Older age, poor performance status and major comorbidities: how to treat high-risk patients with advanced nonsmall cell lung cancer

Sarcopenia as a Prognostic Factor for 90-Day and Overall Mortality in Patients Undergoing Spine Surgery for Metastatic Tumors: A Multicenter Retrospective Cohort Study

BACKGROUND

Novel methods in predicting survival in patients with spinal metastases may help guide clinical decision-making and stratify treatments regarding surgery vs palliative care.

OBJECTIVE

To evaluate whether the frailty/sarcopenia paradigm is predictive of survival and morbidity in patients undergoing surgery for spinal metastasis.

METHODS

A total of 271 patients from 4 tertiary care centers who had undergone surgery for spinal metastasis were identified. Frailty/sarcopenia was defined by psoas muscle size. Survival hazard ratios were calculated using multivariate analysis, with variables from demographic, functional, oncological, and surgical factors. Secondary outcomes included improvement of neurological function and postoperative morbidity.

RESULTS

Patients in the smallest psoas tertile had shorter overall survival compared to the middle and largest tertile. Psoas size (PS) predicted overall mortality more strongly than Tokuhashi score, Tomita score, and Karnofsky Performance Status (KPS). PS predicted 90-d mortality more strongly than Tokuhashi score, Tomita score, and KPS. Patients with a larger PS were more likely to have an improvement in deficit compared to the middle tertile. PS was not predictive of 30-d morbidity.

CONCLUSION

In patients undergoing surgery for spine metastases, PS as a surrogate for frailty/sarcopenia predicts 90-d and overall mortality, independent of demographic, functional, oncological, and surgical characteristics. The frailty/sarcopenia paradigm is a stronger predictor of survival at these time points than other standards. PS can be used in clinical decision-making to select which patients with metastatic spine tumors are appropriate surgical candidates.

Lung Cancer Survival in Lithuania: Changes by Histology, Age, and Sex From 2003-2007 to 2008-2012

Lung cancer is the most common cancer-related death worldwide. The aim of this study is to describe the most recent survival rates by sex, age group, extent of disease, and histology of lung cancer in Lithuania. The study is based on the Lithuanian Cancer Registry database. The analysis included patients with primary invasive lung cancer diagnosed in 1998 to 2012 (International Classification of Diseases, Tenth Revision C33 and C34). Patients were followed up with respect to vital status until December 31, 2012. Five-year relative survival estimates were calculated using period analysis. Relative survival was calculated as the ratio of the observed survival of patients with cancer and the expected survival of the underlying general population. In our study, the overall 5-year relative survival was low but increased slightly (10.7%) from 2003–2007 to 2008–2012. Positive changes in survival were evident in both sexes, in almost all age groups and for all histological groups and disease stages. Adenocarcinoma relative survival increased from 6.7% in 2003–2007 to 12.8% in 2008–2012 and squamous cell carcinoma increased from 7.4% in 2003–2007 to 11.1% in 2008–2012. Patients with small-cell carcinoma had the worst survival (2.9% in 2003-2007 and 3.6% in 2008–2012). The majority of patients with lung cancer are diagnosed with advanced disease. The number of new cases of advanced lung cancer increased from 35.1% to 37.8%. Despite low overall survival, there were positive changes in survival in both sexes, in almost all age groups, and for all histological groups and disease stages. The survival rate of patients with lung cancer in Lithuania is similar to that in other European countries.

[The geriatric syndrome of anemia-Summary of the symposium of the working group anemia during the annual meeting of the German Geriatric Society 2018 in Cologne, Germany]

This year's symposium of the working group anemia of the German Geriatric Society (DGG) aimed to underline the multicausality of anemia in the aged and to highlight definition parallels with geriatric syndromes. For these reasons, nutritional and malignant causes for anemia were discussed and the influence of oxidative stress on the development of anemia was underlined. The need for ongoing research in the field of anemia in the aged was emphasized by the lack of perioperative transfusion strategies in geriatric patients.

Patient, tumor, and healthcare factors associated with regional variability in lung cancer survival: a Spanish high-resolution population-based study

PURPOSE

The third most frequently diagnosed cancer in Europe in 2018 was lung cancer; it is also the leading cause of cancer death in Europe. We studied patient and tumor characteristics, and patterns of healthcare provision explaining regional variability in lung cancer survival in southern Spain.

