Natural course of inoperable lung cancer

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Pre-treatment serum lactate dehydrogenase as a biomarker in small cell lung cancer

BACKGROUND

Small cell lung cancer is a rapidly progressive disease with high fatality. No sensitive and specific biomarker to assist in managing this disease exists currently.

AIM

Role of pretreatment serum lactate dehydrogenase as a biomarker in small cell lung cancer.

METHODS

A hospital-based cancer registry was used to identify eligible patients from 1999 to 2009. Demographic data, lactate dehydrogenase level and clinical outcome of patients were collected for analysis.

RESULTS

One hundred and sixty-eight patients were identified: 61% (n = 103) males and 39% (n = 65) females. Majority had extensive stage (67%). High lactate dehydrogenase (≥230 U/L) was present in 60.4% (n = 75); mean reading 260 U/L (range 148-898 U/L) in limited stage and 470 U/L (range 116-5462 U/L) in extensive stage. Extensive stage patients with high lactate dehydrogenase had lower treatment response rate compared to those with normal lactate dehydrogenase (39% vs 79%, P = 0.002); no difference in treatment response was seen among patients with limited stage. High lactate dehydrogenase conferred a worse survival; mean overall survivals in limited and extensive stage were 8.0 and 5.2 months, respectively, in patients with elevated lactate dehydrogenase. Those with normal lactate dehydrogenase had an overall survival of 16.5 and 8.2 months, respectively. The association remained significant after adjustment for age, sex and treatment (HR 1.8, 95% CI 1.16-2.80, P = 0.009).

CONCLUSION

High pretreatment lactate dehydrogenase is a prognostic marker of survival in both stages of small cell lung cancer. It is also a predictive marker of response to therapy in extensive stage. Larger prospective studies to validate our findings would be beneficial.

The Natural History of Operable Non-Small Cell Lung Cancer in the National Cancer Database

BACKGROUND

The survival of untreated non-small cell lung cancer (NSCLC), or the natural history, is an important perspective for patients considering resection for NSCLC. The National Cancer Database (NCDB) allows untreated NSCLC patients who were recommended to undergo surgical resection (ie, "operable") to be identified. The survival of untreated NSCLC patients in the NCDB was studied to determine the natural history of operable NSCLC.

METHODS

The NCDB was queried for untreated clinical stage I to IIIA NSCLC patients diagnosed between 2003 and 2009. The natural history cohort was defined as patients who were recommended to undergo resection but went untreated.

RESULTS

We identified 1,693 untreated patients with operable NSCLC. The median survival for clinical stage I, II, and IIIA was 16.6, 9.4, and 8.4 months, respectively. The 5-year Kaplan-Meier estimates of survival for clinical stage I, II, and IIIA NSCLC were 10.1%, 7.3%, and 4.9%, respectively. At each stage (I to IIIA), the survival of untreated operable NSCLC patients was superior to that of untreated NSCLC patients not recommended to undergo resection (nonoperable, p < 0.001). A multivariable Cox regression model identified increasing age, male gender, white (vs black) race, increasing comorbidity, squamous cell or large cell histology, and increasing stage as predictors of decreased survival.

CONCLUSIONS

The natural history of operable NSCLC, although poor, varies with clinical stage and is superior to that of nonoperable NSCLC.

Healthy Lifestyle Behaviors of Breast Cancer Survivors

The purpose of this secondary analysis was to describe the extent to which women with breast cancer, who participated in a randomized control trial on exercise, adopted American Cancer Society (ACS) guidelines for healthy lifestyle behaviors. Women in the study exercised during cancer treatment and for 6 months after completion of treatment. The sample included 106 women, average age 50.7 years (SD = 9.6). Adherence to guidelines for 5 servings of fruits and vegetables ranged from 36% (n = 28) to 39% (n = 36). Adherence with alcohol consumption guidelines was 71% (n = 28) to 83% (n = 30). Adherence with meeting a healthy weight ranged from 52% (n = 33) to 61% (n = 31). Adherence with physical activity guidelines ranged from 13% (n = 30) to 31% (n = 35). Alcohol and healthy weight guidelines were followed by more than half of the participants, but physical activity and dietary guidelines were followed by far fewer women. Further prospective clinical studies are indicated to determine whether interventions are effective in producing a healthy lifestyle in cancer survivors.

Survival of patients with non-small cell lung cancer without treatment: a systematic review and meta-analysis

BACKGROUND

Lung cancer is considered a terminal illness with a five-year survival rate of about 16%. Informed decision-making related to the management of a disease requires accurate prognosis of the disease with or without treatment. Despite the significance of disease prognosis in clinical decision-making, systematic assessment of prognosis in patients with lung cancer without treatment has not been performed. We conducted a systematic review and meta-analysis of the natural history of patients with confirmed diagnosis of lung cancer without active treatment, to provide evidence-based recommendations for practitioners on management decisions related to the disease. Specifically, we estimated overall survival when no anticancer therapy is provided.

METHODS

Relevant studies were identified by search of electronic databases and abstract proceedings, review of bibliographies of included articles, and contacting experts in the field. All prospective or retrospective studies assessing prognosis of lung cancer patients without treatment were eligible for inclusion. Data on mortality was extracted from all included studies. Pooled proportion of mortality was calculated as a back-transform of the weighted mean of the transformed proportions using the random-effects model. To perform meta-analysis of median survival, published methods were used to pool the estimates as mean and standard error under the random-effects model. Methodological quality of the studies was examined.

