Ninety-day mortality following curative intent radiotherapy for stage I-III lung cancer in the Netherlands

BACKGROUND AND PURPOSE

The 90-day mortality following lung cancer treatment is a common performance indicator. The aim of this study was to investigate 90-day mortality following (chemo)radiotherapy for stage I-III lung cancer to evaluate the applicability of this outcome indicator in this patient population.

MATERIALS AND METHODS

The Netherlands National Cancer Registry was queried for this retrospective population-based study. Early mortality rates from the start and end of radiotherapy are reported with 95% confidence intervals (CI). The association between clinical characteristics and 90-day mortality was evaluated with multivariable logistic regression analysis.

RESULTS

18,355 Patients treated between 2015 and 2020 were included. The 90-day mortality was 2.56% in stages I-II and 4.60% in stage III, was significantly higher in males, elderly patients and patients with a poor performance status and independent of facility volume. In stage I-II, 90-day mortality was lower after stereotactic versus conventional radiotherapy (2.0% versus 5.25%, OR 0.5 (95%CI 0.4-0.7)). In stage III, mortality decreased from 5.26% in 2015-2016 to 3.73% in 2019-2020 (OR 0.7 (95% CI 0.5-0.9)) and was lower after concurrent versus sequential chemoradiotherapy (3.4% versus 5.9%, OR 1.5 (95%CI 1.2-1.9)). Early mortality increased to 3.20% in stages I-II and 6.70% in stage III when calculated from the end of radiotherapy.

CONCLUSION

Short-term mortality rates following curative intent radiotherapy for lung cancer in the Netherlands are low and independent of facility volume. It was demonstrated that 90-day mortality is an arguable indicator to monitor radiotherapy quality and that standardization of definitions and relevant case-mix factors is warranted.

Stereotactic Lung Re-Irradiation After a First Course of Stereotactic Radiotherapy with In-Field Relapse: A Valuable Option to Be Considered

BACKGROUND/OBJECTIVES

Stereotactic body radiation therapy (SBRT) has demonstrated high local control rates for inoperable early-stage lung cancers. However, 5-15% of patients experience local relapse within the irradiated volume after treatment, with limited curative salvage options. The aim of this review is to clarify the modalities and outcomes after a second course of SBRT in patients with local relapse after a previous lung SBRT.

METHODS

An exhaustive literature review was conducted to identify, analyse and summarise the results of 21 main studies.

RESULTS

Local repeat lung SBRT after a first course of SBRT showed a favourable local control at 1 and 2 years, ranging from 70 to 90% and 45 to 80%, respectively. Good overall survival rates were also observed at 1 and 2 years reaching up to 95% and 85%, respectively. Toxicity was rare but could be severe, with cases of Grade 4 and 5 toxicities (≈5%). An important dose relationship was observed between re-irradiation dose levels and local control, highlighting the importance of precise dosing. The cumulative doses impacting organs at risk were similarly associated with increased radiation-induced toxicity. Central lung lesions presented a higher risk for severe side effects compared to peripheral ones.

CONCLUSIONS

In conclusion, repeat lung SBRT after a first course of SBRT represents a feasible treatment option in cases of local recurrence. In order to limit severe toxicity, patients must be carefully selected, and particular attention should be given to cumulative doses to organs at risk, as well as tumour location. Thus, further investigations are still needed to refine the optimal parameters for SBRT lung re-irradiation.

Treating early-stage centrally-located non-small cell lung cancer with DCAT-SBRT in centers lacking the VMAT technique: a comprehensive study

Background

Volumetric-modulated arc therapy (VMAT) may have the highest overall performance for stereotactic body radiotherapy (SBRT) treatment of inoperable early-stage NSCLC. However, in centers lacking the VMAT technique, the dynamic conformal arc therapy (DCAT) technique is potentially the best option for small and rounded NSCLC-SBRT. Therefore, we will comprehensively analyze the advantages of the DCAT versus the other techniques except VMAT in terms of dosimetry, plan complexity, delivery time, γ-passing rates and the interplay effect.

Methods

36 patients with early-stage centrally located NSCLC with PTV volumes < 65 cc were enrolled. All patients were redesigned with 50Gy/5f, and 100% of the prescribed dose was normalized to cover 95% of the PTV. The other two delivery techniques compared to the DCAT technique include 3-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT), which use the same parameters for all three techniques.

Results

The dosimetric parameters of the 3-group plans all met the RTOG 0813 protocol. Unsurprisingly, plan complexity parameters such as segments and MUs were significantly reduced in the DCAT plans by 159.56 and 925.90 compared to the IMRT plans, respectively (all P < 0.001). The delivery time of the DCAT plans was the least of 164.51 s (all P < 0.05). Compared to the IMRT plans, the γ-passing rates were higher in the DCAT plans (P < 0.001), with the most significant difference of 6.01% in the (2%, 1 mm) criteria. As for the interplay effect, the mean dose difference (MDD) in the DCAT plans was as good as the 3DCRT plans at different respiratory amplitudes but better than the IMRT plans (all P < 0.05), and the MDD of DCAT plans did not exceed 3% in all respiratory amplitude.

Conclusion

In centers lacking the VMAT technique, implementing SBRT treatment based on the DCAT technique for inoperable early-stage centrally-located NSCLC patients with PTV volumes < 65 cc achieves better treatment efficiency and delivery accuracy while maintaining the plan quality.

Peri- and postoperative morbidity and mortality in older patients with non-small cell lung cancer: a matched-pair study

BACKGROUND

Reports from case series suggest that operative outcomes are comparable amongst different age groups following surgery with curative intent for non-small cell lung cancer (NSCLC). The purpose of this study was to compare morbidity and mortality after NSCLC surgery in older patients (≥ 75 years) versus younger patients (< 75 years) and identify independent predictive risk factors.

METHODS

We identified 2015 patients with postoperative stages IA to IIIA according to AJCC/UICC 7th edition who had undergone NSCLC surgery with curative intent at a single specialized lung cancer center from January 2010 to December 2015. A matched-pair analysis was performed on 227 older patients and corresponding 227 younger patients. Short-term surgical outcomes were postoperative morbidity, length of hospital stay, 30-day and 90-day mortality. Long-term operative outcomes were disease-free and overall survival.

RESULTS

454 patients were included in the matched-pair analysis. 36% of younger patients developed postoperative complications versus 42% in older patients (p = 0.163). Age was not significantly associated with the occurrence of postoperative complications. Median length of hospital stay was 14 days in older patients and 13 days in younger patients (p = 0.185). 90-day mortality was 2.2% in younger patients compared to 4% in older patients (p = 0.424). In patients aged 75 and older impaired performance status (ECOG ≥ 1) was associated with decreased overall survival (HR = 2.15, CI 1.34-3.46), as were preoperative serum C-reactive protein / albumin ratio ≥ 0.3 (HR = 1.95, CI 1.23-3.11) and elevated preoperative serum creatinine levels ≥ 1.1 mg/dl (HR = 1.84, CI 1.15-2.95). In the younger cohort male sex (HR = 2.26, CI 1.17-4.36), postoperative stage III disease (HR 4.61, CI 2.23-9.54) and preoperative anemia (hemoglobin < 12 g/dl) (HR 2.09, CI 1.10-3.96) were associated with decreased overall survival.

CONCLUSIONS

Lung resection for NSCLC in older patients is associated with postoperative morbidity and mortality comparable to those of younger patients. In older patients, physical activity, comorbidities and nutritional status are related to survival and should influence the indication for surgery rather than age alone.

Service Improvements and Workload Increases: Royal College of Radiologists (RCR) Re-Audit of Curative Intent Radiotherapy for Non-Small Cell Lung Cancer (NSCLC)

AIMS

The Royal College of Radiologists (RCR) audit of radical radiotherapy (RR) for patients with non-small cell lung cancer (NSCLC) in 2013 concluded that there was under-treatment compared to international comparators and marked variability between cancer networks. Elderly patients were less likely to receive guideline recommended treatments. Access to technological developments was low. Various national and local interventions have since taken place. This study aims to re-assess national practice.

MATERIALS AND METHODS

Radiotherapy departments completed one questionnaire for each patient started on RR for 4 weeks in January 2023.

RESULTS

Ninety-three percent of centres returned data on 295 patients. RR has increased 70% since 2013 but patients on average wait 20% longer to start treatment (p = 0.02). Staging investigations were often outside a desirable timeframe (79% of PET/CT scans). Advanced planning techniques are used more frequently: 4-dimensional planning increased from 33% to 90% (P < 0.001), cone beam imaging from 67% to 97% (p < 0.001) and colleague led peer review increased from 41% to 73% (P < 0.001).

CONCLUSION

There have been significant improvements in care. There has been a considerable increase in clinical oncology workload with evidence of stress on the system that requires additional resourcing.

The management of stage I Non-Small cell lung cancer (NSCLC) in Ontario: A Population-Based study of patterns of care and Stereotactic Ablative Body radiotherapy (SABR) utilization from 2010 to 2019

BACKGROUND

Stereotactic Ablative Body Radiotherapy (SABR) is the standard of care for medically inoperable patients with Stage I NSCLC. The adoption of SABR and its association with cancer outcomes requires characterization.

AIM

We described the management of biopsy-proven Stage I NSCLC with SABR, surgery, non-SABR curative radiotherapy (RT) and observation in Ontario, Canada, between 2010 and 2019. Temporal and geographic trends in practice and survival outcomes were analyzed.

