A Randomized Trial of a Nurse-Led Palliative Care Intervention for Patients with Newly Diagnosed Lung Cancer

Background: Specialist palliative care improves quality of life (QOL), symptom burden, and may prolong survival among patients with advanced lung cancer. Previous trials focused on advanced disease, and less is known about patients across a broad range of stages. Objective: We sought to assess the effect of a nurse-led telephone-based primary palliative care intervention that focused on patients across a broad range of stages. Design, Setting, and Participants: We conducted a multisite randomized controlled trial in the United States involving patients diagnosed within two months with any stage or histology of lung cancer to compare the effects of a telephone-based palliative care intervention delivered by registered nurses trained in primary palliative care versus usual care. Main Outcomes and Measures: The primary outcome was the Functional Assessment of Cancer Therapy-Lung Scale Total Outcome Index (FACT-L TOI), which measures QOL and symptoms. We estimated having 80% power to detect a 5-point change from baseline to three months. Secondary outcome was a change in satisfaction of care, measured by the FAMCARE-P13. Results: A total of 151 patients were enrolled over 30 months. Patients were, on average, male (98%), age 70 years, White (85%), and 36% diagnosed with stage I-II, and 64% had stage III-IV. In comparison to usual care, patients in the nurse-led intervention did not report improvement in QOL from baseline to three months follow-up or demonstrate differences in treatment effect by site or cancer stage: FACT-L TOI 1.03 (95% confidence interval [CI]: -3.98 to 6.04). Satisfaction with care did not significantly improve: 0.66 (95% CI: -2.01 to 3.33). Conclusions: Among patients with newly diagnosed lung cancer, a nurse-led, primary palliative care intervention did not significantly improve QOL, symptom burden, or satisfaction of care. In contrast to several clinical trials demonstrating the effectiveness of delivering specialty palliative care with disease-modifying treatments on QOL among patients with advanced lung cancer, this intervention did not significantly improve QOL among patients with any stage lung cancer. Future research should identify which specific components of primary palliative care improve outcomes for patients newly diagnosed with lung cancer.

Abstract 23: Will novel systemic treatments alter the benefit of lung cancer screening?: A microsimulation study

Background: The U.S. Preventive Services Task Force has recently updated its 2013 lung cancer screening guidelines with low-dose computed tomography. In the last decade, population level mortality for advanced non-small cell lung cancer fell significantly due to the novel targeted and immunotherapy-based treatments. Moreover, with detection of new molecular targets, these therapies are expected to become the ultimate curative options. However, how these treatments might impact the benefits of lung cancer screening is unknown.

Methods: We utilize a computer microsimulation modeling framework to screen the U.S. population aged 50 to 80 who had a 20 pack-year smoking history and currently smoked or had quit within the past 15 years under both standard treatments (chemotherapy and radiotherapy) and novel treatments (immunotherapy and targeted therapy) settings. The corresponding mortality reductions associated with the stage shift via low-dose computed screening are projected for each setting.

Results: Over 25 years, risk-targeted screening saves 243 lives per 20,000 under standard therapies (12% mortality reduction) and 99 per 20,000 under fully adopted novel therapies (6% mortality reduction). Under standard treatment, 1.28 cancers are over-diagnosed per life saved; under fully adopted novel therapies, this increases to 3.46. Over 25 years the number needed to screen to avert one death is 82 under standard treatment and 202 under fully adopted novel therapies.

Conclusions: Ongoing transition from chemotherapy and radiotherapy to novel immunotherapies and targeted therapies may reduce the expected lives saved by low-dose computed tomography screening. Screening recommendations might need to be reconsidered as novel treatments become widespread.

Citation Format: Kemal Caglar Gogebakan, Jane Lange, Christopher Slatore, Ruth Etzioni. Will novel systemic treatments alter the benefit of lung cancer screening?: A microsimulation study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 23.

Screening Adherence in the Veterans Administration Lung Cancer Screening Demonstration Project

BACKGROUND

Adherence to annual low-dose CT was 95% in the National Lung Screening Trial and must be replicated to achieve mortality benefit from screening.

RESEARCH QUESTION

How do we determine adherence rates within the Veterans Affairs Lung Cancer Screening Demonstration Project and identify factors predictive of adherence?

STUDY DESIGN AND METHODS

A secondary data analysis of the Lung Cancer Screening Demonstration Project that was conducted at eight Veterans Affairs medical centers was performed to determine adherence to follow up imaging and to determine factors predictive of adherence.

