The prognostic value of Eastern Cooperative Oncology Group performance status on overall survival among patients with metastatic prostate cancer: a systematic review and meta-analysis

Background

There is heterogeneity in the literature regarding the strength of association between Eastern Cooperative Oncology Group performance status (ECOG PS) and mortality. We conducted a systematic review and meta-analysis of studies reporting the prognostic value of ECOG PS on overall survival (OS) in metastatic prostate cancer (mPC).

Methods

PubMed was searched from inception to March 21, 2022. A meta-analysis pooling the effect of ECOG PS categories (≥2 vs. <2, 2 vs. <2, and ≥1 vs. <1) on OS was performed separately for studies including patients with metastatic castration-resistant prostate cancer (mCRPC) and metastatic castration-sensitive prostate cancer (mCSPC) using a random-effects model. Analyses were stratified by prior chemotherapy and study type.

Results

Overall, 75 studies, comprising 32,298 patients, were included. Most studies (72/75) included patients with mCRPC. Higher ECOG PS was associated with a significant increase in mortality risk, with the highest estimate observed among patients with mCRPC with an ECOG PS of ≥2 versus <2 (hazard ratio [HR]: 2.10, 95% confidence interval [CI]: 1.87-2.37). When stratifying by study type, there was a higher risk estimate of mortality among patients with mCRPC with an ECOG PS of ≥1 versus <1 in real-world data studies (HR: 1.98, 95% CI: 1.72-2.26) compared with clinical trials (HR: 1.32, 95% CI: 1.13-1.54; p < 0.001). There were no significant differences in the HR of OS stratified by previous chemotherapy.

Conclusion

ECOG PS was a significant predictor of OS regardless of category, previous chemotherapy, and mPC population. Additional studies are needed to better characterize the effect of ECOG PS on OS in mCSPC.

Impact of performance status on efficacy of systemic therapy for prostate cancer: a meta-analysis

OBJECTIVE

To evaluate the efficacy of systemic therapies in patients with worse performance status (PS) treated for high-risk non-metastatic prostate cancer (PCa), metastatic hormone-sensitive PCa (mHSPC), and non-metastatic/metastatic castration-resistant PCa (nmCRPC/mCRPC), as there is sparse pooled data showing the effect of PS on oncological outcomes in patients with PCa.

METHODS

Three databases were queried in June 2022 for randomised controlled trials (RCTs) analysing patients with PCa treated with systemic therapy (i.e., adding androgen receptor signalling inhibitor [ARSI] or docetaxel [DOC] to androgen-deprivation therapy [ADT]). We analysed the oncological outcomes of patients with PCa with worse PS, defined as Eastern Cooperative Oncology Group PS ≥ 1, treated with combination therapies and compared these to patients with good PS. The main outcomes of interest were overall survival (OS), metastasis-free survival (MFS), and progression-free survival.

RESULTS

Overall, 25 and 18 RCTs were included for systematic review and meta-analyses/network meta-analyses, respectively. In all clinical settings, combination systemic therapies significantly improved OS in patients with worse PS as well as in those with good PS, while the MFS benefit from ARSI in the nmCRPC setting was more pronounced in patients with good PS than in those with worse PS (P = 0.002). Analysis of treatment ranking in patients with mHSPC revealed that triplet therapy had the highest likelihood of improved OS irrespective of PS; specifically, adding darolutamide to DOC + ADT had the highest likelihood of improved OS in patients with worse PS. Analyses were limited by the small proportion of patients with a PS ≥ 1 (19%-28%) and that the number of PS 2 was rarely reported.

CONCLUSIONS

Among RCTs, novel systemic therapies seem to benefit the OS of patients with PCa irrespective of PS. Our findings suggest that worse PS should not discourage treatment intensification across all disease stages.