METHODS

This was a retrospective population-based cohort study conducted by linking electronic radiotherapy (RT) records to a population-based cancer registry.

RESULTS

A total of 12,065 patients were identified, 61.7 % underwent surgery, 17.9 % received SABR, 8.6 % received non-SABR curative RT and 11.7 % were observed. Between 2010 and 2019, the utilization of surgery decreased (63.8 % to 49.9 %, p < 0.0001), while SABR use increased (7.5 % to 24.4 %, p < 0.0001), non-SABR curative RT use increased (6.7 % to 9.6 %, p < 0.0014) and patients observed decreased (14.4 % to 12.0 %, p < 0.0001). Substantial variation in practice exists across Ontario. Two- yr CSS improved for the entire cohort (81.9 % to 85.0 %, p < 0.0001). While there was improvement in 2 yr CSS for surgical patients (92.1 %% to 95.7 %, p < 0.001), survival for patients who received SABR, Non-SABR curative RT and observation remained stable.

CONCLUSION

There has been an increase in SABR utilization and a reduction in surgical utilization with a corresponding increased survival of stage I patients in Ontario between 2010 and 2019. Substantial differences in practice patterns exist across health regions, suggesting the need for strategies to improve access to SABR in many jurisdictions.

Utilisation of radiotherapy in lung cancer: A scoping narrative literature review with a focus on the introduction of evidence-based therapeutic approaches in Europe

Background and purpose

The aim of this study was to review the published studies on the utilisation of radiotherapy in lung cancer (both small and non-small cell lung cancer, SCLC and NSCLC) patients in European countries with a population-based perspective.

Material and methods

A literature search since January 2000 until December 2022 was carried out. Only English-published papers were included, and only European data was considered. PRISMA guidelines were followed. A scoping narrative review was undertaken due to the hetereogeneity of the published papers.

Results

38 papers were included in the analysis, with the majority from the Netherlands (52.6%) and the UK (18.4%). Large variability is observed in the reported radiotherapy utilisation, around 40% for NSCLC in general and between 26 and 42% in stage I NSCLC. Stereotactic body radiotherapy (SBRT) shows a wide range of utilisation across countries and over time, from 8 to 63%. Similary, in stage III lung cancer, chemoradiotherapy (CRT) utilisation varied considerably (11-70%). Eleven studies compared radiotherapy utilisation between older and younger age-groups, showing that younger patients receive more CRT, while the opposite applies for SBRT. An widespreadlack of data on relevant covariates such as comorbidty and health-services related variables is observed.

Conclusion

The actual utilisation of radiotherapy for lung cancer reported in patterns-of-care studies (POCs) is notably lower than the evidence-based optimal utilisation. Important variability is observed by country, time period, stage at diagnosis and age. A wider use of POCs should be promoted to improve our knowledge on the actual application of evidence-based treatment recommendations.

Local control and survival after stereotactic body radiation therapy of early-stage lung cancer patients in Slovenia

BACKGROUND

Stereotactic body radiation therapy (SBRT) precisely and non-invasively delivers ablative radiation dose to tumors in early-stage lung cancer patients who are not candidates for surgery or refuse it. The aim of research was to evaluate local control, overall survival (OS), local progression free survival (LPFS), distant metastases free survival (DMFS), disease free survival (DFS) and toxicity in early-stage lung cancer patients treated with SBRT in a single tertiary cancer centre.

PATIENTS AND METHODS

We retrospectively evaluated medical records and radiation treatment plan parameters of 228 tumors irradiated in 206 early-stage lung cancer patients between 2016 and 2021 at the Institute of Oncology Ljubljana.

RESULTS

After 25 months of median follow up, 68 of 206 (33%) patients died. Median OS was 46 months (CI 36-56), 1-year, 2-year and 3-year OS were 87%, 74% and 62% and 5-year OS was 31%. A total of 45 disease progressions have been identified in 41 patients. Local progress only was noticed in 5 (2%) patients, systemic progress in 32 (16%) and combined systemic and local in 4 (2%) patients. Local control rate (LCR) at 1 year was 98%, at 2 and 3 years 96% and 95% at 5 years. The 1-, 2- and 3-year LPFS were 98%, 96% and 94%, respectively and 5-year LPFS was 82%. One, 2-, 3- and 5-year DFS were 89%, 81%, 72% and 49%, respectively. Among 28 toxicities recorded only one was Grade 4 (pneumonitis), all others were Grade 1 or 2. No differences in LCR, LPFS, DFS were found in univariate analysis comparing patient, tumor, and treatment characteristics. For OS the only statistically significant difference was found in patients with more than 3 comorbidities compared to those with less comorbidities.

CONCLUSIONS

Early lung cancer treated with SBRT at single tertiary cancer centre showed that LCR, LPFS, DFS, DMFS and OS were comparable to published studies. Patients with many comorbidities had significantly worse overall survival compared to those with less comorbidities. No other significant differences by patient, tumor, or treatment characteristics were found for DMFS, LPFS, and DFS. Toxicity data confirmed that treatment was well tolerated.

Mortality after radiotherapy or surgery in the treatment of early-stage non-small-cell lung cancer: a population-based data analysis in the clinical cancer registry of Brandenburg-Berlin

PURPOSE

Stereotactic body radiotherapy (SBRT) is an established treatment method with favorable toxicity for inoperable early-stage non-small-cell lung cancer (NSCLC) patients. This paper aims to evaluate the importance of SBRT in the treatment of early-stage lung cancer patients compared to surgery as standard of care.

METHODS

The German clinical cancer register of Berlin-Brandenburg was assessed. Cases of lung cancer were considered if they had a TNM stage (clinical or pathological) of T1-T2a and N0/x and M0/x, corresponding to UICC stages I and II. In our analyses, cases diagnosed between 2000 and 2015 were included. We adjusted our models with propensity score matching. We compared patients treated with SBRT or surgery regarding age, Karnofsky performance status (KPS), sex, histological grade, and TNM classification. Further, we assessed the association of cancer-related parameters with mortality; hazard ratios (HR) from Cox proportional hazards models were computed.

RESULTS

A total of 558 patients with UICC stages I and II NSCLC were analyzed. In univariate survival models, we found similar survival rates in patients who underwent radiotherapy compared with surgery (HR 1.2, 95% confidence interval [CI] 0.92-1.56; p = 0.2). Our univariate subgroup analyses of patients > 75 years showed a statistically nonsignificant survival benefit for patients treated with SBRT (HR 0.86, 95% CI 0.54-1.35; p = 0.5). Likewise, in our T1 subanalysis, survival rates were similar between the two treatment groups regarding overall survival (HR 1.12, 95% CI 0.57-2.19; p = 0.7). The availability of histological data might be slightly beneficial in terms of survival (HR 0.89, 95% CI 0.68-1.15; p = 0.4). This effect was also not significant. Regarding the availability of histological status in our subgroup analyses of elderly patients, we could show similar survival rates as well (HR 0.70, 95% CI 0.44-1.23; p = 0.14). T1-staged patients also had a statistically nonsignificant survival benefit if histological grading was available (HR 0.75, 95% CI 0.39-1.44; p = 0.4). Concerning adjusted covariates, better KPS scores were associated with better survival in our matched univariate Cox regression models. Further, higher histological grades and TNM stages were related to a higher mortality risk.

CONCLUSION

Using population-based data, we observed an almost equal survival of patients treated with SBRT compared to surgery in stage I and II lung cancer. The availability of histological status might not be decisive in treatment planning. SBRT is comparable to surgery in terms of survival.

WS-LungNet: A two-stage weakly-supervised lung cancer detection and diagnosis network

Computer-aided lung cancer diagnosis (CAD) system on computed tomography (CT) helps radiologists guide preoperative planning and prognosis assessment. The flexibility and scalability of deep learning methods are limited in lung CAD. In essence, two significant challenges to be solved are (1) Label scarcity due to cost annotations of CT images by experienced domain experts, and (2) Label inconsistency between the observed nodule malignancy and the patients' pathology evaluation. These two issues can be considered weak label problems. We address these issues in this paper by introducing a weakly-supervised lung cancer detection and diagnosis network (WS-LungNet), consisting of a semi-supervised computer-aided detection (Semi-CADe) that can segment 3D pulmonary nodules based on unlabeled data through adversarial learning to reduce label scarcity, as well as a cross-nodule attention computer-aided diagnosis (CNA-CADx) for evaluating malignancy at the patient level by modeling correlations between nodules via cross-attention mechanisms and thereby eliminating label inconsistency. Through extensive evaluations on the LIDC-IDRI public database, we show that our proposed method achieves 82.99% competition performance metric (CPM) on pulmonary nodule detection and 88.63% area under the curve (AUC) on lung cancer diagnosis. Extensive experiments demonstrate the advantage of WS-LungNet on nodule detection and malignancy evaluation tasks. Our promising results demonstrate the benefits and flexibility of the semi-supervised segmentation with adversarial learning and the nodule instance correlation learning with the attention mechanism. The results also suggest that making use of the unlabeled data and taking the relationship among nodules in a case into account are essential for lung cancer detection and diagnosis.

Real-World Impact of SABR on Stage I Non-Small-Cell Lung Cancer Outcomes at a Scottish Cancer Centre

INTRODUCTION

Stereotactic ablative body radiotherapy (SABR) offers patients with stage I non-small-cell lung cancer (NSCLC) a safe, effective radical therapy option. The impact of introducing SABR at a Scottish regional cancer centre was studied.