METHODS

A population-based cohort study included all 1196 incident first invasive primary lung cancer (C33-C34 according to ICD-10) cases diagnosed between 2010 and 2011 with follow-up until April 2015. Data were drawn from local population-based cancer registries and patients' hospital medical records from all public and private hospitals from two regions in southern Spain.

RESULTS

There was evidence of regional differences in lung cancer late diagnosis (58% stage IV in Granada vs. 65% in Huelva, p value < 0.001). Among patients with stage I, only 67% received surgery compared with 0.6% of patients with stage IV. Patients treated with a combination of radiotherapy, chemotherapy, and surgery had a 2-year mortality risk reduction of 94% compared with patients who did not receive any treatment (excess mortality risk 0.06; 95% CI 0.02-0.16). Geographical differences in survival were observed between the two regions: 35% vs. 26% at 1-year since diagnosis.

CONCLUSIONS

The observed geographic differences in survival between regions are due in part to the late cancer diagnosis which determines the use of less effective therapeutic options. Results from our study justify the need for promoting lung cancer early detection strategies and the harmonization of the best practice in lung cancer management and treatment.

Young age increases risk for lymph node positivity but decreases risk for non-small cell lung cancer death

Non-small cell lung cancer (NSCLC) prognosis and risk of lymph node positivity (LN+) are reference points for reasonable treatments. The aim of the current study was to investigate the effect of age on LN+ and NSCLC death. Data from the Surveillance, Epidemiology, and End Results (SEER) registry were used to identify 82,253 patients with NSCLC diagnosed between 1988 and 2008. All the patients underwent standard lung cancer surgery with lymph node examination. Demographic and clinicopathological parameters were extracted and compared among each age group. Impact of age on LN+ and NSCLC death was evaluated by the Cochran-Armitage trend test and logistic univariate and multivariate analyses for all T stages. Overall, 22,711 (27.60%) patients of the entirety had lymph node metastasis and 28,968 (35.22%) patients died of NSCLC within 5 years. With the increase in age, LN+ rates decreased regardless of T stages (P<0.001), whereas NSCLC-specific mortality increased in stages T1-T3 (P<0.001). Controlling other covariates in multivariable logistic regression, age remained an independent risk factor for LN+ in all T stages (P<0.05) and in stages T1-T3 (P<0.05). Our SEER analysis demonstrated a higher rate of LN+ and lower mortality in younger patients with NSCLC, after accounting for other covariates.

Prognostic factors in patients with skeletal-related events at non-small-cell lung cancer diagnosis

The aim of the present study was to detect prognostic factors in patients with skeletal-related events (SREs) and bone metastasis at the time of non-small-cell lung cancer (NSCLC) diagnosis. A total of 85 NSCLC patients were retrospectively enrolled, 47 (55.2%) of whom presented with SREs at the time of NSCLC diagnosis. Multivariate logistic regression analysis identified squamous cell carcinoma as a risk factor for SRE. Kaplan-Meier analysis demonstrated that there was no difference in the overall survival between the SRE and no SRE groups. Cox hazard model revealed that a higher Eastern Cooperative Oncology Group (ECOG) performance status (PS) score was a risk factor for poor prognosis, while surgery for bone metastasis and molecular-targeted therapy were factors for better prognosis in patients with SREs at the time of NSCLC diagnosis. Multivariate analysis revealed that a higher ECOG PS score and metastasis to the adrenal gland were risk factors for poor prognosis, while surgery for bone metastasis and molecular-targeted therapy were factors for better prognosis. Thus, while surgical treatment and molecular-targeted therapy appear to improve the prognosis of patients with bone metastasis at the time of NSCLC diagnosis, those with a higher ECOG PS score and adrenal metastasis may benefit more from radiotherapy or supportive care.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Personalized Therapy of Non-small Cell Lung Cancer (NSCLC)

Lung cancer remains the most common cause of cancer related deaths in both men and women in the United States and non-small cell lung cancer (NSCLC) accounts for over 85 % of all lung cancers. Survival of these patients has not significantly altered in over 30 years. This chapter initially discusses the clinical presentation of lung cancer patients. Most patients diagnosed with lung cancer due to symptoms have advanced stage cancer. Once diagnosed, lung cancer patients need imaging studies to assess the stage of the disease before decisions regarding therapy are finalized. The most important prognostic factors are stage of the disease and performance status and these factors also determine therapy. The chapter subsequently discusses management of each stage of the disease and the impact of several pathologic, clinical factors in personalizing therapy for each individual patient. Transition from chemotherapy for every patient to a more personalized approach based on histology and molecular markers has occurred in the management of advanced stage NSCLC. It is expected that such a personalized approach will extend to all stages of NSCLC and will likely improve the outcomes of all NSCLC patients.