Effects of Semisupervised Exercise Training on Health Outcomes in People With Lung or Head and Neck Cancer: Protocol for a Randomized Controlled Trial

BACKGROUND

Lung or head and neck cancers are known for their high prevalence and mortality rates. Chemotherapy and radiotherapy are usually recommended as cancer treatment for these malignancies; however, they can negatively impact both the physical and mental status of patients. Hence, it is reasonable to consider resistance and aerobic exercise training to prevent these negative health outcomes. Further, several factors prevent patients from attending outpatient exercise training programs, and, therefore, a semisupervised home-based exercise training program may be seen as a well-accepted alternative.

OBJECTIVE

The aim of this study will be to investigate the effects of a semisupervised home-based exercise training program on physical performance, body composition, and self-reported outcomes; changes in the initial cancer treatment dose prescribed; number of hospitalizations at 3, 6, and 9 months; and 12-month survival in people with primary lung or head and neck cancer.

METHODS

Participants will be randomly allocated to the training group (TG) or control group (CG). The TG will undergo semisupervised home-based resistance and aerobic exercise training throughout their cancer treatment. The resistance training will be performed using elastic bands (TheraBand) twice a week. The aerobic training (ie, brisk walk) will be performed for at least 20 minutes per day outdoors. The equipment and tools used during the training sessions will be provided. This intervention will start the week before treatment commencement, will be performed throughout the duration of the treatment, and will continue for 2 weeks after treatment completion. The CG will undergo usual care (ie, cancer treatment with no formal exercise prescription). Assessments will take place 2 weeks before the beginning of the usual cancer treatment and 2 weeks after treatment completion. The measures of physical function (peripheral muscle strength, functional exercise capacity, and physical activity), body composition, and self-reported outcomes (symptoms of anxiety and depression, health-related quality of life, and symptoms related to the disease and treatment) will be collected. We will report on any change in the initial cancer treatment dose prescribed; number of hospitalizations at 3, 6, and 9 months; and 12-month survival.

RESULTS

In February 2021, the clinical trial registration was approved. Recruitment and data collection for the trial are ongoing (as of April 2023, 20 participants had already been randomized), and findings of this study are likely to be published late in 2024.

CONCLUSIONS

This exercise training as a complementary treatment for patients with cancer is likely to promote positive effects on the health outcomes assessed, over and above any change in the CG, and prevent the reduction of initial cancer treatment dose prescribed. If these positive effects are shown, they will likely impact long-term outcomes such as hospitalizations and 12-month survival.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (ReBEC) RBR-5cyvzh9; https://ensaiosclinicos.gov.br/rg/RBR-5cyvzh9.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43547.

Does surgery for metastatic spinal tumors improve functional outcomes in patients without spinal cord compression but with potentially unstable spines?

OBJECTIVE

In the absence of spinal cord compression, it is unclear if surgery is more effective than radiation treatment for improving functional outcomes in metastatic spinal tumor patients with potentially unstable spines. The authors compared functional status outcomes assessed with Karnofsky Performance Status (KPS) and Eastern Cooperative Oncology Group (ECOG) scores after surgery or radiation in patients without spinal cord compression with Spine Instability Neoplastic Score (SINS) values of 7-12 indicating possible instability (SINS 7-12).

METHODS

A retrospective review was performed of patients with metastatic spinal tumor SINS values of 7-12 at a single institution between 2004 and 2014. Patients were divided into two different groups: 1) those treated with surgery and 2) those treated with radiation. Baseline clinical characteristics were measured, and KPS and ECOG scores were obtained pre- and postradiation or postsurgery. The paired, nonparametric Wilcoxon signed-rank test and ordinal logistic regression analysis were used for statistical analysis.