METHODS

The Edinburgh Cancer Centre Lung Cancer Database was assessed. Treatment patterns and outcomes were compared across treatment groups (no radical therapy (NRT), conventional radical radiotherapy (CRRT), SABR and surgery) and across three time periods reflecting the availability of SABR (A, January 2012/2013 (pre-SABR); B, 2014/2016 (introduction of SABR); C, 2017/2019, (SABR established)).

RESULTS

1143 patients with stage I NSCLC were identified. Treatment was NRT in 361 (32%), CRRT in 182 (16%), SABR in 132 (12%) and surgery in 468 (41%) patients. Age, performance status, and comorbidities correlated with treatment choice. The median survival increased from 32.5 months in time period A to 38.8 months in period B to 48.8 months in time period C. The greatest improvement in survival was seen in patients treated with surgery between time periods A and C (HR 0.69 (95% CI 0.56-0.86), p < 0.001). The proportion of patients receiving a radical therapy rose between time periods A and C in younger (age ≤ 65, 65-74 and 75-84 years), fitter (PS 0 and 1), and less comorbid patients (CCI 0 and 1-2), but fell in other patient groups.

CONCLUSIONS

The introduction and establishment of SABR for stage I NSCLC has improved survival outcomes in Southeast Scotland. Increasing SABR utilisation appears to have enhanced the selection of surgical patients and increased the proportion of patients receiving a radical therapy.

Lung stereotactic radiation therapy: Intercomparison of irradiation devices in terms of outcome and predictive factors

PURPOSE

To compare three different radiotherapy devices able to perform pulmonary stereotactic radiotherapy: CyberKnife® (CK), Helical Tomotherapy® (HT), and volumetric modulated arc therapy (VMAT). This study aims to define the patients' outcome in terms of SBRT efficacy and toxicities depending of the device choice.

MATERIALS AND METHODS

We retrospectively analyzed the clinical, radiological, and dosimetric data of patients treated with lung SBRT between 2016 and 2020 at Lausanne University Hospital, using the Chi² test for proportions, the t-test for means comparisons, the Kaplan-Meier method for survival, and the Log-rank test and Cox-regression for intergroups comparisons.

RESULTS

We identified 111 patients treated by either CK (59.9%), VMAT (38.0%), or HT (2.1%). Compared to other techniques, CK treated comparable gross tumor volume (GTV; 2.1 vs. 1.4cm³, P=0.84) with smaller planning treatment volume (PTV; 12.3 vs. 21.9cm³, P=0.013) and lower V5 (13.5 vs. 19.9cm³, P=0.002). Local control rates at 2years were not different whatever the irradiation device, respectively of 96.2% (range, 90.8-100) and 98.1% (range, 94.4-100), P=0.68. Toxicity incidence significantly increased with V5 value>17.2% (56.0 vs. 77.4%, P=0.021).

CONCLUSION

Compared to other SBRT techniques, CK treatments permitted to treat comparable GTV with reduced PTV and V5. Toxicity incidence was less frequent when reducing the V5. CK is particularly attractive in case of multiple courses of lung SBRT or lung reirradiation.

A Lower False Positive Pulmonary Nodule Detection Approach for Early Lung Cancer Screening

Pulmonary nodule detection with low-dose computed tomography (LDCT) is indispensable in early lung cancer screening. Although existing methods have achieved excellent detection sensitivity, nodule detection still faces challenges such as nodule size variation and uneven distribution, as well as excessive nodule-like false positive candidates in the detection results. We propose a novel two-stage nodule detection (TSND) method. In the first stage, a multi-scale feature detection network (MSFD-Net) is designed to generate nodule candidates. This includes a proposed feature extraction network to learn the multi-scale feature representation of candidates. In the second stage, a candidate scoring network (CS-Net) is built to estimate the score of candidate patches to realize false positive reduction (FPR). Finally, we develop an end-to-end nodule computer-aided detection (CAD) system based on the proposed TSND for LDCT scans. Experimental results on the LUNA16 dataset show that our proposed TSND obtained an excellent average sensitivity of 90.59% at seven predefined false positives (FPs) points: 0.125, 0.25, 0.5, 1, 2, 4, and 8 FPs per scan on the FROC curve introduced in LUNA16. Moreover, comparative experiments indicate that our CS-Net can effectively suppress false positives and improve the detection performance of TSND.

Radiotherapy utilisation rates for patients with cancer as a function of age: A systematic review

INTRODUCTION

There is an increasing incidence of cancer in older people, but limited data on radiotherapy uptake, and in particular, radiotherapy utilisation (RTU) rates. The RTU rate for older adults with cancer may be lower than recommended due to lower tolerance for radiotherapy as well as additional comorbidities, reduced life expectancy and travel for treatment. Radiotherapy use must be aligned with best available, age-specific evidence to ensure older adults with cancer receive optimal benefit without harms.

MATERIALS AND METHODS

A systematic review was conducted to synthesise the published data on the actual RTU rate for patients with cancer as a function of age. MEDLINE and EMBASE were systematically searched to identify relevant population-based and hospital-based cohort studies on radiotherapy utilisation for all age groups, published in English, from 1 January 1990 to 1 July 2020. We focused on the following common cancers in older adults for which radiotherapy is recommended: breast, prostate, lung, rectal cancer, glioblastoma multiforme (GBM), and cervical cancer. Age-specific radiotherapy utilisation data were extracted and analysed as a narrative synthesis.

RESULTS

From 2606 studies screened, 75 cohort and population-based studies were identified with age-specific radiotherapy utilisation data. The total number of patients in the 75 studies was 4,792,138. The RTU rate decreased with increasing age for all tumour sites analysed, except for patients receiving curative radiotherapy as definitive treatment for prostate or cervical cancer. This reduction with increasing age was demonstrated in both palliative and curative settings.

DISCUSSION

There is a global reduction in radiotherapy utilisation with increasing age for most tumour sites. The reduction in delivery of radiotherapy warrants further examination and evidence-based guidelines specific to this population.

Initial treatment of early-stage small-sized non-small cell lung cancer for octogenarians: a population-based study

The objectives of this study is to figure out the appropriate initial treatment and criteria for clinical decision for early-stage small-sized non-small cell lung cancer (NSCLC) among octogenarians. Elderly patients (≥80 years) with stage I NSCLC (<3 cm) were identified between 2004 and 2015 in the Surveillance, Epidemiology, and End Results database. Patients were divided into four cohorts regarding treatment modalities, and overall survival and cancer-specific survival were evaluated via Kaplan-Meier analysis and Cox proportional hazard model. The propensity score matching method was introduced in the subgroup analysis stratified by four clinical characteristics to identify the preferable treatment. A total of 7861 patients were included with a median overall survival of 43 months (range 1-155 months). In younger patients (80-85 years), lobectomy was superior in improving the survival (versus segmentectomy, HR = 0.68, 95%CI 0.55-0.84; versus wedge resection, HR = 0.77; 95%CI 0.67-0.88). While in those over 85 years, lobectomy was superior to wedge resection (HR = 0.72; 95%CI 0.53-0.98), and all other treatments were comparable. As stratified by T stage in those over 85 years, lobectomy was superior to wedge resection (P = 0.023) for T1 disease, and the four treatments were all comparable in overall survival for T2 disease. In conclusions, the favored treatment of early stage NSCLC for octogenarians may be evaluated by age and T stage. Lobectomy might be preferred in patients between 80 and 85 years whenever possible. Among those over 85 years, radiotherapy might lead to a comparable prognosis and could be recommended as the prior treatment, while should surgery be recommended, lobectomy might be preferred for T1 disease and wedge resection for T2 disease.

Patterns of Use of Stereotactic Body Radiation Therapy Compared With Surgery for Definitive Treatment of Primary Early-stage Non-small Cell Lung Cancer

OBJECTIVE

As stereotactic body radiation therapy (SBRT) becomes widely available for early-stage non-small cell lung cancer (NSCLC), there may be concerns in the surgical community that SBRT is being offered for patients with operable tumors, even though surgery is standard of care. We evaluated the trends in SBRT and surgery over time for patients with NSCLC.

MATERIALS AND METHODS

The National Cancer Database was queried for patients with node-negative NSCLC ≤5 cm from 2004 to 2016. The relationships between definitive local treatment modalities and year were analyzed using a multinomial regression model while controlling for other covariates.

RESULTS

Among the 202,367 patients who met the inclusion criteria, there was a steady decrease in mean tumor size in all treatment modalities, from 2.44 cm (SD=1.08) to 2.25 cm (SD=1.00) over the study period. In the multinomial model, the probability of receiving lobectomy demonstrated a slight decline from 58% (2004) to 53% (2016). The use of SBRT increased from 1% to 20%, while patients receiving no therapy declined from 27% to 16%. The likelihood of SBRT increased with year of diagnosis (P<0.0001) and decreasing tumor size (P<0.0001), compared with lobectomy. Age, race, income, facility, and Charlson-Deyo score were also associated with treatment modality.

CONCLUSIONS

The mean tumor size of early-stage NSCLC decreased over the study period for all treatment modalities. SBRT use has increased, mostly among older patients with smaller tumors and Charlson-Deyo scores ≥3. The increase in SBRT contributed to the significant decline in patients who had no therapy.