RESULTS

Seven cohort studies (4,418 patients) and 15 randomized controlled trials (1,031 patients) were included in the meta-analysis. All studies assessed mortality without treatment in patients with non-small cell lung cancer (NSCLC). The pooled proportion of mortality without treatment in cohort studies was 0.97 (95% CI: 0.96 to 0.99) and 0.96 in randomized controlled trials (95% CI: 0.94 to 0.98) over median study periods of eight and three years, respectively. When data from cohort and randomized controlled trials were combined, the pooled proportion of mortality was 0.97 (95% CI: 0.96 to 0.98). Test of interaction showed a statistically non-significant difference between subgroups of cohort and randomized controlled trials. The pooled mean survival for patients without anticancer treatment in cohort studies was 11.94 months (95% CI: 10.07 to 13.8) and 5.03 months (95% CI: 4.17 to 5.89) in RCTs. For the combined data (cohort studies and RCTs), the pooled mean survival was 7.15 months (95% CI: 5.87 to 8.42), with a statistically significant difference between the two designs. Overall, the studies were of moderate methodological quality.

CONCLUSION

Systematic evaluation of evidence on prognosis of NSCLC without treatment shows that mortality is very high. Untreated lung cancer patients live on average for 7.15 months. Although limited by study design, these findings provide the basis for future trials to determine optimal expected improvement in mortality with innovative treatments.

Comparisons of exercise dose and symptom severity between exercisers and nonexercisers in women during and after cancer treatment

CONTEXT

Although numerous studies of the efficacy of exercise are reported, few studies have evaluated changes in characteristics of exercise dose in women with cancer both during and after cancer treatment.

OBJECTIVES

To describe the characteristics of exercise dose (i.e., frequency, duration, and intensity) and evaluate for differences in symptom severity (i.e., fatigue, sleep disturbance, depression, and pain) between women who did and did not exercise during and after cancer treatment.

METHODS

In a sample of 119 women, two groups were classified: exercisers and nonexercisers. Exercisers were defined as women who met specific criteria for frequency (three times per week), duration (20 minutes/session), intensity (moderate), and mode (aerobic). Nonexercisers were defined as women who did not meet all these criteria. Evaluation of exercise dose was completed at baseline (T1: the week before chemotherapy cycle 2), at the end of cancer treatment (T2), and at the end of the study (T3: approximately one year after the T1 assessment) using self-report exercise questionnaires.

RESULTS

Approximately 50% of the participants exercised during treatment and 70% exercised after treatment. At T1, exercisers had lower total fatigue, lower behavioral and sensory subscale fatigue scores, and lower depression scores (P = 0.038) than nonexercisers. No significant differences in sleep disturbance or pain were found between groups. At T2, exercisers had lower cognitive/mood subscale fatigue and depression scores than nonexercisers (P = 0.047). At T3, no significant differences were found between groups in any symptom severity scores.

CONCLUSION

Both during and after cancer treatment, achieving or maintaining exercise guideline levels were met by most patients. Further study is needed to examine the link between exercise dose and symptom severity.

Extended survival observed in adoptive activated T lymphocyte immunotherapy for advanced lung cancer: results of a multicenter historical cohort study

Purpose

To clarify the long-term effect of immunotherapy, the effect of adoptive activated T lymphocyte immunotherapy on advanced lung cancer was evaluated in terms of survival time. In addition, the performance status of cancer patients under immunotherapy was examined.

Experimental design

Over 5 × 10⁹ alpha–beta T lymphocytes cultured ex vivo with an immobilized anti-CD3 antibody and interleukin-2 were injected intravenously into patients, once every 2 weeks for 3 months or longer. Follow-up of these patients was carried out using clinical records and by telephone interview questionnaire. Patients undergoing immunotherapy in immunotherapy clinics and those undergoing other anticancer therapies without immunotherapy in seven hospitals in Tokyo were enrolled in this study. Data were analyzed by a third-party statistician. Performance status was studied on another series of various cancer patients who underwent immunotherapy.

Results

The overall median survival time of the patients with the best supportive care, which was obtained using Kaplan–Meier’s model, was 5.6 months, and those with immunotherapy alone, chemotherapy alone, and immuno-chemotherapy were 12.5, 15.7, and 20.8 months, respectively. Using Cox’ proportional hazard model, we examined the possible factors on survival time by univariate analysis. Then, the patients were stratified by gender and histological type for multivariate analysis. Significantly low hazard ratios were observed for immunotherapy and radiotherapy in males with squamous cancer; for chemotherapy and radiotherapy in male with adenocarcinoma; and for immunotherapy in females with adenocarcinoma. Addition of immunotherapy to chemotherapy resulted in a statistically significant decrease in hazard ratio in females with adenocarcinoma. Studies on the performance status (PS), determined according to the European Cooperative Oncology Group criteria, revealed a continuous high level of PS under immunotherapy until around 2 months before death, in contrast to the gradual increase of tumor marker level.

Conclusions

The effectiveness of immunotherapy on advanced lung cancer is limited but may extend life span under certain conditions. Immunotherapy itself provided no clinical benefit by itself as compared with chemotherapy, but a significant additive effect of immunotherapy on chemotherapy was observed in females with adenocarcinoma. Moreover, immunotherapy can maintain good quality of life of the patients until near the time of death.

Hyponatremia as prognostic factor in small cell lung cancer--a retrospective single institution analysis

PURPOSE

The aim of this retrospective study is to present data on clinical significance of hyponatremia in an unselected contemporary patient population with small cell lung cancer (SCLC) with limited disease (LD) and extensive disease (ED).

PATIENTS AND METHODS

Our electronic database was searched for patients with newly diagnosed SCLC from June 2004 to December 2008. 395 cases were identified. We collected data on patient characteristics including clinical performance status, serum sodium values, serum LDH values, metastatic sites, chemotherapy regimens and response, radiotherapy and survival.