RESULTS

A total of 162 patients met inclusion criteria; 63 patients were treated operatively and 99 patients were treated with radiation. The mean follow-up was 1.9 years, with a median of 1.1 years for the surgical cohort (ranging from 2.5 months to 13.8 years) and a mean of 2 years with a median of 0.8 years for the radiation cohort (ranging from 2 months to 9.3 years). After covariates were accounted for, the average posttreatment changes in KPS scores in the surgical cohort were 7.46 ± 17.3 and in the radiation cohort were -2 ± 13.6 (p = 0.045). No significant difference was observed in ECOG scores. KPS scores improved postoperatively in 60.3% of patients in the surgical group and postradiation in 32.3% of patients in the radiation cohort (p < 0.001). Subanalysis within the radiation cohort revealed no differences in fracture rates or local control between patients treated with external-beam radiation therapy versus stereotactic body radiation therapy. In patients initially treated with radiation, 21.2% eventually developed compression fractures at a treated level. Five of the 99 patients in the radiation cohort-all of whom had a fracture-eventually underwent either methyl methacrylate augmentation or instrumented fusion.

CONCLUSIONS

Patients with SINS values of 7-12 who underwent surgery had greater improvement in KPS scores-but not in ECOG scores-than patients undergoing radiation alone. In patients treated with radiation, treatment was converted to a procedural intervention such as surgery only in patients who sustained fractures. Of the patients with fractures after radiation (21 of 99), 5 patients underwent an invasive procedure and 16 did not.

Impact of Performance Status on Oncologic Outcomes in Patients with Advanced Urothelial Carcinoma Treated with Immune Checkpoint Inhibitor: A Systematic Review and Meta-analysis

CONTEXT

Immune checkpoint inhibitors (ICIs) are widely used in the management of patients with advanced urothelial carcinoma (aUC). However, its performance in aUC patients with poor performance status (PS) remains unknown.

OBJECTIVE

We aimed to assess the impact of patients' performance status on the oncologic outcomes in patients with aUC treated with ICIs.

EVIDENCE ACQUISITION

We searched PubMed, Web of Science, and Scopus from inception until July 2022 to identify studies assessing the association between the Eastern Cooperative Oncology Group (ECOG) PS and the oncologic outcomes in patients with aUC treated with ICIs in randomised (RCTs) and nonrandomised (NRCTs) control studies according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The outcomes of our interests were overall survival (OS), cancer-specific survival (CSS), progression-free survival (PFS), and objective response rate (ORR).

EVIDENCE SYNTHESIS

Overall, six RCTs comprising 5428 patients and 32 NRCTs comprising 6069 patients were included. The meta-analysis of the RCTs revealed that patients with ECOG PS = 0 and PS ≥1 had a trend towards better OS with ICIs compared with those treated with chemotherapy (pooled hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.71-1.04, and HR: 0.74, 95% CI: 0.53-1.03, respectively). There was no significant difference in terms of response to ICIs between patients with poor and good PS (I² = 0%, p = 0.46). The meta-analysis of the NRCTs revealed that patients with PS ≥2 had significantly worse OS than those with PS <2 (pooled HR: 2.52, 95% CI: 2.00-3.17), as well as worse CSS (pooled HR: 3.35, 95% CI: 1.90-5.91), PFS (pooled HR: 2.89, 95% CI: 1.67-5.01), and ORR (pooled odds ratio: 0.47, 95% CI: 0.27-0.82). Similarly, patients with PS ≥1 had significantly worse oncologic outcomes than those with PS = 0.

CONCLUSIONS

In the NRCTs, poor PS was correlated with worse oncologic outcomes in aUC patients treated with ICIs. In the RCTs, ICIs performed better than chemotherapy across all PS categories. These findings should be interpreted with caution due to the high heterogeneity across the studies and patient populations. More RCTs including poor PS are needed to assess the impact of PS on ICI therapy outcomes.

PATIENT SUMMARY

Immune therapy for patients with urothelial carcinoma should not be restricted on the grounds of performance status. However, patients with poor performance status should be considered for other factors such as life expectancy and comorbidities.