Photodynamic therapy for stage I and II non-small cell lung cancer: A SEER-Medicare analysis 2000-2016

ABSTRACT

We analyzed mortality (all-cause and lung cancer-specific) and time to follow-up treatment in stage I and II non-small cell lung cancer (NSCLC) patients treated with photodynamic therapy (PDT) compared with ablation therapy and radiation therapy.From Surveillance, Epidemiology, and End Results-Medicare linked data, patients diagnosed with stage I and II NSCLC between 2000 and 2015 were identified. Outcomes were mortality (overall and lung cancer-specific) and time to follow-up treatment. We analyzed mortality using Cox proportional hazard models. We used generalized linear model to assess time to follow-up treatment (PDT and ablation groups). Models were adjusted for inverse probability weighted propensity score.Of 495,441 NSCLC patients, 56 with stage I and II disease received PDT (mono or multi-modal), 477 received ablation (mono or multi-modal), and 14,178 received radiation therapy alone. None from PDT group had metastatic disease (M0) and 70% had no nodal involvement (N0). Compared with radiation therapy alone, PDT therapy was associated with lower hazard of overall (hazard ratio = 0.56, 95% CI = 0.39-0.80), and lung cancer-specific mortality (hazard ratio = 0.64, 95% CI = 0.43-0.97). Unadjusted mean time to follow-up treatment was 70days (standard deviation = 146) for PDT group and 67 days (standard deviation = 174) for ablation group. Compared with ablation, PDT was associated with an average increase of 125days to follow-up treatment (P = .11).Among stage I and II NSCLC patients, PDT was associated with improved survival, compared with radiation alone; and longer time to follow-up treatment compared with ablation. Currently, PDT is offered in various combinations with surgery and radiation. Larger studies can investigate the efficacy and effectiveness of these combinations.

Are older patients with non-small cell lung cancer receiving optimal care? A population-based study

BACKGROUND

Results from studies addressing age-related patterns of cancer care have found evidence of unjustified differences in management between younger and older patients.

METHODS

We examined associations between age and clinical presentation, management and mortality in patients diagnosed with non-small cell lung cancer (NSCLC) between 2002 and 2016. Analyses were adjusted for comorbidity and other factors that may have affected management decisions and outcomes.

RESULTS

The study population encompassed 40,026 patients with NSCLC. Stage at diagnosis did not differ between age groups ≤ 84. The diagnostic intensity was similar in age groups <80 years. In patients with stage IA-IIB disease and PS 0-2, surgery was more common in the youngest age groups and decreased with increasing age, and was rarely performed in those ≥ 85 years. The use of stereotactic body radiotherapy (SBRT) increased with age (≤69 years 5.4%; ≥85 years 35.8%). In patients with stage IIIA disease and PS 0-2, concurrent chemoradiotherapy was more common in younger patients (≤69 years 55.3%; ≥85 years 2.2%). In stage IA-IIIA disease, no major differences in treatment-related mortality was observed. In stage IIIB-IV and PS 0-2, chemotherapy was more common in patients <80 years. However, 58.1% of patients 80-84 years and 30.3% ≥ 85 years received treatment. In stage IA-IIIA, overall and cause-specific survival decreased with increasing age. No age-differences in survival were observed in patients with stage IIIB-IV NSCLC.

CONCLUSION

Treatments were readily given to older patients with metastatic disease, but to a lesser degree to those with early stage disease. Significant differences in cause specific survival were observed in early, but not late stage disease. Our findings underscore the importance of individualized assessment of health status and life expectancy. Our results indicate that older patients with early stage lung cancer to a higher extent should be considered for curative treatment.

Optimal and actual rates of Stereotactic Ablative Body Radiotherapy (SABR) utilisation for primary lung cancer in Australia

•

Stereotactic Ablative Body Radiotherapy (SABR) plays a major role in the management of early-stage non-small cell lung cancer (NSCLC).

•

An evidence-based model is developed to estimate optimal rates of lung SABR utilisation within the Australian population.

•

Optimal utilisation rates are compared against actual utilisation rates to evaluate service provision.

Background and purpose

Radiotherapy utilisation rates considerably vary across different countries and service providers, highlighting the need to establish reliable benchmarks against which utilisation rates can be assessed. Here, optimal utilisation rates of Stereotactic Ablative Body Radiotherapy (SABR) for lung cancer are estimated and compared against actual utilisation rates to identify potential shortfalls in service provision.

Materials and Methods

An evidence-based optimal utilisation model was constructed after reviewing practice guidelines and identifying indications for lung SABR based on the best available evidence. The proportions of patients likely to develop each indication were obtained, whenever possible, from Australian population-based studies. Sensitivity analysis was performed to account for variations in epidemiological data. Practice pattern studies were reviewed to obtain actual utilisation rates.

Results

A total of 6% of all lung cancer patients were estimated to optimally require SABR at least once during the course of their illness (95% CI: 4–6%). Optimal utilisation rates were estimated to be 32% for stage I and 10% for stage II NSCLC. Actual utilisation rates for stage I NSCLC varied between 6 and 20%. For patients with inoperable stage I, 27–74% received SABR compared to the estimated optimal rate of 82%.

Conclusion

The estimated optimal SABR utilisation rates for lung cancer can serve as useful benchmarks to highlight gaps in service delivery and help plan for more adequate and efficient provision of care. The model can be easily modified to determine optimal utilisation rates in other populations or updated to reflect any changes in practice guidelines or epidemiological data.

Oesophageal IGRT considerations for SBRT of LA-NSCLC: barium-enhanced CBCT and interfraction motion

Background

To determine the optimal volume of barium for oesophageal localisation on cone-beam CT (CBCT) for locally-advanced non-small cell lung cancers (NSCLC) and quantify the interfraction oesophageal movement relative to tumour.

Methods

Twenty NSCLC patients with mediastinal and/or hilar disease receiving radical radiotherapy were recruited. The first five patients received 25 ml of barium prior to their planning CT and alternate CBCTs during treatment. Subsequent five patient cohorts, received 15 ml, 10 ml and 5 ml. Six observers contoured the oesophagus on each of the 107 datasets and consensus contours were created. Overall 642 observer contours were generated and interobserver contouring reproducibility was assessed. The kappa statistic, dice coefficient and Hausdorff Distance (HD) were used to compare barium-enhanced CBCTs and non-enhanced CBCTs. Oesophageal displacement was assessed using the HD between consensus contours of barium-enhanced CBCTs and planning CTs.

Results

Interobserver contouring reproducibility was significantly improved in barium-enhanced CBCTs compared to non-contrast CBCTs with minimal difference between barium dose levels. Only 10 mL produced a significantly higher kappa (0.814, p = 0.008) and dice (0.895, p = 0.001). The poorer the reproducibility without barium, the greater the improvement barium provided. The median interfraction HD between consensus contours was 4 mm, with 95% of the oesophageal displacement within 15 mm.

Conclusions

10 mL of barium significantly improves oesophageal localisation on CBCT with minimal image artifact. The oesophagus moves substantially and unpredictably over a course of treatment, requiring close daily monitoring in the context of hypofractionation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01946-8.

[Resection of Lung Cancer in Old Patients - Does Demographic Change Cause a Rethink?]

Due to the demographic change prevailing in Germany, the age pyramid is shifting more and more upwards. According to the WHO, a patient over the age of 75 is considered to be old. Whether or not and to what extent an old patient can tolerate thoracic surgery purely based on his age and comorbidities remains unclear. Under most circumstances the surgeon's experience seems to be crucial in this decision. PATIENTS AND METHODS:  The data analysis included data from 01. 2016-01. 2018 based on the German Thorax Register (Project ID: 2017-03), which was set up under the patronage of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the German Society for Thoracic Surgery (DGT). A total of 1357 patients were included, 658 patients had histologically proven lung cancer stage I-II. These were divided into three groups according to their age; group I (< 65 years), group II (65- ≤ 75) years and group III (> 75 years). We were able to show that group III had essentially no increased postoperative complication rates (all = 48.00 %; group I = 40.90 %; group II = 53.00 %; group III = 52.90 %) and even performed better than group II (65 to ≤ 75) regarding pulmonary complications. (postoperative pneumonia group II = 19.20 %, group III = 12.90 %) The mortality was lowest in patients who were operated on in centers of the German Thorax Register (all = 1.70 %, group I = 1.90 %; group II = 1.70 %; group III = 1.30 %), compared to national german average. (all = 1.99 %; group I = 1.23 %; group II = 2.18 %; group III = 3.78 %) In particular, patients of group III showed the greatest difference. Furthermore, we saw that the majority of anatomical resections performed in centers of the German Thorax Register were resected by VATS (Video-assisted Thoracoscopic Surgery) as opposed to patients operated on in hospitals not affiliated with the German Thorax Register. DISCUSSION:  Considering these results, the question arises whether in Germany all old patients were treated according to current guidelines. Although there is a certain selection bias in group III, operative candidates fit for surgery are operated in the centers of the German Thorax Register. Our results permit us to conclude that this group of patients should be given optimal surgical therapy when indicated. Age alone should not be the sole determining factor in decision-making regarding thoracic surgery.

Can reducing planning safety margins broaden the inclusion criteria for lung stereotactic ablative body radiotherapy?

INTRODUCTION

Stereotactic ablative body radiotherapy (SABR) is currently indicated for inoperable, early-stage non-small cell lung carcinoma (NSCLC). Advancements in image-guidance technology continue to improve treatment precision and enable reductions in planning safety margins. We investigated the dosimetric benefits of margin reduction, its potential to extend SABR to more NSCLC patients and the factors influencing plan acceptability.