RESULTS

Hyponatremia (sodium <135 mmol/l) was present in 18.9% of all cases. Severe hyponatremia (sodium <129 mmol/l) was detected in 8.8%. Hyponatremia was present in 58 out of 241 (24%) patients with ED SCLC and 17 of 154 (11%) patients with LD SCLC. Hyponatremia was associated with significantly shorter median survival (SCLC all patients: 9.0 vs. 13.0 months, p < 0.001, LD SCLC: 9.0 vs. 17.0, p = 0.050, ED SCLC 9.0 vs. 10.0, p = 0.135). After adjustment for age, gender, LDH and performance status hyponatremia was an independent predictor of mortality in patients with ED and LD SCLC.

CONCLUSION

According to the extensive statistical analyses in our comprehensive unselected patient population, hyponatremia seems to constitute an independent prognostic factor in patients with SCLC.

Identification of latent classes in patients who are receiving biotherapy based on symptom experience and its effect on functional status and quality of life

PURPOSE/OBJECTIVES

to identify subgroups of patients receiving biotherapy with pain, fatigue, sleep disturbance, and depression and to determine functional status and quality of life differences between subgroups.

DESIGN

a descriptive, prospective, cohort study design.

SETTING

internet-based survey.

SAMPLE

187 patients with cancer receiving biotherapy.

METHODS

pain intensity, Piper Fatigue Scale, General Sleep Disturbance Scale, Center for Epidemiological Studies-Depression, Karnofsky Performance Scale, and the Multidimensional Quality of Life Scale-Cancer were used at two time points one month apart (T1 and T2). Latent profile analysis identified subgroups.

MAIN RESEARCH VARIABLES

biotherapy, symptoms, functional status, and quality of life.

FINDINGS

At T1 (N = 187), five patient subgroups were identified, ranging from subgroup 1 (mild fatigue and sleep disturbance) to subgroup 5 (severe on all four symptoms). At T2 (N = 114), three patient subgroups were identified, ranging from subgroup 1 (mild pain, fatigue, and sleep disturbance without depression) to subgroup 3 (mild pain, moderate fatigue, and sleep disturbance with severe depression). At each time point, the patient subgroup with the most severe symptoms showed significantly lower functional status and quality of life.

CONCLUSIONS

as with other cancer treatments, biotherapy can be divided into similar patient subgroups with four prevalent symptoms. Subgroups of patients differ in functional status and quality of life as a result of symptom severity.

IMPLICATIONS FOR NURSING

clinicians should assess and identify patients with severe levels of the four prevalent symptoms and offer appropriate interventions. Future study is needed to investigate the factors that contribute to symptom severity and to examine the occurrence of symptom clusters that may place patients at increased risk for poorer outcomes.

A randomized controlled trial of home-based exercise for cancer-related fatigue in women during and after chemotherapy with or without radiation therapy

BACKGROUND

Few studies have evaluated an individualized home-based exercise prescription during and after cancer treatment.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a home-based exercise training intervention, the Pro-self Fatigue Control Program on the management of cancer-related fatigue.

INTERVENTIONS/METHODS

Participants (N = 119) were randomized into 1 of 3 groups: group 1 received the exercise prescription throughout the study; group 2 received their exercise prescription after completing cancer treatment; and group 3 received usual care. Patients completed the Piper Fatigue Scale, General Sleep Disturbance Scale, Center for Epidemiological Studies-Depression Scale, and Worst Pain Intensity Scale.

RESULTS

All groups reported mild fatigue levels, sleep disturbance, and mild pain, but not depression. Using multilevel regression analysis, significant linear and quadratic trends were found for change in fatigue and pain (ie, scores increased, then decreased over time). No group differences were found in the changing scores over time. A significant quadratic effect for the trajectory of sleep disturbance was found, but no group differences were detected over time. No significant time or group effects were found for depression.

CONCLUSIONS

Our home-based exercise intervention had no effect on fatigue or related symptoms associated with cancer treatment. The optimal timing of exercise remains to be determined.

IMPLICATIONS FOR PRACTICE

Clinicians need to be aware that some physical activity is better than none, and there is no harm in exercise as tolerated during cancer treatment. Further analysis is needed to examine the adherence to exercise. More frequent assessments of fatigue, sleep disturbance, depression, and pain may capture the effect of exercise.

Nutritional symptom and body composition outcomes of aerobic exercise in women with breast cancer

The purpose of this secondary analysis was to examine the nutritional symptoms and body composition outcomes of aerobic exercise in women with breast cancer. A single-blind clinical trial, randomized to tailored Pro-Self(©) exercise during and after chemotherapy, after chemotherapy only, or no Pro-Self (usual care). One hundred women, average age 49.9 years (SD = 9.6), participated. Mild taste changes, nausea, constipation, and anorexia were experienced by 47% to 55% at baseline and end of treatment but diminished post treatment. No group differences were found in total nutritional symptoms or symptom severity. Intervention group participants maintained lean body mass; control group participants had nonsignificant lean body mass loss. Issues related to self-report, protocol adherence, and generalizability limit findings. Aerobic exercise is useful in achieving healthy weight and body composition, but the intensity and duration achieved during cancer treatment and recovery did not produce significant changes.

Lactate dehydrogenase as prognostic factor in limited and extensive disease stage small cell lung cancer - a retrospective single institution analysis

PURPOSE

The aim of this retrospective study is to present data on clinical significance of lactate dehydrogenase (LDH) serum levels in an unselected contemporary patient population with small cell lung cancer (SCLC) in limited disease (LD) and extensive disease stage (ED).

PATIENTS AND METHODS

From June 2004 to June 2008, our electronic database including all in-patient and out-patient contacts was searched for patients with newly diagnosed LD and ED SCLC. 397 cases were identified. We collected data on patient characteristics including clinical performance status and LDH serum levels, metastatic sites, efficacy of first line chemotherapy and survival.