The role of LENT and PROMISE scores in predicting survival in malignant pleural effusion

Background:

Malignant pleural effusion (MPE) is a condition, that can be seen in 15% of patients diagnosed with cancer. Because of the short overall survival, it is important to identify the appropriate treatment. In addition to the palliation of secondary symptoms due to MPE, it should also be decided in which cases a more aggressive treatment is to be followed. The purpose of the study was to evaluate the performance of LENT and clinical PROMISE scores in predicting survival in patients with MPE

Methods:

Age, sex, smoking history, Eastern Cooperative Oncology Group (ECOG) score, cancer type, history of chemotherapy/radiotherapy, laboratory values, and pleural fluid lactate dehydrogenase were recorded. The LENT and the PROMISE scores were calculated and risk categories were determined. During the follow-up, blood tests and tomography controls were performed on the patients as routine. The overall survival was calculated as the period from the date of diagnosis of MPE to death or until December 31, 2019

Results:

A total of 169 patients were included. The median age was 65 (26–86). In the single-variable analysis, there was a significant increase in mortality risk in the poor performance score and if the LENT risk group progressed from the low-to medium-/high-risk group or PROMISE categories A to B, A to C or A to D. In multivariate analysis, mortality risk in 1, 3, 6, and 12 months increased significantly in poor performance score, in PROMISE category B, C, and D. In high LENT risk-group, an increased mortality risk was shown in only 12 months of survival

Conclusions:

Our data show that poor performance score (ECOG 3-4), PROMISE category B, C, and D significantly increase mortality risk and the LENT score is inadequate in predicting survival.

Facilitating clinical research through automation: Combining optical character recognition with natural language processing

BACKGROUND/AIMS

Performance status is crucial for most clinical research, as an eligibility criterion, a comorbidity covariate, or a trial endpoint. Yet information on performance status often is embedded as free text within a patient's electronic medical record, rather than coded directly, thereby making this concept extremely difficult to extract for research. Furthermore, performance status information frequently resides in outside reports, which are scanned into the electronic medical record along with thousands of clinic notes. The image format of scanned documents also is a major obstacle to the search and retrieval of information, as natural language processing cannot be applied to unstructured text within an image. We, therefore, utilized optical character recognition software to convert images to a searchable format, allowing the application of natural language processing to identify pertinent performance status data elements within scanned electronic medical records.

METHODS

Our study cohort consisted of 189 subjects diagnosed with diffuse large B-cell lymphoma for whom performance status was a required data element for analysis of prognostic factors related to recurrence and survival. Manual abstraction of performance status was previously conducted by a clinical Subject Matter Expert, serving as the gold standard. Leveraging our data warehouse, we extracted relevant scanned electronic medical record documents and applied optical character recognition to these images using the ABBYY FineReader software. The Linguamatics i2e natural language processing software was then used to run queries for performance status against the corpus of electronic medical record documents. We evaluated our optical character recognition/natural language processing pipeline for accuracy and reduction in data extraction effort.

RESULTS

We found that there was high accuracy and reduced time for extraction of performance status data by applying our optical character recognition/natural language processing pipeline. The transformed scanned documents from a random sample of patients yielded excellent precision, recall, and F score, with <1% incorrect results. Time savings from a second cohort showed that median time to review documents for patients with performance status data present was reduced by a third. The major time savings was in the review of those documents that in fact did not contain performance status information: median of 18 minutes versus 108 minutes for manual review, an 83% reduction in data abstraction effort.

CONCLUSION

By applying this optical character recognition/natural language processing pipeline, we achieved significant operational improvement and reduced time for information retrieval to support clinical research. Our study demonstrated that optical character recognition software provides an effective mechanism to transform scanned electronic medical record images to allow the application of natural language processing, yielding highly accurate data abstraction. We conclude that our optical character recognition/natural language processing pipeline can greatly facilitate research data abstraction by providing a highly focused data review, eliminating unnecessary manual review of the entire chart, and thus freeing time for abstracting other data elements requiring more human interpretation.

Neo-adjuvant chemotherapy followed by either continuous hyper-fractionated accelerated radiation therapy week-end less or conventional chemo-radiotherapy in locally advanced NSCLC-A randomised prospective single institute study

Context

Better locoregional control and increased overall survival by continuous hyper fractionated accelerated radiotherapy have been shown in unresectable nonsmall cell lung carcinoma (NSCLC). Dose escalation and neoadjuvant chemotherapy (NACT) along with continuous hyperfractionated accelerated radiotherapy week end-less (CHARTWEL) were also tried for improved survival. In this present study, we compared the results of NACT followed by CHARTWEL against NACT followed by conventional concurrent chemo-radiation therapy.