METHODS

This retrospective analysis included 61 patients (stage IA-IIIA) treated with conventional radiotherapy. Patients were ineligible for SABR due to tumour size or proximity to organs at risk (OAR). Using Pinnacle auto-planning, three SABR plans were generated for each patient: a regular planning target volume margin plan, a reduced margin plan (gross tumour volume GTV+3 mm) and a non-margin plan. Targets were planned to 48Gy/4 or 50Gy/5 fractions depending on location. Plans were compared in terms of target coverage, OAR doses and dosimetric acceptability based on local guidelines. Predictors of acceptability were investigated using logistic regression analysis.

RESULTS

Compared to regular margin plans, both reduced margin and non-margin plans resulted in significant reductions to almost all dose constraints. Dose conformity was significantly worse in non-margin plans (P < 0.05) and strongly correlated with targets' surface area/volume ratio (R2  = 0.9, P < 0.05). 26% of reduced margin plans were acceptable, compared to 54% of non-margin plans. GTV overlap with OARs significantly affected plan acceptability (OR 0.008, 95% CI 0.001-0.073).

CONCLUSION

Margin reduction significantly reduced OAR doses enabling acceptable plans to be achieved for patients previously excluded from SABR. Indications for lung SABR may broaden as treatment accuracy continues to improve; further work is needed to identify patients most likely to benefit.

Lung Thermal Ablation: Comparison between an Augmented Reality Computed Tomography (CT) 3D Navigation System (SIRIO) and Standard CT-Guided Technique

Simple Summary

Lung cancer is the leading cause of cancer mortality worldwide. In recent years, numerous technologies have been used to perform image-guided percutaneous thermal ablation, mainly including radiofrequency ablation, microwave ablation, and cryoablation. These image-guided ablation techniques have emerged as a safe, cost-effective, minimally invasive treatment alternative for patients who do not require surgery. Procedural planning, monitoring, and lesion targeting are generally performed with the help of computed tomography; navigation systems are emerging as valid tool to reduce procedural time and radiation dose administration. In the present paper, we investigate the efficacy of an optical-based navigation system (SIRIO) to perform lung thermal ablation. SIRIO proved to be a reliable and effective tool when performing CT-guided LTA, displaying a significant decrease in the number of required CT scans, procedure time, and radiation doses administered to patients.

Abstract

(1) Background: The aim of this retrospective study is to assess safety and efficacy of lung radiofrequency (RFA) and microwave ablation (MWA) using an augmented reality computed tomography (CT) navigation system (SIRIO) and to compare it with the standard CT-guided technique. (2) Methods: Lung RFA and MWA were performed with an augmented reality CT 3D navigation system (SIRIO) in 52 patients. A comparison was then performed with a group of 49 patients undergoing the standard CT-guided technique. All the procedures were divided into four groups based on the lesion diameter (>2 cm or ≤2 cm), and procedural time, the number of CT scans, radiation dose administered, and complications rate were evaluated. Technical success was defined as the presence of a “ground glass” area completely covering the target lesion at the immediate post-procedural CT. (3) Results: Full technical success was achieved in all treated malignant lesions for all the considered groups. SIRIO-guided lung thermo-ablations (LTA) displayed a significant decrease in the number of CT scans, procedure time, and patients’ radiation exposure (p < 0.001). This also resulted in a dosage reduction in hypnotics and opioids administrated for sedation during LTA. No significant differences were observed between the SIRIO and non-SIRIO group in terms of complications incidence. (4) Conclusions: SIRIO is an efficient tool to perform CT-guided LTA, displaying a significant reduction (p < 0.001) in the number of required CT scans, procedure time, and patients’ radiation exposure.

Developments in radiation techniques for thoracic malignancies

Radiation therapy is a cornerstone of modern lung cancer treatment alongside surgery, chemotherapy, immunotherapy and targeted therapies. Advances in radiotherapy techniques have enhanced the accuracy of radiation delivery, which has contributed to the evolution of radiation therapy into a guideline-recommended treatment in both early-stage and locally advanced nonsmall cell lung cancer. Furthermore, although radiotherapy has long been used for palliation of disease in advanced lung cancer, it is increasingly having a role as a locally ablative treatment in patients with oligometastatic disease.This review provides an overview of recent developments in radiation techniques, particularly for non-radiation oncologists who are involved in the care of lung cancer patients. Technical advances are discussed, and findings of recent clinical trials are highlighted, all of which have led to a changing perception of the role of radiation therapy in multidisciplinary care.

Stage I non-small cell lung cancer: Treatment modalities, Dutch daily practice and future perspectives

OBJECTIVES

Several treatment modalities are available for patients with stage I non-small cell lung cancer (NSCLC). Over the past decade, these treatment modalities have been further investigated and might have changed current treatment regimens. In this review we present an overview of the treatment options, developments and future perspectives for stage I NSCLC. Furthermore, we describe the current use of these treatment modalities in the Netherlands.

MATERIALS AND METHODS

A bibliographical search was performed in PubMed and the Cochrane Library for publications concerning treatment modalities for stage I NSCLC. In addition, evidence-based guidelines of the European Society for Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN) were studied.

RESULTS

The guideline-recommended treatment for operable stage I NSCLC patients is a lobectomy with systematic lymph node dissection. Inoperable patients or those refusing surgery are offered stereotactic ablative radiotherapy (SABR). Percutaneous ablation, such as radiofrequency ablation, is a non-surgical minimally invasive technique offered to those who are ineligible for surgery or SABR. The role of systemic therapy is currently limited. However, the efficacy of immunotherapy is being investigated in clinical trials. In the Netherlands, an increasing use of SABR and a relative decrease in resection rates have been observed.

CONCLUSION

Surgery and SABR are currently the prevailing treatment modalities for stage I NSCLC patients. Despite optimization of treatment regimens, survival of patients with stage I NSCLC remains to be improved. Future studies are required to optimize treatment strategies, but also to investigate factors influencing treatment decision-making for patients with stage I NSCLC.

Age-related treatment patterns for stage I NSCLC in three European countries

INTRODUCTION

Surgery is the preferred treatment for patients with early-stage non-small cell lung cancer (NSCLC) while stereotactic body radiation therapy (SBRT) may be applied in patients with major comorbidity or high age. We evaluated the association between age and treatment utilization for early-stage NSCLC in patients diagnosed in 2015-2016 in three European countries.

PATIENTS AND METHODS

Information was retrieved from population-based registries in England, Norway and the Netherlands. Treatment patterns and two-year overall survival rates for 105,124 patients with clinical stage I were analysed by age-group.

RESULTS

Surgical resection rates were higher in Norway (55%) and England (53%) than in the Netherlands (47%), and decreased with increasing age. SBRT use was highest in the Netherlands (41%), followed by Norway (29%) and England (12%). In the Netherlands, SBRT was the prevailing treatment in patients aged 70 years or older. In octogenarians, the proportion not receiving curative intent treatment was 53% in England, versus 35% in Norway and 22% in the Netherlands. Two-year survival rates were better for surgery than for SBRT and slightly better in Norway.

CONCLUSION

In patients aged 70 years or older, the proportion not receiving any curative treatment remains substantial, and differs significantly between countries. Measures to address these disparities are needed.

Validation of Polymorphisms Associated with the Risk of Radiation-Induced Oesophagitis in an Independent Cohort of Non-Small-Cell Lung Cancer Patients

Simple Summary

Genetic variants identified in association with radiation therapy side effects in non-small-cell lung cancer patients require an independent validation. Therefore, the aim of our study was to replicate, in an independent cohort, the analyses of previously published studies associating single-nucleotide polymorphisms with radiation-induced oesophagitis. Following the original models, 2 of the 18 variants associated with radiation-induced oesophagitis in non-small-cell lung cancer patients were confirmed. Furthermore, we meta-analysed our cohort together with those of the reference studies. Twelve variants located in genes of inflammation and DNA double-strand break repair pathways remained associated with oesophagitis. These variants could be included in models for clinical prediction of radiation-induced oesophagitis to evaluate their performance.

Abstract

Several studies have identified single-nucleotide polymorphisms (SNPs) associated with adverse effects in non-small-cell lung cancer (NSCLC) patients treated with radiation therapy. Here, using an independent cohort, we aimed to validate the reported associations. We selected 23 SNPs in 17 genes previously associated with radiation-induced oesophagitis for validation in a cohort of 178 Spanish NSCLC patients. Of them, 18 SNPs were finally analysed, following the methods described in the original published studies. Two SNPs replicated their association with radiation-induced oesophagitis (rs7165790 located in the BLM gene: odds ratio (OR) = 0.16, 95% CI = 0.04–0.65, p-value = 0.010; rs4772468 at FGF14: OR = 4.36, 95% CI = 1.15–16.46, p-value = 0.029). The SNP rs2868371 at HSPB1 was also validated but displayed an opposite effect to the formerly described (OR = 3.72; 95% CI = 1.49–9.25; p-value = 0.004). Additionally, we tested a meta-analytic approach including our results and the previous datasets reported in the referenced publications. Twelve SNPs (including the two previously validated) retained their statistically significant association with radiation-induced oesophagitis. This study strengthens the role of inflammation and DNA double-strand break repair pathways in the risk prediction of developing radiation-induced oesophagitis in NSCLC patients. The validated variants are good candidates to be evaluated in risk prediction models for patient stratification based on their radiation susceptibility.