RESULTS

In both limited and extensive disease SCLC, elevated LDH serum levels resulted in significantly shorter median survival. The effect was most pronounced if levels were 300 U/l or higher. In patients with limited disease and normal LDH levels, median survival was 18.0 months. If LDH was higher than 300 U/l, overall survival was reduced to 12 months. In cases with extensive disease, overall survival was significantly lower in patients with elevated LDH serum levels with an additional reduction in overall survival in patients with LDH levels above 300 U/l. (7.0 vs. 12.0 months, p = <0.001). Multivariate Cox regression analyses revealed LDH levels to be an independent predictor of mortality after adjustment for age and Performance Status in LD and ED SCLC (HR 1.003, p = 0.017; HR 1.001, p = 0.002 respectively). However, categorizing LDH levels revealed no significant difference in LD SCLC.

CONCLUSION

In our contemporary comprehensive patient population, LDH is proved to be a strong, independent predictive factor of median survival in patients with LD and ED SCLC.

The effect of symptom clusters on functional status and quality of life in women with breast cancer

PURPOSE

The purposes of this study of women with breast cancer receiving chemotherapy with/without radiation therapy were to determine whether: (1) subgroups of oncology outpatients can be identified based on a specific symptom cluster (i.e., pain, fatigue, sleep disturbances, depression); (2) these subgroups differ on outcomes (i.e., functional status, quality of life); (3) subgroup membership changes over time.

METHODS

A secondary data analysis using data collected from 112 women at initial chemotherapy. Symptom and outcome measures were completed at three time points: baseline (i.e., the week before cycle two - T1); end of cancer treatment (T2), end of the study (approximately one year after the start of chemotherapy - T3). Cluster analysis identified patient subgroups based on symptom severity scores.

RESULTS

At T1 and T2, four patient subgroups were identified: ALL LOW (one or no symptom greater than the cut score), MILD (two symptoms), MODERATE (three or four symptoms), and ALL HIGH (four symptoms). At T3, three subgroups were identified: MILD, MODERATE and ALL HIGH. Subgroups with high severity levels of all four symptoms had poorer functional status and QOL at each time point than other subgroups (p<0.001). Group membership changed over time.

CONCLUSIONS

Subgroups of patients with different symptom experiences were identified. For some patients severity of all four symptoms persisted months after cancer treatment. Initial and ongoing assessment to identify those patients in the ALL HIGH patient subgroup is important so that appropriate interventions to improve functional status and quality of life can be offered.

Fluorodeoxyglucose-PET in characterizing solitary pulmonary nodules, assessing pleural diseases, and the initial staging, restaging, therapy planning, and monitoring response of lung cancer

Fluorodeoxyglucose-PET imaging has secured an important role in the assessment and management of a multitude of pulmonary disorders, including solitary pulmonary nodules, lung cancer, and pleural diseases. While conventional imaging modalities such as chest radiography and CT are considered essential in these settings, FDG-PET can provide new information and complement structural imaging techniques in the evaluation of such disorders. In this review, the authors present a growing body of evidence that demonstrates and supports the utility of FDG-PET in the differentiation of benign and malignant pulmonary nodules, the assessment of lung cancer in various stages of disease, and the characterization of pleural diseases. In addition, new developments--such as prospects for potential utility of novel radiotracers and delayed imaging--that can further refine the role of FDG scans in the work-up of lung nodules and cancer and forecast the future place of PET in these common modalities are discussed.

Complexities in prognostication in advanced cancer: "to help them live their lives the way they want to"

Predicting survival and disclosing the prediction to patients with advanced disease, particularly cancer, is among the most difficult tasks that physicians face. With the de-emphasis of prognosis in favor of diagnosis and therapeutics in the medical literature, physicians may have difficulty finding the survival information they need to make appropriate estimates of survival for patients who develop cancer. Quite separate from the challenge of estimating survival accurately, physicians may also find the process of disclosing the prognosis to their patients difficult. Using the vignette of a real patient with advanced cancer who far outlived her physician's prognostic estimate, we discuss clinical issues related to the science of prognosis in advanced cancer and the art of its disclosure.

Prognosis in lung cancer: physicians' opinions compared with outcome and a predictive model

BACKGROUND

Although the study of prognostic factors in small cell lung cancer has reached the stage where they are used to guide treatment, fewer data are available for non-small cell lung cancer. Although correct management decisions in non-small cell lung cancer depend upon a prognostic assessment by the supervising doctor, there has never been any measurement of the accuracy of physicians' assessments.

METHODS

A group of consecutive patients with non-small cell lung cancer was studied and the predictions of their physicians as to how long they would survive (in months) was compared with their actual survival. A prognostic index was also developed using features recorded at the patients' initial presentation.

RESULTS

Two hundred and seven consecutive patients diagnosed and managed as non-small cell lung cancer, who did not receive curative treatment for their condition, were studied. Of the 196 patients whose date of death was known, physicians correctly predicted, to within one month, the survival of only 19 patients (10%). However, almost 59% of patients (115/196) had their survival predicted to within three months and 71% (139/196) to within four months of their actual survival. Using Cox's regression model, the sex of the patient, the activity score, the presence of malaise, hoarseness and distant metastases at presentation, and lymphocyte count, serum albumin, sodium and alkaline phosphatase levels were all identified as useful prognostic factors. Three groups of patients, distinct in terms of their survival, were identified by the use of these items. When the prediction of survival made by the physician was included as a prognostic factor in the original model, it was shown to differentiate further between the group with a poor prognosis and the other two groups in terms of survival.