Aims

The aim of this study is to compare the locoregional control and toxicities in NSCLC Stage IIIA and B in both arms.

Settings and Design

Randomized, prospective single-institutional study with a study population comprising all locally advanced unresectable NSCLC patients enrolled in 2014 at our institute.

Subjects and Methods

All enrolled patients were randomized into two arms-CHARTWEL and concomitant chemo-radiotherapy (CCRT), after three weeks of the fourth cycle of NACT. In CHARTWEL arm 30 patients received two-dimensional radiotherapy (RT) 58.5 Gy/39 fr/2.5 weeks while in CCRT arm 30 received 66 Gy/33 fr/6.5 weeks. Disease response was evaluated at 6 months and toxicity assessment during and after treatment completion. Data were analyzed using tools such as percentage, mean, Chi-square test and P value. Chi-square and P value was calculated by statistical online software (http://quantpsy.org).

Results

28% of patients in study arm and 20% in control arm had complete response at 6 months after RT. Locoregional disease control was observed in 44% in study arm and 32% in control arm of patients. There was no statistical difference in grades of toxicities or overall survival (OS)/disease-free survival except persistent esophagitis Grade III seen in two patients of study arm.

Conclusions

Study suggests that CHARTWEL in combination with NACT is an effective strategy to treat patients with locally advanced lung cancer with the advantage of a smaller dose and shorter duration. Although large multivariate studies still needed.

Functional impairment attenuates the association between high serum phosphate and mortality in dialysis patients: a nationwide cohort study

BACKGROUND

Both functional impairment and abnormalities in mineral and bone disorder (MBD) parameters are well-known predictors of mortality in dialysis patients. However, previous studies have not evaluated whether functional impairment modifies the association between MBD parameters and mortality.

METHODS

A nationwide prospective cohort study was conducted using data from the Japanese Society for Dialysis Therapy Renal Data Registry collected at the end of 2009 and 2010. The Eastern Cooperative Oncology Group performance status (PS) was used to assess functional status. Cox proportional hazards models were used to assess the associations of baseline functional status, serum phosphate, albumin-corrected calcium and intact parathyroid hormone (PTH) with 1-year all-cause mortality.

RESULTS

By 31 December 2010, 18 447 of 220 054 prevalent dialysis patients (8.4%) had died. Mortality significantly increased with worsening PS grade. PS grade modified the association of serum phosphate levels with mortality (Pinteraction = 0.001). Worsening PS grade attenuated the association of hyperphosphatemia (≥7.4 mg/dL) with mortality, and hyperphosphatemia was no longer significant on mortality among patients with the worst PS grade (hazard ratio = 1.1, 95% confidence interval 0.88-1.39), compared with the level between 3.5 and 4.7 mg/dL. In contrast, hypophosphatemia (<3.5 mg/dL) had a greater adjusted risk of mortality irrespective of PS grade. Serum-corrected calcium (Pinteraction = 0.26) and intact PTH (Pinteraction = 0.17) showed consistent associations with mortality irrespective of PS grade. Findings were robust in several sensitivity analyses.

CONCLUSIONS

Functional impairment was significantly associated with 1-year mortality and attenuated the effect of hyperphosphatemia on mortality among prevalent dialysis patients.

Interconversion of two commonly used performance tools: An analysis of 5844 paired assessments in 1501 lung cancer patients

AIM

To establish the Karnofsky performance status (KPS) categories which would facilitate the interconversion of the KPS scale to the Eastern Cooperative Oncology Group (ECOG) performance status (PS) scale.

METHODS

This was a retrospective analysis of all patients attending the lung cancer clinic at a tertiary care center over a 5-year period (September 2009 to August 2014). All patients were assessed with both KPS and ECOG PS scales at each visit. Correlation between KPS and ECOG PS was assessed using Spearman’s correlation coefficient. KPS categories equivalent to ECOG PS scores were compared using hit rate and weighted kappa (κ_w).