Lung cancer survival in Germany: A population-based analysis of 132,612 lung cancer patients

OBJECTIVES

Lung cancer is the most common cancer-related death worldwide. In Germany it accounts for 25% of cancer deaths in men, and 14% in women. The aim of this study is to provide an overview of 5-year relative survival by sex, age, histology, and tumour stage in Germany representing a population of 26.7 million people.

MATERIALS AND METHODS

The study is based on a pooled German dataset including data from 12 population-based cancer registries covering around one third of the German population. A total of 132,612 patients diagnosed with lung cancer from 2002 to 2010 were included in the analysis. Survival estimates for the time period 2007-2010 were calculated using period analysis. Differences in survival between sexes were tested for statistical significance by model-based period analysis (poisson regression model). The relative excess risk (RER) of death (women vs. men) was extracted from the model with the p value for the difference in RER.

RESULTS

The overall age adjusted 5-year relative survival was 15.5% (standard error (SE) 0.2) for men and 20.3% (SE 0.3) in women. Survival differed markedly according to age (men: <60 years 18.5% vs. 80+ years 8.4% and women 23.7% vs. 10.6%, respectively), histology (largest difference between histological groups: men 25.7 and women 44.4% points) and stage (men: UICC Ia 62.9%, vs. UICC IV 4.6% and women 75.2% vs. 7.0%, respectively). Our study showed survival advantages for women compared to men, most notably in younger aged patients (RER 0.83, p<0.0001), patients with adenocarcinoma (RER 0.80, p<0.0001), and patients with lower stage cancer (RER 0.62, p<0.0001).

CONCLUSIONS

This study presents up-to-date survival estimates for lung cancer in Germany. Compared to other European countries survival was relatively high. Women showed higher survival than men independent of age, histology and stage. The reasons for the survival differences require further clarification.

Surgery for non-small cell lung cancer in younger patients: what are the differences?

BACKGROUND

Non-small cell lung cancer (NSCLC) in young adults is uncommon. The objective of this study was to evaluate the clinicopathological characteristics, outcomes and prognosis of people younger than 50 years old treated surgically for NSCLC.

METHODS

A retrospective study was conducted using the institutional database of four thoracic surgery units to collect patients with NSCLC younger than 50 years who had undergone surgery. These patients were compared with older patients (>75-years) operated in the same institutions and in the same period.

RESULTS

We identified 113 young patients and 347 older patients. Younger patients were more likely to be female, non-smokers, with fewer comorbidities. Younger patients were more likely to be symptomatic at the time of diagnosis. Risk factors for poor prognosis in younger patients were T-stage, and disease-free-interval less than 548 days. Kaplan-Meier analysis showed a lower five-year survival in older patients compared with the younger ones (66% vs 38%, p=0.001).

CONCLUSIONS

In conclusion NSCLC in younger patients has some distinct clinicopathological characteristics. The overall-survival of young patients is better than in older patients. Young patients receive more complete and aggressive treatment that could explain better survival. Further prospective studies with larger patient populations are required, to clarify the biological and genetic variance of NSCLC in younger patients.

Different prevalence of metabolic control and chronic complication rate according to the time of referral to a diabetes care unit in the elderly