Navigating Diagnostic and Treatment Decisions in Non-Small Cell Lung Cancer: Expert Commentary on the Multidisciplinary Team Approach

Non-small cell lung cancer (NSCLC) accounts for approximately one in five cancer-related deaths, and management requires increasingly complex decision making by health care professionals. Many centers have therefore adopted a multidisciplinary approach to patient care, using the expertise of various specialists to provide the best evidence-based, personalized treatment. However, increasingly complex disease staging, as well as expanded biomarker testing and multimodality management algorithms with novel therapeutics, have driven the need for multifaceted, collaborative decision making to optimally guide the overall treatment process. To keep up with the rapidly evolving treatment landscape, national-level guidelines have been introduced to standardize patient pathways and ensure prompt diagnosis and treatment. Such strategies depend on efficient and effective communication between relevant multidisciplinary team members and have both improved adherence to treatment guidelines and extended patient survival. This article highlights the value of a multidisciplinary approach to diagnosis and staging, treatment decision making, and adverse event management in NSCLC. IMPLICATIONS FOR PRACTICE: This review highlights the value of a multidisciplinary approach to the diagnosis and staging of non-small cell lung cancer (NSCLC) and makes practical suggestions as to how multidisciplinary teams (MDTs) can be best deployed at individual stages of the disease to improve patient outcomes and effectively manage common adverse events. The authors discuss how a collaborative approach, appropriately leveraging the diverse expertise of NSCLC MDT members (including specialist radiation and medical oncologists, chest physicians, pathologists, pulmonologists, surgeons, and nursing staff) can continue to ensure optimal per-patient decision making as treatment options become ever more specialized in the era of biomarker-driven therapeutic strategies.

Systematic review of stereotactic body radiotherapy in stage III non-small cell lung cancer

Despite adequate treatment, 50% of stage III locally advanced inoperable non-small cell lung cancer (NSCLC) patients have a locoregional relapse. Local control on early stages on the contrary, is as high as 85-90% with stereotactic body radiotherapy (SBRT). The addition of SBRT to conventional chemoradiation or its use in monotherapy in stage III NSCLC is a novel strategy to decrease local failure that has been explored by various authors. This is a systematic review of studies using SBRT in inoperable stage III NSCLC. Search results obtained 141 articles of which only 6 original studies were pointed as relevant. Three of these studies were prospective, of which 2 were phase I dose-scalation studies and remaining 3 were retrospective. In summary, SBRT outcomes on 134 patients were included. Median dose in the SBRT treatment was 22.5 Gy in 2 to 7 fractions. Obtained global toxicity was 3.7% grade 5 and 14.17% grade 3. Dose-escalation studies proposed a 2 fraction SBRT schedule of 20-24 Gy, obtaining a 78% local control rate at 1 year and an OS of 67%. Initial improvement in local control with this innovative therapeutic strategy has led to ongoing phase II and III clinical trials that will evaluate the efficiency of SBRT in stage III NSCLC clinical scenario.

Change in treatment modality and trends in survival among stage I non-small cell lung cancer patients: a population-based study

Background

A number of treatment modalities are available to patients with early non-small cell lung cancer (NSCLC) but there is inconsistency regarding their effects on survival. The associated survival of each treatment modality is crucial for patients in making informed treatment decisions. We aimed to examine the change in treatment modality and trends in survival for patients with stage I NSCLC and assess the association between treatment modality and survival.

Methods

All patients diagnosed with stage I NSCLC in the Canadian province of Ontario between 2007 and 2015 were included in this population-based study. We used a flexible parametric model to estimate the trends in survival rate.

Results

Overall, 11,910 patients were identified of which 7,478 patients (62.8%) received surgical resection and 2,652 (22.3%) radiation only. The proportion of patients who received radiation only increased from 13.2% in 2007 to 28.0% in 2015 (P-for-trend <0.001). Survival increased for all treatment modalities from 2007 to 2015. The increase in 5-year survival was more than 20% for all surgical groups and more than 35% for radiation-only group.

Conclusions

The survival of patients with stage I NSCLC increased for all treatment modalities over the study period, most distinctly in elderly patients, which coincided with a rise in the use of radiation therapy. While surgical resection was associated with the best chance of 5-year survival, radiation therapy is a safe and effective treatment for medically inoperable patients with early disease.

Endobronchial Treatment of Bronchial Carcinoid in the Elderly

Purpose of the Review

Although surgical resection is considered the gold standard of curative treatment for bronchial carcinoid, endobronchial treatment (EBT) can serve as a less invasive curative or palliative treatment in a selection of patients. It is unclear whether elderly patients with bronchial carcinoid should be treated in the same way as younger patients. In order to study the characteristics and treatment of elderly patients with bronchial carcinoid, we analyzed data from a cohort of patients that have been treated for bronchial carcinoid with EBT, surgical resection, or a combination of both. We used our existing database of patients referred for EBT and defined two groups of patients: ≥ 65 and < 65 years. We compared the characteristics, treatment, and causes of death between these groups. Successful EBT was defined as definitive treatment without signs of recurrence during follow-up with CT and bronchoscopy.

Recent Findings

Thirty-five patients (19%) were ≥ 65 years. The incidence of atypical carcinoid was the same in both age groups (31%). Thirty-six of 184 patients (20%) were directly referred for surgical resection and 148 (80%) underwent EBT. There was no significant difference in success of EBT between patients <65 years (58/122, 48%) and patients ≥ 65 years (15/26, 58%) (p = 0.347). Complication rates were similar in both groups. After unsuccessful EBT, only 70% (14/20) of the elderly patients was operated, whereas 93% (85/91) of the patients < 65 years was operated (p = 0.001). Disease specific mortality was 6% (2/35) in the group ≥ 65 years and 2% (3/149) in the group < 65 years.

Summary

The incidence of atypical carcinoid is similar between the elderly and younger patients. Success rate and complication rate of EBT do not differ significantly between the age groups. After unsuccessful EBT, elderly patients were less likely to undergo surgical resection, which does not seem associated with excess disease specific mortality, although the number of events in this study is low.

Survival outcome of non-small cell lung cancer patients: Comparing results between the database of the Comprehensive Cancer Center Zürich and the Epidemiological Cancer Registry Zurich and Zug

BACKGROUND

Cancer cases among the population of the canton Zurich, are registered in the Cancer Registry of the cantons of Zurich and Zug (KKR). The Thoracic Oncology Center, founded in 2011 is one of 17 multidisciplinary centers within the Comprehensive Cancer Center Zurich (CCCZ).

METHODS

The aim of the current study is to quantify the mortality risk of patients with NSCLC and identify differences on survival and other factors between patients receiving their primary treatment at the CCCZ and those treated elsewhere and registered by KKR. The differential effect between CCCZ and KKR cohorts on survival: overall, by stage, sex and age, is explored. Stratified log-rank and Wilcoxon tests, Cox models and restricted mean survival times (RMST) are estimated. Propensity score matching (PSM) is also used to adjust for confounding factors.

RESULTS

Analysis included 848 NSCLC cases from the CCCZ and 1759 from the KKR, diagnosed between January 2011 and December 2015. At a median follow-up of 57 months, overall survival (OS) was significantly superior for patients treated at the CCCZ compared to KKR [Median OS: 36.0 months (95%CI: 31.0-45.0) and 12.0 months (95%CI: 11.0-13.0), respectively, stratified log-rank p < 0.001; adjusted HR = 1.31, (95% CI: 1.18-1.46), difference in RMST up to 72 months: 13.8 months (95%CI: 11.5-16.2), p < 0.001]. The effect of cohort was significant for stages III and IV (overall and also by sex and age). After PSM OS remained significantly superior for patients treated at the CCCZ compared to KKR.

CONCLUSIONS

The survival probability for patients in the CCCZ cohort was superior to that of patients in the canton Zürich treated outside the center. This analysis provides further evidence of the importance of the volume of experience and the availability of a multidisciplinary organization and research environment, as delivered by a comprehensive cancer center, on the outcome of patients with NSCLC.

Recent developments and advances in secondary prevention of lung cancer

Lung cancer prevention may include primary prevention strategies, such as corrections of working conditions and life style - primarily smoking cessation - as well as secondary prevention strategies, aiming at early detection that allows better survival rates and limited resections. This review summarizes recent developments and advances in secondary prevention, focusing on recent technological tools for an effective early diagnosis.

Stereotactic body radiotherapy for elderly patients (≥ 75 years) with early-stage non-small cell lung cancer

PURPOSE

Stereotactic body radiotherapy (SBRT) is the primary treatment method for early-stage non-small cell lung cancer (NSCLC) considered inoperable due to medical comorbidities. However, the application of SBRT in patients aged ≥ 75 years has not been adequately studied. This retrospective study aimed to investigate the effectiveness and safety of SBRT in early-stage NSCLC patients aged ≥ 75 years, and the impact of treatment on nutritional status and self-care ability.

METHODS

Histopathologically confirmed early-stage (T1-3N0M0) NSCLC patients aged ≥ 75 years treated with SBRT between 2013 and 2018 at our center were identified from the electronic database. Treatment efficacy, treatment toxicities, impact of treatment on nutritional status, and self-care ability were retrospectively analyzed. Toxicities were evaluated according to the Common Terminology Criteria for Adverse Event (CTCAE) (Common 2010) version 4.0. Nutritional status was assessed by Nutritional Risk Screening 2002 criteria, and self-care ability by Barthel index and fall risk index.

