17
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Wang Y, Pang Z, Chen X, Bie F, Wang Y, Wang G, Liu Q, Du J. Survival nomogram for patients with initially diagnosed metastatic non-small-cell lung cancer: a SEER-based study. Future Oncol 2019; 15:3395-3409. [PMID: 31512954 DOI: 10.2217/fon-2019-0007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aim: Prognosis of patients with metastatic non-small-cell lung cancer differ widely. Methods: All patients were randomly divided into training or validation cohort. Cox-regression analyses were conducted to select independent predictors. We built a nomogram by R code and evaluated the accuracy and the reliability of the model using C-index, calibration curves and decision curve analyses. We made a risk classification system based on the nomogram. Results: In the validation cohort, C-index was 0.729 and 0.738 for 1- and 2-year overall survival. Calibration plots and decision curve analyses presented great prognostic accuracy and clinical applicability. Its prognostic accuracy preceded the American Joint Committee on Cancer staging with evaluated integrated discrimination improvement. Conclusion: The model can be a practical tool in treatment decision and individual counseling.
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Affiliation(s)
- Yu Wang
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Zhaofei Pang
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Xiaowei Chen
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Fenglong Bie
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Yadong Wang
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Guanghui Wang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Qi Liu
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
| | - Jiajun Du
- Institute of Oncology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China.,Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, PR China
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18
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Radkiewicz C, Dickman PW, Johansson ALV, Wagenius G, Edgren G, Lambe M. Sex and survival in non-small cell lung cancer: A nationwide cohort study. PLoS One 2019; 14:e0219206. [PMID: 31247015 PMCID: PMC6597110 DOI: 10.1371/journal.pone.0219206] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/18/2019] [Indexed: 12/25/2022] Open
Abstract
Aim To in detail delineate sex differences in non-small cell lung cancer outcome and investigate possible underlying drivers. Methods We performed a nationwide, population-based cohort study using data on all incident cases of lung squamous cell carcinoma (n = 10,325) and adenocarcinoma (n = 23,465) recorded in the Swedish Lung Cancer Register in 2002–2016. Flexible parametric models were applied to compute adjusted female-to-male hazard ratios (aHRs) and standardized survival proportions over follow-up including age, calendar year, education, marital status, birth country, health care region, performance status, smoking history, comorbidities, and tumor location in the final model. Results Women presented with better performance status, were younger, and more often never-smokers. Women with adenocarcinoma also had lower comorbidity burden, less advanced stage, and were more often EGFR positive. Men with adenocarcinoma had a consistently poorer lung cancer-specific survival across stage; HR 0.69; 95% CI 0.63–0.76 (stage IA-IIB) to 0.94; 95% CI 0.88–0.99 (stage IIIB-IV), remaining largely unchanged after adjustments; aHR 0.74; 95% CI 0.66–0.82 to 0.84; 95% CI 0.81–0.87. The same pattern was observed in squamous cell carcinoma, except in stage IIIA disease, where we found no sex differences in survival. Conclusions Men with non-small cell lung cancer have a consistently poorer prognosis, even after careful adjustments for a wide range of prognostic factors. While the pattern was similar in both squamous cell and adenocarcinoma, it was larger and more consistent in the latter.
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Affiliation(s)
- Cecilia Radkiewicz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Södersjukhuset, Stockholm, Sweden
- * E-mail:
| | - Paul William Dickman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Anna Louise Viktoria Johansson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Cancer Registry of Norway, Oslo, Norway
| | - Gunnar Wagenius
- Cancer Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gustaf Edgren
- Department of Medicine Solna, Clinical Epidemiology Division T2, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Mats Lambe
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Regional Cancer Center Uppsala-Örebro, Uppsala, Sweden
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19
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Abstract
Gender-affirming hormonal treatment (HT) in transgender people is considered safe in general, but the question regarding (long-term) risk on sex hormone-related cancer remains. Because the risk on certain types of cancer differs between men and women, and some of these differences are attributed to exposure to sex hormones, the cancer risk may be altered in transgender people receiving HT. Although reliable epidemiologic data are sparse, the available data will be discussed in this article. Furthermore, recommendations for cancer screening and prevention will be discussed as well as whether to withdraw HT at time of a cancer diagnosis.
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Affiliation(s)
- Christel J M de Blok
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Koen M A Dreijerink
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Internal Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
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