CONCLUSIONS

Physicians were highly specific in identifying patients who would live less than three months. However, they had a tendency to overestimate survival in these patients, failing to identify almost half the patients who actually died within this time. Both the physicians and the prognostic factor model gave similar performances in that they were more successful in identifying patients who had a short time to survive than those who had a moderate or good prognosis. Physicians appear to use information not identified in the prognostic factor analysis to reach their conclusions.

Weight change and lung cancer: relationships with symptom distress, functional status, and smoking

The pattern of weight change (at five 6-week intervals beginning 2 months after diagnosis of advanced disease) is described in adults with progressive lung cancer (N = 60). Weight loss of 10% or more at study entry occurred in 35% of subjects; 37% lost weight at three or more intervals; and 25% lost weight at only one interval. Pre-illness weight loss was moderately correlated with subsequent decreased functional status (Enforced Social Dependency Scale) at Times 1, 2, and 3 (r = -.49, r = -.43, r = -.48, p < .001). Weight loss correlated with subsequent increased symptom distress (Symptom Distress Scale, SDS) at three times (Times 2, 4, and 5: r = -.34, r = -.30, r = -.43, p < .05). Chemotherapy (50% of subjects) and smoking (25% at study entry) predicted weight loss from Time 1 to 5, explaining 28% of the variance.

Prognostic factors for survival in terminal lung cancer patients

OBJECTIVE

To determine the factors that are related to short-term survival and to develop a model that can be used to estimate prognosis in terminal lung cancer patients.

DESIGN

Longitudinal cohort study of hospice lung cancer patients followed from date of admission to hospice until death.

SETTING

Community-based nonprofit home hospice service.

PATIENTS

Three hundred ten consecutive lung cancer patients admitted to hospice, with a separate validation sample of 78 consecutive hospice lung cancer patients.

MEASUREMENTS

The relationships between survival and admission demographic characteristics, information from the history and physical examination, assessments of performance and nutrition, particular symptoms, and the presence of a living will were evaluated.

RESULTS

Mean survival was 51 days, with a median survival of 27 days. Shorter survival was independently associated with those who had no living will on admission to hospice (p = 0.008), those who had tissue types other than squamous cell or adenocarcinoma (p = 0.008), those who had liver metastases (p = 0.04), those who were tachycardic (p < 0.001), those who required assistance or were dependent in their toileting (p < 0.001) and feeding (p = 0.001), those who had dry mouths (p = 0.01), and those who had severe or incapacitating pain (p < 0.05). A model estimating survival time based on the number of these significant variables present is reported (r = 0.53 in the original sample; r = 0.38 in the validation sample).

CONCLUSIONS

Multiple factors, including tissue type, the presence of metastases, assessments of functional status, specific symptoms, and the presence of a living will, were related to short-term survival in terminal lung cancer patients admitted to hospice. A model utilizing these specific factors allows useful estimates of short-term survival for these patients.

Analysis of early and late deaths on RTOG non-small cell carcinoma of the lung trials: comparison with CALGB 8433

In a major study that showed a treatment advantage for induction chemotherapy followed by radiation therapy (CALGB 8433), there was a significantly (P = 0.02) lower proportion of patients dying within 105 days of registration in the chemotherapy/radiation arm than the radiation therapy arm; without this difference, the overall survival was marginally better (P = 0.059) for the chemotherapy/radiation group. A retrospective analysis of RTOG trials sought explanations for the phenomenon.

MATERIALS AND METHODS

Patients who fit the CALGB eligibility criteria and received radiation therapy alone in four prospective trials of the RTOG conducted between 1983 and 1989 were analyzed to determine factors that distinguished patients dying within 105 days from longer survivors. Two were trials of altered fractionation and two used standard fractionation. Of 683 patients identified, 107 (15.7%) died within 105 days after registration. The log linear model was used to evaluate relationships between death within 105 days and known prognostic factors. Karnofsky performance status (KPS), < 90 vs. > or = 90, was the only factor significantly related to death within 105 days (P = 0.0052). A Cox model with the same factors plus fractionation and total dose found KPS and T-stage associated with overall survival (P = 0.0005 and 0.025, respectively). The choice of the hyperfractionation arm (HFX) for Phase III study (69.6 Gy at 1.2 Gy b.i.d.) was based in part on comparison with standard fractionation (STD) from a concurrent RTOG protocol, 8321. Review of early deaths showed that this HFX arm had a lower proportion of patients dying within 105 days (7.9%) than STD in 8321 (21.0%).(ABSTRACT TRUNCATED AT 250 WORDS)

The stress process in family caregivers of persons receiving chemotherapy

The purpose of this analysis was to explore strain and depression among family caregivers of persons receiving chemotherapy for cancer using the Pearlin Stress Process Model. Seventy-five family caregivers of persons receiving chemotherapy participated, completing the Caregiver Strain Index and the Depression Subscale of the Profile of Mood States within 3 weeks of the initiation of chemotherapy. Hierarchical regression analyses indicated that 44% of the variance in strain and 40% of the variance in depression were explained by the antecedent variables of caregiver age and gender, patient age and gender, patient functional status, the presence of recurrent disease, perceived efficacy of coping strategies, and perceived adequacy of social support. Further analysis aimed at delineating the mechanisms through which coping and social support operate in the model found no evidence for a moderating or stress-buffering effect. However, coping mediated the relationship between strain and depression and social support mediated the relationship between functional status and depression.