RESULTS

A total of 68 patients were enrolled. Median follow-up duration was 46.3 (3.9-80.1) months. The 1-, 3-, and 5-year overall survival rates were 92.6%, 77.2%, and 59.1%, respectively, and the 1-year, 3-year and 5-year local control rates were 95.6%, 88.9% and 85.6%, respectively. Grade 1-2 and grade 3 radiation pneumonitis occurred in 60/68 (96.8%) and 1/68 (1.5%) patients, respectively. Fall risk at 3 months after treatment was not significantly different from that before treatment (P = 0.22). Barthel index increased significantly after treatment (P < 0.001).

CONCLUSIONS

SBRT appears to be effective and safe for NSCLC patients aged ≥ 75 years, with no adverse impact on nutritional status and self-care ability.

The role of surgery for stage I non-small cell lung cancer in octogenarians in the era of stereotactic body radiotherapy in the Netherlands

OBJECTIVES

Resection is the standard treatment for stage I non-small cell lung cancer (NSCLC) in operable patients. Stereotactic body radiotherapy (SBRT) is recommended for inoperable patients. A shift from surgery to SBRT is expected in elderly patients due to increased frailty and competing risks. We assessed the current influence of age on treatment decision-making and overall survival (OS).

MATERIALS AND METHODS

We performed a retrospective cohort study using data from patients with clinical stage I NSCLC diagnosed in 2012-2016 and treated with lobectomy, segmentectomy, wedge resection, or SBRT, retrieved from the Netherlands Cancer Registry. Patient characteristics and OS were compared between SBRT and (sub)lobar resection for patients aged 18-79 and ≥80 years.

RESULTS AND CONCLUSION

8764 patients treated with lobectomy (n = 4648), segmentectomy (n = 122), wedge resection (n = 272), or SBRT (n = 3722) were included. In 2012-2016, SBRT was increasingly used for octogenarians and younger patients from 75.3% to 83.7% and from 30.8% to 43.2%, respectively. Five-year OS in the whole population was 70% after surgery versus 39% after SBRT and 50% versus 27% in octogenarians. After correction for age, gender, year of diagnosis, and clinical T-stage, OS was equal after lobectomy and SBRT in the first 2 years after diagnosis. However, after >2 years, OS was better after lobectomy than after SBRT. SBRT is the prevailing treatment in octogenarians with stage I NSCLC. While surgery is associated with better OS than SBRT, factors other than treatment modality (e.g. comorbidity) may have had a significant impact on survival. The wider application of SBRT in octogenarians likely reflects the frailty of this group. Registries and trials are required to identify key determinants of frailty in this specific population to improve patient selection for surgery or SBRT.

Quality of life after pulmonary stereotactic fractionated radiotherapy (SBRT): Results of the phase II STRIPE trial

BACKGROUND AND PURPOSE

Preserving health related quality of life (HRQOL) plays an important role in considering stereotactic body fractionated radiotherapy (SBRT). The prospective monocenter phase II STRIPE trial investigated long-term HRQOL after SBRT, efficacy and toxicity.

MATERIALS AND METHODS

Patients with ≤2 pulmonary lesions ≤5 cm were treated with 4DPET/CT-based SBRT (3 × 12.5 Gy or risk-adapted 5 × 7 Gy, to 60% isodose). Follow up (FU) was performed 2 and 7 weeks after SBRT, then 3-monthly for 2 years with assessment of response (primary endpoint: 2-year cumulative incidence of local progression (LP); secondary endpoints: local progression free survival (LPFS), overall survival (OS) and toxicity (CTCAE)). Impact of predefined patient and treatment related factors on HRQOL (EORTC QLQ-C30 and EORTC QLQ-LC13) was evaluated.

RESULTS

Between 02/2011 and 11/2014, 100 patients were given SBRT for 56 NSCLC and 44 pulmonary metastases (M1). Long-term FU overall revealed stable Quality of Life (QoL)/Global health status (GHS), functions-scores and symptoms. For QoL/GHS, patients with low (<median) initial QoL/GHS-Score revealed significantly stronger improvement than those with good QoL/GHS-scores (p < 0.001). Probability for LP, LPFS and OS 2 years after SBRT was 8.1% (NSCLC: 7.3%, M1:9.2%), 53.3% (NSCLC: 50.7%, M1: 56.0%) and 62.2% (NSCLC: 57.2%, M1: 68.4%). ≥G3-Toxicity was <4%, but ≥G3 dyspnea was 6% at baseline and 14.5% 2 years after SBRT.

CONCLUSIONS

These prospective data on representative pulmonary SBRT patients confirm stable preservation of HRQOL after SBRT and demonstrate a QoL/GHS-benefit for patients with low initial QoL/GHS-scores, the regimen of 3 × 12.5 Gy SBRT being efficient and well tolerated. This result may inform shared decision making when discussing SBRT for frail patients.

Diagnosis and treatment of early and locally advanced non-small-cell lung cancer: The 2019 AIOM (Italian Association of Medical Oncology) clinical practice guidelines

The Italian Association of Medical Oncology (AIOM) has developed clinical practice guidelines for the diagnosis and treatment of patients with early and locally advanced non-small cell lung cancer. In the current paper a panel of AIOM experts in the field of thoracic malignancies discussed these topics, analyzing available scientific evidences, with the final aim of providing a summary of clinical recommendations, which may guide physicians in their current practice.

Population-based analysis of curative therapies in stage II non-small cell lung cancer: the role of radiotherapy in medically inoperable patients

OBJECTIVES

Curative intent therapy of stage II NSCLC may include surgical resection or definitive radiotherapy. Primary management with surgery or radiotherapy may be influenced by patient and disease characteristics. We sought to perform a comparison of patients receiving surgery or radical radiation therapy as their curative treatment, and explore the impact of known prognostic factors on outcome.

MATERIALS AND METHODS

A retrospective review was completed of all patients with stage II NSCLC referred to the BC Cancer Agency from 2005 to 2012. Cases were filtered to identify those receiving curative intent therapy including surgery or radiotherapy. Information was collected on known prognostic and predictive factors. The primary outcome measure was overall survival. We compared survival among patients receiving curative intent radiotherapy versus surgical intervention.

RESULTS

A total of 535 patients were referred. Of these, 245 (46%) received curative intent surgery, 132 (25%) curative intent radiotherapy, and 158 (30%) did not receive curative therapy. There were significant differences between cohorts with respect to median age, histology, ECOG PS, smoking status, and weight loss. Median OS was significantly different between cohorts: 61.4 m surgery, 26.5 m curative RT, and 13.1 m non-curative therapy. In a case-matched analysis, median OS remained superior for surgery at 101.6 m vs 28.1 m for curative RT. In a multivariate analysis, ECOG PS, weight loss, and treatment cohort all influenced survival. Among patients receiving curative intent radiotherapy, the use of concurrent chemotherapy and RT dose > = 60Gy were associated with improved outcomes.

CONCLUSIONS

Among patients with stage II NSCLC, many are unable to undergo standard of care surgical resection. Radiotherapy provides an inferior yet still curative option in the management of inoperable patients. Further work is needed to optimize outcomes in this population.

Contrast enhanced oesophageal avoidance for stereotactic body radiotherapy: Barium vs. Gastrografin

INTRODUCTION

SABR may facilitate treatment in a greater proportion of locally-advanced NSCLC patients, just as it has for early-stage disease. The oesophagus is one of the key dose-limiting organs and visualization during IGRT would better ensure toxicity is avoided. As the oesophagus is poorly seen on CBCT, we assessed the extent to which this is improved using two oral contrast agents.

MATERIALS & METHODS

Six patients receiving radiotherapy for Stage I-III NSCLC were assigned to receive 50 mL Gastrografin or 50 mL barium sulphate prior to simulation and pre-treatment CBCTs. Three additional patients who did not receive contrast were included as a control group. Oesophageal visibility was determined by assessing concordance between six experienced observers in contouring the organ. 36 datasets and 216 contours were analysed. A STAPLE contour was created and compared to each individual contour. Descriptive statistics were used and a Kappa statistic, Dice Coefficient and Hausdorff distance were calculated and compared using a t-test. Contrast-induced artefact was assessed by observer scoring.

RESULTS

Both contrast agents significantly improved the consistency of oesophagus localisation on CBCT across all comparison metrics compared to CBCTs without contrast. Barium performed significantly better than Gastrografin with improved kappa statistics (p = 0.007), dice coefficients (p < 0.001) and Hausdorff distances (p = 0.002), although at a cost of increased image artefact.

DISCUSSION

Barium produced lower delineation uncertainties but more image artefact, compared to Gastrografin and no contrast. It is feasible to use oral contrast as a tool in IGRT to help guide clinicians and therapists with online matching and monitoring of the oesophageal position.

Mortality after radiotherapy or surgery in the treatment of early stage non-small-cell lung cancer: a population-based study on recent developments

BACKGROUND

Stereotactic body radiotherapy (SBRT) can achieve high tumour control with limited toxicity for inoperable early stage non-small-cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

The German Epidemiologic Cancer Registries from the Robert-Koch Institute were assessed. Periods according to the availability of SBRT were: (1) 2000-2003 (pre-SBRT); (2) 2004-2007 (interim); and (3) 2007-2014 (broad availability of SBRT). To assess the association of cancer-related parameters with mortality, hazard ratios (HR) from Cox proportional hazards models were computed. To evaluate the change of treatment-related mortality, we performed interaction analyses and the relative excess risk due to interaction (RERI, additive scale) was computed.