The time of diagnosis is crucial for type 2 diabetes mellitus (T2DM) in terms of disease severity and chronic complications, as initial glycated haemoglobin (HbA1c) predicts 5-year cardiovascular mortality. The Italian health-care system relies on about 650 diabetes care units (DCU) interfacing with a large number of general practitioners (GPs). It may thus reach the goal of preventing complications easier than others by adopting a more comprehensive multifactorial approach. To assess whether the interval between diagnosis and referral to the DCU might influence the course of the disease in terms of HbA1c, associated cardiovascular risk factors, drug utilisation, and chronic complications in the elderly, the electronic records of 313 elderly T2DM patients (74.6 ± 4.9 years) followed by their GPs until referral to our DCU were retrospectively analysed for the above-mentioned parameters and divided into an early referral (ER) group (diagnosed within 12 months, n = 111) and a late referral (LR) group (diagnosed >12 months before, n = 202). A further set of 200 patients routinely taken care by our DCU, matched with the LR group for age, gender, and disease duration, was classified as "long-standing follow-up" (LSF) and compared to the others to rule out any confounding effects of long-standing disease per se on the clinical outcomes investigated in our study. About 35 % of T2DM patients referred to our DCU within 12 months of diagnosis; the rest did so some 5 years after diagnosis. LR patients displayed worse HbA1c levels (10.8 vs. 7.7 %, p < 0.01), used more drugs, and had more than twice as high complication rates as their ER counterparts. Almost all risk factors and complications were lower in the LSF (0.001 < p < 0.05) and ER groups than in the LR group. In both the ER and the LSF groups, we observed a lower burden of diabetes than in the LR group. This rules out the possibility that disease duration might play a major role per se in the burden of the disease in the elderly as opposed to the thoughtful patient care attitude exhibited by the DCU. A better and more efficient organisation has to be developed, including a strong interaction among GPs, diabetes specialists, and elderly people with T2DM allowing the latter to take charge of their own disease management through a sustained empowerment policy.

Predicting Survival in Patients with Advanced Non-squamous Non-small Cell Lung Cancer: Validating the Extent of Metastasis

Purpose

A number of factors related to overall survival (OS) have been addressed in advanced non-small cell lung cancer (NSCLC). This study was conducted to determine the impact of whole-body metastatic regions on survival outcome in advanced non-squamous NSCLC.

Materials and Methods

Between March 2005 and February 2011, 112 eligible patients with newly confirmed stage IV non-squamous NSCLC, available for epidermal growth factor receptor (EGFR) mutation status 18-21 analysis, and accessible for the determination of pretreatment whole-body metastatic regions were enrolled in this retrospective study. The total number of synchronous metastatic regions was scored according to the following disease sites: abdomen/pelvis, lung to lung/pulmonary lymphangitic spread, bone, pleura/pleural effusion/pericardial effusion, neck/axillary lymph nodes, other soft tissue, brain.

Results

The median age of the cohort was 65 years (range, 31 to 88 years). The median whole-body metastatic score was 2 (range, 1 to 6), and bone and lung to lung were the most common metastatic sites. EGFR mutations were observed in 40 (35.7%) patients with a deletion in exon 19 and Leu858Arg mutation in exon 21 being detected in 16 (40.0%) and 19 (47.5%) patients, respectively. Multivariate analysis for OS revealed that treatment factors (p=0.005), performance status (p=0.006), whole-body metastatic score (p<0.001), and EGFR mutation status (p=0.095) were significantly or marginally associated with OS.

Conclusion

The results of the present study demonstrated that whole-body metastatic extent strongly affects survival outcome, even after adjustment for other significant variables in advanced non-squamous NSCLC. The clinical validity of more curative multimodal approaches in cohorts with limited metastases remains to be explored.

Key factors influencing lung cancer survival in northern Italy

AIM

Lung cancer is a major cause of cancer death worldwide. The aims of this study were to analyze presentation, treatment and survival for lung cancer in northern Italy, and identify factors influencing survival.

METHODS

A total of 1180 lung cancer cases diagnosed in four north Italian cancer registries (Biella, Modena, Reggio Emilia, Romagna) in 2003-2005 were analyzed. Information on morphology, stage, diagnostic examinations, chemotherapy, radiotherapy, and surgical treatment was collected from clinical records. Three-year relative survival and relative excess risks of death were estimated.

RESULTS

Overall, 10% of cases were stage I, 50% stage IV, and 12% stage unknown. Romagna - where sophisticated diagnostic examinations were performed more often - had proportionately more microscopically verified cases and resected cases than Biella. Romagna had also high proportions of cases given chemotherapy and radiotherapy. Three-year survival was 14%, range 10% (Biella) to 19% (Romagna); 69% for stage I, 3% for stage IV. Stage I survival was higher in Romagna (82%) than Reggio Emilia and Biella (60-61%) but for operated stage I cases, survival was similar (88%) in Romagna and Biella. The fully adjusted model showed a higher risk of death in Biella (1.23, 95%CI 1.02-1.48) than Modena (reference).

CONCLUSIONS

Stage and surgery are key factors influencing survival. Centralizing lung cancer treatment to improve diagnostic work-up may improve outcomes.