RESULTS

A total of 2,103 patients were screened. The adherence to screening from baseline scan (T0) to first follow-up scan (T1) was 82.2% and 65.2% from T1 to second follow-up scan (T2). Logistic regression modeling showed that presence of a nodule and the site of lung cancer screening were predictive of adherence. After three rounds of screening, 1,343 patients (64%) who underwent baseline screening underwent both subsequent annual low-dose CT scans; 225 patients (11%) had only one subsequent low-dose CT; 0.4% did not have a T1 scan but did have a T2 scan; 70 patients (3%) died, and 36 patients (1.7%) were diagnosed with lung cancer. There was significant variation in screening adherence across the eight sites, which ranged from 63% to 94% at T1 and 52% to 82% at T2 (P < .05).

INTERPRETATION

Despite a centralized program design with dedicated navigator and registry to assist with adherence to annual lung cancer screening, variations between sites suggest that active follow-up strategies are needed to optimize adherence. For the mortality benefit from lung cancer screening to be recognized, adherence to annual screening must achieve higher rates.

The effect of radiographic emphysema in assessing lung cancer risk

PURPOSE

Lung cancer risk models optimise screening by identifying subjects at highest risk, but none of them consider emphysema, a risk factor identifiable on baseline screen. Subjects with a negative baseline low-dose CT (LDCT) screen are at lower risk for subsequent diagnosis and may benefit from risk stratification prior to additional screening, thus we investigated the role of radiographic emphysema as an additional predictor of lung cancer diagnosis in participants with negative baseline LDCT screens of the National Lung Screening Trial.

METHODS

Our cohorts consist of participants with a negative baseline (T0) LDCT screen (n=16 624) and participants who subsequently had a negative 1-year follow-up (T1) screen (n=14 530). Lung cancer risk scores were calculated using the Bach, PLCOm2012 and Liverpool Lung Project models. Risk of incident lung cancer diagnosis at the end of the study and number screened per incident lung cancer were compared between participants with and without radiographic emphysema.

RESULTS

Radiographic emphysema was independently associated with nearly double the hazard of lung cancer diagnosis at both the second (T1) and third (T2) annual LDCT in all three risk models (HR range 1.9-2.0, p<0.001 for all comparisons). The number screened per incident lung cancer was considerably lower in participants with radiographic emphysema (62 vs 28 at T1 and 91 vs 40 at T2).

CONCLUSION

Radiographic emphysema is an independent predictor of lung cancer diagnosis and may help guide decisions surrounding further screening for eligible patients.

Refractory Hypoxemia in a Patient with Submassive Pulmonary Embolism and an Intracardiac Shunt: A Case Report and Review of the Literature

INTRODUCTION

Acute pulmonary embolism is the third leading cause of cardiovascular death. Management options include anticoagulation with or without thrombolysis. Concurrent persistent hypoxemia should be a clue to the existence of an intracardiac shunt.

CASE PRESENTATION

A 46-year-old man experienced acute hypoxemic respiratory failure requiring mechanical ventilation after anesthesia induction for elective hip arthroplasty. He was found to have submassive bilateral pulmonary emboli with acute right ventricular dysfunction and a coexisting patent foramen ovale with right-to-left shunt. He remained profoundly hypoxemic despite catheter-directed thrombolysis. He underwent surgical embolectomy with partial endarterectomy, resulting in clinical improvement.

DISCUSSION

The management of acute submassive pulmonary embolism is undertaken on an individualized basis because of the wide spectrum of clinical presentations. In this report we review the literature and discuss the evidence behind the management of cases of acute pulmonary embolism complicated by hypoxemia from a patent foramen ovale. In a case of acute pulmonary embolism complicated by refractory hypoxemia from an intracardiac shunt, adjunctive therapies in addition to anticoagulation and thrombolysis must be considered.

An Official American Thoracic Society Workshop Report. A Framework for Addressing Multimorbidity in Clinical Practice Guidelines for Pulmonary Disease, Critical Illness, and Sleep Disorders

Coexistence of multiple chronic conditions (i.e., multimorbidity) is the most common chronic health problem in adults. However, clinical practice guidelines have primarily focused on patients with a single disease, resulting in uncertainty about the care of patients with multimorbidity. The American Thoracic Society convened a workshop with the goal of establishing a strategy to address multimorbidity within clinical practice guidelines. In this Workshop Report, we describe a framework that addresses multimorbidity in each of the key steps of guideline development: topic selection, panel composition, identifying clinical questions, searching for and synthesizing evidence, rating the quality of that evidence, summarizing benefits and harms, formulating recommendations, and rating the strength of the recommendations. For the consideration of multimorbidity in guidelines to be successful and sustainable, the process must be both feasible and pragmatic. It is likely that this will be achieved best by the step-wise addition and refinement of the various components of the framework.

Lung cancer prevention

Lung cancer is a common form of cancer.There are things you can do to lower your risk of lung cancer. Stop smoking tobacco. Ask your health care provider for help in quitting, including use of medicines to help with nicotine dependence. discuss with your healthcare provider,what you are taking or doing to decrease your risk for lung cancer