Women with lung cancer: impact on quality of life

The purpose of this study was to describe disruptions in quality of life (QOL) in women suffering from lung cancer, the leading cause of cancer-related death in the United States. QOL was measured with the CARES-SF. Symptom distress was measured with the modified Symptom Distress Scale, and functional status was measured with the Karnofsky Performance Status Scale. Sixty-nine women with lung cancer participated in a one-time data collection. The typical subject was under 65 years of age, married, has had primary or recurrent non-small cell lung cancer for over 12 months, had limited disease, and was not currently receiving treatment. Subjects had greater disruptions in global QOL and its dimensions compared to a normative heterogeneous female cancer sample. The most prevalent serious disruptions were fatigue, difficulty with household chores, worry about ability to care for self, and worry about cancer progression. The global CARES-SF score was moderately correlated to functional status (r = 0.69, p = < 0.001), and to symptom distress (r = 0.72, p = < 0.001). Symptom distress was associated strongly with the physical subscale of QOL (r = 0.80, p = 0.001) and significantly but less strongly with all other dimensions of QOL. Significantly greater differences in disruptions of quality of life occurred in women younger than 65 years (p = 0.04), women with recurrent disease (p = 0.003), and women with low income (p = 0.008). In stepwise regression, symptom distress predicted 53% of the variance followed by functional status (59%) and recurrence (63%) when QOL was the outcome variable.

Measuring quality of life in stroke

BACKGROUND AND PURPOSE

Little attention has been focused on quality of life in stroke outcome research. The purpose of this review is to outline the meaning of the concept, describe important methodological issues and methods of assessment, review existing quality of life measures, and discuss criteria for selecting an appropriate instrument.

SUMMARY OF REVIEW

The following 10 quality of life instruments were reviewed: COOP Charts; Euroqol; Frenchay Activities Index; Karnofsky Performance Status Scale; McMaster Health Index Questionnaire; Medical Outcomes Study 20-Item Short-Form Health Survey; Nottingham Health Profile; Quality of Life Index; Quality of Well-being Scale; and the Sickness Impact Profile. They were evaluated in terms of length, time needed to complete, content, scoring, and psychometric characteristics.

CONCLUSIONS

Emphasis should be placed on further psychometric evaluation of existing quality of life measures rather than on generating new instruments. There is particular need for supplementary data on the responsiveness of the instruments to changes in patients' clinical status over time. The choice of a suitable quality of life instrument should be based not only on psychometric properties but also on careful consideration of the research question, the relevance to the objectives of the study, the feasibility of the instrument, and the specific characteristics of the stroke patients under investigation.

Performance and prognosis in patients with lung cancer. The Edinburgh Lung Cancer Group

The Edinburgh Lung Cancer Group prospectively registered 651 new patients presenting with lung cancer during 1981; only 47 survived five years (7%). The survival rate was highest in patients selected for surgery (35/116, 30%) and in this group was related to cell type, stage of disease, and possibly to Karnofsky performance score (not statistically significant). By comparison with non-surgical patients these 116 patients undergoing surgery were highly selected in terms of age, favourable histological type, stage of disease, and performance score. Forty-two of the 535 non-surgical patients were given radical radiotherapy alone and seven (17%) survived five years. The remaining 493 received palliative radiotherapy, chemotherapy (alone or combined with radiotherapy), or symptomatic treatment alone; only five (1%) survived five years. Median survival was related to cell type (adenocarcinoma 2.6 months, squamous cell carcinoma 6.2 months), stage (stage I 8.5 months, stage III 4 months), and Karnofsky performance index (greater than or equal to 90 9.3 months, less than or equal to 50 1.2 months). Age and sex had no independent prognostic value in any group. Performance score was highly correlated with stage (and age) and in this study represented the "best prognostic factor" in clinical practice.

Primary lung cancer: characterization and survival of 1024 patients treated in a single institution

This report describes the presenting features, smoking history, diagnostic techniques and their yields, histological typing and tumor-node-metastases (TNM) staging for a cohort of 1024 Australian patients with primary lung cancer. It also includes survival data for the group as a whole and for subgroups of patients based on clinical stage, histology, treatment modality and postsurgical stage. Ninety-six per cent of patients had smoked. A much higher proportion of patients with adenocarcinoma had smoked than has commonly been believed. In surgically treated patients, stage, but not histological type or age, was related to survival. Approximately one-third of all patients had such advanced disease that no treatment to the primary site was offered.

Curative radiotherapy of early operable non-small cell lung cancer

The results of 44 patients with early operable non-small cell lung cancer treated from January 1975 through 1981 are retrospectively analysed. All were proven by pathology and/or cytology and denied surgery in our joint Chest Clinic for various reasons. 55-70 Gy/6-7 weeks was delivered by conventional fractionation through A-P portals by telecobalt and/or 25-35 MeV high energy electron beam or 8 MV X-ray. 40 Gy/4 weeks was given prophylactically to the mediastinum. The 1-, 3-, and 5-year survival rates, 93, 55, and 32%, are superior to what is reported in the literature. In the present series, the favorable factors are: (1) patients without any intercurrent disease but refused operation; (2) T1 lesions; (3) complete regression of the lesion at the conclusion of radiotherapy; (4) doses ranging from 69 to 70 Gy. It is shown that early non-small cell lung cancer can be cured by radiotherapy alone giving survival rates comparable to surgery. Prospective randomized clinical trials are warranted.

Benefit-risk assessment of investigational drugs: current methodology, limitations, and alternative approaches

Development of investigational drugs is a process integrated traditionally into four overlapping phases. The goal is to introduce new therapies to clinical medicine by assessing benefits and risks associated with administering the new drug. Benefit assessment is performed with respect to the disease for which the drug may comprise an effective treatment. In contrast, safety assessment is relatively standardized across many pharmacologic classes of agents. For purposes of benefit-risk assessment, investigational drugs are developed to provide benefit in three major disease categories: acute, episodic, and chronic. Benefit assessment is the major focus of conventional methodologies. Inherent limitations of risk assessment produced by conventional approaches are illustrated by the historical inability to detect toxicities of various drugs until large patient populations have been treated, typically after the drug is marketed. Alternative approaches to overcome these limitations include assessment of safety in studies specifically designed to optimize such evaluation and more extensive safety testing of investigational drugs in patient subgroups at higher risk. Such approaches serve the interest of patients, physicians, and developers by facilitating the development of new therapies by providing a more complete benefit-risk assessment prior to initial marketing of the drug.