RESULTS

A total of 16,292 patients with UICC stage I NSCLC diagnosed between 2000 and 2014 were analysed. Radiotherapy utilization increased from 5% in pre-SBRT era to 8.8% after 2007. In univariate analyses, survival in the whole cohort improved only marginally when 2000-2003 is compared to 2004-2007 (HR 0.92, 95% CI 0.85-1.01) or 2008-2014 (HR 0.93, 95% CI 0.86-1.01). Comparing surgery/radiotherapy, mortality in the radiotherapy group started from a 3.5-fold risk in 2000-2003 to 2.6 after 2007. The interaction analysis revealed a stronger improvement for radiotherapy (multiplicative scale for 2000-2003 vs. > 2007: 0.74, 95% CI 0.58-0.94). On an additive scale, treatment × period interaction revealed an RERI for 2000-2003 vs. > 2007 of - 1.18 (95% CI - 1.8, - 0.55).

CONCLUSIONS

Using population-based data, we observed a survival improvement in stage I lung cancer over time. With an increasing utilization of radiotherapy, a stronger improvement occurred in patients treated with radiotherapy when compared to surgery.

Toxicity and Efficacy of Stereotactic Ablative Body Radiotherapy for Moderately Central Non-small Cell Lung Cancers Using 50 Gy in Five Fractions

AIMS

Stereotactic ablative body radiotherapy doses for peripheral lung lesions caused high toxicity when used for central non-small cell lung cancer (NSCLC). To determine a safe stereotactic ablative body radiotherapy dose for central tumours, the phase I/II Radiation Therapy Oncology Group RTOG 0813 trial used 50 Gy/five fractions as a baseline. From 2013, 50 Gy/five fractions was adopted at the Beatson West of Scotland Cancer Centre for inoperable early stage central NSCLC. We report our prospectively collected toxicity and efficacy data.

MATERIALS AND METHODS

Patient and treatment characteristics were obtained from electronic medical records. Tumours were classed as moderately central or ultra-central tumours using published definitions. Toxicity was assessed in a centralised follow-up clinic at 2 weeks, 6 weeks, 3 months, 6 months, 1 year and 2 years after treatment.

RESULTS

Fifty patients (31 women, 19 men, median age 75.1 years) were identified with T1-2N0M0 moderately central NSCLC; one patient had both an ultra-central and a moderately central tumour. Eighty-four per cent were medically unfit for surgery. Forty per cent had biopsy-proven NSCLC and 60% were diagnosed radiologically using 18-fluorodeoxyglucose positron emission tomography/computed tomography imaging. Fifty-six per cent of patients were Eastern Cooperative Oncology Group (ECOG) performance status 2 or worse. All patients received 50 Gy/five fractions on alternate days on schedule. Two patients died within 90 days of treatment, one from a chest infection, the other cause of death was unknown. There was one episode of early grade 3 oesophagitis and one grade 3 late dyspnoea. There was no grade 4 toxicity. Over a median follow-up of 25.2 months (range 1-70 months), there were 34 deaths: 18 unrelated to cancer and 16 due to cancer recurrence. The median overall survival was 27.0 months (95% confidence interval 20.6-35.9) and cancer-specific survival was 39.8 months (95% confidence interval 28.6, not reached).

CONCLUSION

This study has shown that 50 Gy/five fractions is a safe dose and fractionation for early stage inoperable moderately central NSCLC, with outcomes comparable with other series, even with patients with a poor performance status.

Treatment strategy and decision-making for elderly surgical candidates with early lung cancer

Among elderly cancer patients of the same chronological age, there is a wide range of heterogeneity in their ability to tolerate surgery. When an elderly patient comes to a thoracic surgeon, the surgeon first considers how healthy the patient is. If the patient looks healthy or in fit condition, the surgeon offers lobectomy plus mediastinal lymph node dissection. On the other hand, if the patient looks frail, the surgeon may offer, instead of a standard treatment, lobectomy without lymph node dissection, sublobar resection, or radiotherapy or may not offer any kind of treatment. This review was conducted to obtain an overview of these options and compare the treatment outcomes reported in the literature for the purpose of making a good decision for elderly surgical candidates with early lung cancer.

Video-assisted thoracic lobectomy versus stereotactic body radiotherapy for stage I nonsmall cell lung cancer in elderly patients: a propensity matched comparative analysis

Comparative studies of the overall survival (OS) in elderly patients with nonsmall cell lung cancer (NSCLC) after surgery or stereotactic body radiotherapy (SBRT) have been limited by mixed extents of resection and different surgical approaches.

792 patients aged ≥65 years with clinical stage I NSCLC underwent video-assisted thoracic surgery (VATS) lobectomy or SBRT between 2010 and 2015. The propensity score-matched primary analysis included data from the full cohort; the secondary analysis included data from a subgroup of patients with data on pulmonary function.

Median OS for unmatched patients was 77 months for patients undergoing VATS lobectomy and 38 months for SBRT. The 1-, 3- and 5-year OS rates after VATS lobectomy were 92%, 76% and 65%, and after SBRT were 90%, 52% and 29% (p<0.001). Median OS for matched patients in the primary analysis was 77 months for patients undergoing VATS lobectomy and 33 months for SBRT. The 1-, 3- and 5-year OS rates after VATS lobectomy were 91%, 68% and 58%, and after SBRT were 87%, 46% and 29% (p<0.001). The survival advantage with VATS lobectomy persisted in the secondary analysis after adjusting for non-matched variables (p=0.034).

We suggest that elderly patients with stage I NSCLC undergoing VATS lobectomy have a better rate of OS than patients undergoing SBRT, irrespective of matching. This could be clinically important in decision-making for elderly patients who can tolerate surgery.

Prediction of early mortality following stereotactic body radiotherapy for peripheral early-stage lung cancer

BACKGROUND/PURPOSE

To investigate prognostic factors for death within 6 months of stereotactic body radiotherapy (SBRT) for patients with peripheral early-stage non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

This analysis included 586 NSCLC patients with peripheral tumors treated with SBRT. Potential patient and tumor prognostic factors, including the Charlson Comorbidity Index (CCI) and Cumulative Illness Rating Scale (CIRS), were analyzed by logistic regression analysis for association with early mortality (death <6 months after SBRT). Additionally, CCI and CIRS were compared with respect to their predictive ability for early mortality by comparing multivariate models with each comorbidity index, and assessing their respective discriminatory abilities (C-index).

RESULTS

A total of 36 patients (6.1%) died within 6 months of the start of SBRT. With a median follow-up of 25 months, 3-year overall survival was 54%. CIRS and tumor diameter were significant predictors of early mortality on multivariate analysis (p = .001). Patients with a CIRS score of 8 or higher and a tumor diameter over 3 cm had a 6-month survival of 70% versus 97% for those lacking these two features (p < .001). CCI was not predictive for early mortality on univariate nor multivariate analysis; the model containing CCI had a C-index of 0.65 versus 0.70 for the model containing CIRS.

CONCLUSION

CIRS and tumor diameter predict for early-mortality in peripheral early-stage NSCLC treated with SBRT. CIRS may be a more useful comorbidity index than CCI in this population when assessing short-term life expectancy.

Empiric Radiotherapy for Lung Cancer Collaborative Group multi-institutional evidence-based guidelines for the use of empiric stereotactic body radiation therapy for non-small cell lung cancer without pathologic confirmation

The standard of care for managing early stage non-small cell lung cancer (NSCLC) is definitive surgical resection. Stereotactic body radiation therapy (SBRT) has become the standard treatment for patient who are medically inoperable, and it is increasingly being considered as an option in operable patients. With the growing use of screening thoracic CT scans for patients with a history of heavy smoking, as well as improved imaging capabilities, the discovery of small lung nodes has become a common dilemma. As a result, clinicians are increasingly faced with managing lung nodules in patients in whom diagnostic biopsy is not safe or feasible. Herein, we describe the scope of the problem, tools available for predicting the probability that a lung nodule is a malignancy, staging procedures, benefits of pathology-proven and empiric SBRT, considerations of safety based on location of the lesion of concern, and overall efficacy of SBRT.

Modern Radiation Further Improves Survival in Non-Small Cell Lung Cancer: An Analysis of 288,670 Patients

Background: Radiation therapy plays an increasingly important role in the treatment of patients with non-small-cell lung cancer (NSCLC). The purpose of the present study is to assess the survival outcomes of radiotherapy treatment compared to other treatment modalities and to determine the potential role of advanced technologies in radiotherapy on improving survival. Methods: We used cancer incidence and survival data from the Surveillance, Epidemiology, and End Results database linked to U.S. Census data to compare survival outcomes of 288,670 patients with stage I-IV NSCLC treated between 1999 and 2008. The primary endpoint was overall survival. Results: Among the 288,670 patients diagnosed with stage I-IV NSCLC, 92,374 (32%) patients received radiotherapy-almost double the number receiving surgery (51,961, 18%). Compared to other treatment groups and across all stages of NSCLC, patients treated with radiotherapy showed greater median and overall survival than patients without radiation treatment (p < 0.0001). Radiotherapy had effectively improved overall survival regardless of age, gender, and histological categorization. Radiotherapy treatment received during the recent time period 2004 - 2008 is correlated with enhanced survival compared to the earlier time period 1999 - 2003. Conclusion: Radiation therapy was correlated with increased overall survival for all patients with primary NSCLC across stages. Combined surgery and radiotherapy treatment also correlates with improved survival, signaling the value of bimodal or multimodal treatments. Population-based increases in overall survival were seen in the recent time period, suggesting the potential role of advanced radiotherapeutic technologies in enhancing survival outcomes for lung cancer patients.