Staging of non-small cell bronchogenic carcinoma. Relationship of the clinical evaluation to organ scans

Organ scans are generally performed on patients with bronchogenic carcinoma only when clinical evaluation is suspicious for metastases. However, it is not clear whether the clinical abnormalities will direct attention to the single organ which should be scanned, or if all three organs (bone, brain, liver) should be evaluated if any clinical abnormality is present. We investigated the use of triple organ radionuclide scanning and computerized tomography (CT) of the brain in the initial staging of patients with non-small cell bronchogenic carcinoma with no obvious metastases. Of 122 patients with newly diagnosed lung cancer, 53 met our criteria for further study. Thirty-three (62 percent) of these had at least one clinical abnormality suggestive of metastasis. Bone scanning detected metastases in seven (21 percent) and head CT in two additional patients (6 percent). Brain and liver scanning had no yield. In only five of these nine patients did the clinical abnormality direct attention to the organ with detectable metastases. Twenty of the 53 (38 percent) patients had a negative routine clinical evaluation, yet bone scanning showed metastases in three (15 percent). We concluded that clinical abnormalities are not specific for the organ in which metastases may be detected, so three scans (bone, liver, CT of the brain) should be obtained if there is any suspicion of metastasis based on history, physical examination, and laboratory tests. The value of bone scanning in clinically normal patients deserves further study.

A randomized prospective study of vindesine versus doxorubicin and cyclophosphamide in the treatment of epidermoid lung cancer

A randomized prospective study was conducted comparing vindesine (VDS) with doxorubicin and cyclophosphamide (D/C) in the treatment of advanced squamous cell carcinoma of the lung. No patient had a complete response. Seven of 28 (25%) patients had partial response (PR) to VDS while one of 19 (5%) had a PR to D/C (P less than 0.08). Adding PR plus minor response (MR), ten of 28 (36%) patients responded to VDS while two of 19 (11%) responded to D/C (P less than 0.05). Median survival was improved among patients showing PR and MR over those not responding (P less than 0.05). This study concludes, VDS is an active agent in the treatment of squamous cell carcinoma of the lung and should be considered for combination chemotherapy and adjuvant trials. VDS toxicity appears acceptable with six weekly doses of 3 mg/m2. The benefit of a maintenance schedule could not be demonstrated.

Nonanatomic prognostic factors in carcinoma of the lung: a multivariate analysis

Existing records of 651 patients with bronchogenic carcinoma registered at the Kingston Clinic of the Ontario Cancer Treatment and Research Foundation during the period between 1965-1974 were examined in order to determine the relationship to survival of the following four "nonanatomic" prognostic factors: symptomatic history, performance status, weight loss, and age. Even when stage, histologic factors, and treatment were taken into account, it was found that weight loss and performance status significantly affected survival. Age, however, was related to survival only when the treatment given to the patient was not considered. Symptomatic history was important in so far as it related to weight loss and performance status. These results are compared to those obtained in other series and the implications discussed.

Clinical indicators of prognosis in unresected lung cancer

A prognosis estimate in palliative treatment for inoperable lung cancer is thought to be of value. Performance status is now recognized as being of major importance, but only recently has been consistently available. We examined other simple information not requiring clinical or laboratory tests that is available in the clinical histories of a series of 1,839 patients with unresected lung cancer. Actuarial survivals at 1, 2, and 5 years were 21.9, 7.8, and 2.0 percent, respectively. The median survival rate was 24 weeks. Squamous cell histology and an increasing interval between the first symptoms and diagnosis were associated with a better prognosis. The number of symptoms recorded at the time of assessment had strong negative association with survival; asymptomatic patients had a two-year survival of 26 percent compared with 6 percent or less with four or more symptoms. A similar discrimination is given by Feinstein's index, which combines information on the number and type of symptoms and on the interval between first symptom and diagnosis. The clinical stage was strongly related to survival. Additional statistical analysis showed that the prognostic value of each of the most powerful prognostic factors, the number of symptoms, and Feinstein's index was little altered by the use of data on stage and histology in addition. The data show a range of median survival of 18 to 60 weeks for Feinstein's indices from 6 to 1, suggesting that the symptom index is useful particularly in the relatively well patients and the performance status particularly in those more ill. The combination may be better than either alone, and it is recommended that such information be recorded for all lung cancer patients.

5-fluorouracil, adriamycin, and mitomycin-C (Hi-FAM) chemotherapy for adenocarcinoma of the lung

Thirty patients with unresectable adenocarcinoma of the lung were treated with high doses of 5-fluorouracil, Adriamycin, and mitomycin-C (Hi-FAM). Objective responses were seen in ten patients (one complete and nine partial remissions). No patient with pleural disease responded to treatment. Responses were seen in all other sites of involvement including liver. In a subgroup of patients younger than 65 years, who had not had prior treatment, and who had a performance status of greater than 60 (Karnofsky), an overall response rate of 50% was realized. The overall median survival for responding patients was 10+ months while nonresponders had a median survival of 5.21 months. Patients who had had prior irradiation had a median survival of 4.81 months compared with patients who had not had any prior treatment, whose median survival was 8.45 months. Toxicity was substantial and included primarily bone marrow suppression and stomatitis. Elderly patients with poor performance status and prior treatment tolerated therapy less well. These results indicate that Hi-FAM is useful in selected groups of patients with advanced adenocrcinoma of the lung.

In vitro monocyte maturation as a prediction of survival in squamous cell carcinoma of the lung

In vitro monocyte maturation was studied in patients with squamous cell carcinoma of the lung--limited to the ipsilateral hemithorax in 30 and more extensive in 40. The patients were studied prospectively and initial monocyte maturation was correlated with survival. Monocyte maturation in patients with limited disease before treatment ranged from 3.1 to 57.6% with a median value of 21.4%. The survival of those patients in whom monocyte maturation was less than the normal range (less than 30.4%) was significantly shorter than the survival in those with normal maturation ( p less than 0.05). Four of the five patients whose initial maturation was less than 10% proved to be inoperable at surgery. Patients with extensive disease had monocyte maturation ranging from 2.4 to 52.9% with a median value of 13.2%, significantly lower than in those with limited disease (p less than 0.025). Patients with extensive disease and low monocyte maturation survived a significantly shorter time than those with normal maturation ( p less than 0.005). The depression of monocyte development may explain the finding of negative delayed hypersensitivity skin reactions in many patients with lung carcinoma and may prove useful as an index of prognosis.

Bronchoscopy and bone marrow examinations. An efficient strategy to establish the diagnosis of small cell carcinoma of the lung

The utility of various diagnostic procedures, including fiberoptic bronchoscopy and bone marrow aspirate/biopsy for small cell carcinoma, was examined in 150 patients. From a chart review of the first 100 patients, 55 required an invasive procedure such as mediastinoscopy or thoracotomy to establish the tissue diagnosis. In 50 consecutive prospective patients, only four required an invasive procedure for tissue confirmation. Eighteen of the 50 prospective patients had positive iliac crest bone marrow aspirates or biopsies diagnostic for small cell carcinoma. Fiberoptic bronchoscopy was nondiagnostic in 15 prospective patients, but the bone marrow examination was diagnostic in 12 of this subgroup. The combination of fiberoptic bronchoscopy and bone marrow examination in patients with centrally located small cell carcinoma greatly reduced the need for more expensive and invasive diagnostic procedures.

Serum zinc levels in lung cancer patients

Serum zinc concentrations were determined in 26 extensive squamous cell lung cancer patients and were tested for correlations with survival, response to therapy, nutritional status indices, and various host defense characteristics. Subnormal serum zinc levels were found in 24 of the 26 patients. The mean serum zinc concentration was 43.2/micrograms 100 ml +/- 3.6 S.E.M. (normal = 80-100 micrograms/100 ml). A significant (P = 0.007) survival advantage was demonstrated for those patients with pretreatment zinc concentrations greater than 45 micrograms%, but serum zinc levels did not correlate with response to chemotherapy (also significantly affecting survival). Decreased serum zinc concentrations were significantly associated with decreased neutrophil migration measured by the skin window technique and with decreased triceps skin fold thickness but not with any of the other host defense and nutritional induces measured. These data suggest that further studies are indicated to examine the role of serum zinc concentration as a possible sensitive prognostic characteristic and to determine if zinc administration may be of therapeutic benefit in cancer patients.

Surgery, BCG immunotherapy, and multichemotherapy in T3 stage-3 bronchogenic carcinoma

Thirteen consecutive unselected patients suffering from stage-3 bronchogenic carcinomas (12 with T3 tumors and one T2 primary bilateral simultaneous carcinoma) underwent surgical resection followed by intrapleural, deep upper bilateral intercostal injections and oral immunostimulation with living fresh Pasteur strains of bacillus Calmette-Guérin (BCG). Since the 30th postoperative day, patients were started on intermittent multichemotherapy with suboptimal doses of methotrexate, 5-fluorouracil, and cyclophosphamide associated with oral therapy with BCG. The length of survival in the "study group" was compared to the results observed in nine unselected, consecutive, and concomitant semirandomized patients with T3 stage-3 carcinomas treated with cobalt therapy plus identical immunochemotherapy (control group A). Comparison of results was also made with 69 out of 100 consecutive patients with T3 stage-3 unresectable carcinomas who survived longer than two months after exploratory thoracotomies (control group B), representing the natural course of unresectable cases. Twelve (92 percent) of the 13 patients in the study group survived longer than six months, ten (77 percent) survived more than 12 months, six (46 percent) lived 18 months or more, and five (37 percent) have surpassed the 24th month of survival to date. Differences in survival at 6, 12, 18, and 24 months and the average length of survival in the study group to date (19.1 months) are statistically significant when compared to control groups A and B. The quality of postoperative life measured by the performance status according to Karnofsky's scale demonstrates an average of 79.3 percent for the entire study group.

The use of lithium carbonate to reduce infection and leukopenia during systemic chemotherapy

To investigate whether lithium ameliorates the infectious complications that accompany systemic chemotherapy, we studied 45 patients with small-cell bronchogenic carcinoma receiving combination chemotherapy and radiation therapy. Twenty received lithium carbonate, and 25 received no additional therapy. Control subjects experienced more days with neutropenia than the lithium-treated group (2.17 days per 100 patient-days vs. 0.29), more severe febrile episodes (seven patients vs. one patient), more days hospitalized with fever and neutropenia (1.92 per 100 patient-days vs. 0.18), and more infection-related deaths (five vs. none). Infection-free survival was significantly longer in the lithium-treated group than in controls (P less than 0.05). Delay in subsequent chemotherapy was longer (P less than 0.01) and the number of dose reductions greater (P less than 0.01) in the control group. For both leukocytes and neutrophils, the first cycle nadir, mean of all treatment nadirs, and the lowest nadir observed during treatment were significantly higher in the lithium group. Mean mid-cycle monocyte counts were greater in the lithium group (P less than 0.05) and correlated with concurrent serum lithium levels (rs = 0.74, P less than 0.05). We believe that lithium carbonate shows promise as a means of lowering the risk of infection among patients receiving cytotoxic therapy.