RESULTS

A total of 1501 patients were assessed over the study period, providing 5844 paired KPS and ECOG PS assessments. The study cohort had a mean (standard deviation; SD) age of 58.4 (10.8) years, with the majority being current or ex-smokers (76.9%) and males (82.3%). Non-small cell lung cancer was the most common histological type (n = 1196, 79.7%) with the majority having advanced (stage IIIB/IV) disease (83.4%). Mean baseline KPS and ECOG PS scores were 77.6 (SD = 14.4) and 1.5 (SD = 1) respectively. The most frequent KPS score was 80 (29%), and the most frequent ECOG PS score was 1 (43%). The overall correlation between KPS and ECOG PS was good (Spearman r = -0.84, P < 0.0001) but ranged from -0.727 to -0.972 between visits. KPS categories derived from our cohort [10-40 (ECOG 4), 50-60 (ECOG 3), 70 (ECOG 2), 80-90 (ECOG 1), 100 (ECOG 0)] performed better [hit rate 78.1%, κ_w = 0.749 (0.736-0.762) P < 0.0001] than those suggested in the past literature.

CONCLUSION

The current study provides the largest set of paired KPS-ECOG assessments to date. We suggest that the KPS categories 10-40, 50-60, 70, 80-90, and 100 are equivalent to ECOG PS categories of 4, 3, 2, 1, and 0 respectively.

Specialized Palliative Care and the Quality of Life for Hospitalized Cancer Patients at a Low-Resource Hospital in India

AIM

This study aimed to compare the quality of life (QoL) of cancer patients, with an Eastern Cooperative Oncology Group (ECOG) performance of 3-4, in contact with or without contact, with a specialized palliative care unit (PCU) at a low-resource governmental cancer hospital, as well as studying the impact of this contact on the QoL in their caregivers.

MATERIALS AND METHODS

Hospitalized patients with an ECOG performance of 3 or 4 and their primary caregiver were asked to participate in this observational study. Patients in contact with the specialized PCU and their closest caregivers formed Group A, while patients and families without this contact formed Group B. Contact was mainly one consultation. The patients were asked to complete the Palliative Care Outcome Scale (POS), and the caregivers were asked to complete the Hospital Anxiety and Depression Scale (HADS) and the distress thermometer (DT).

RESULTS

There was no statistically significant difference between the median POS values of the patient groups, neither regarding the total sum nor per any item. There were also no statistically significant differences between the median HADS values and median DT values when comparing the caregivers to Group A and B.

CONCLUSION

Consultation with a specialized PCU at this tertiary referral center did not alter the QoL of patients with an ECOG performance of 3-4 nor did it affect the psychological well-being of their caregivers. We argue that monitoring prescribed treatment and follow-up is a necessary component of PC.

An Observational Study Evaluating the Performance of LENT Score in the Selected Population of Malignant Pleural Effusion from Lung Adenocarcinoma in Singapore

BACKGROUND

Patients with malignant pleural effusion (MPE) secondary to lung cancer have been associated with poor prognosis historically. LENT score developed to risk-stratify unselected patients with MPE predicts prognosis of < 6 months in patients with lung cancer.

OBJECTIVE

To assess the performance of LENT score in predicting prognosis in selected population of MPE secondary to lung adenocarcinoma alone.

METHODS

A retrospective observational study was conducted by reviewing the medical records of patients managed for MPE in the year 2012.

RESULTS

Seventy patients with lung adenocarcinoma presenting with MPE were studied. The median (range) LENT score at initial diagnosis was 5 (2-7), and the median survival 7.9 (0.13-40) months. Thirty-nine patients received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKIs). The median LENT score and median survival was 4 (2-7) and 14.4 months, respectively, in this group. Those in high-risk category by LENT in this group (n = 19) had a median survival and 6-month survival of 17.4 months and 73.6%, respectively. Thirty-one patients were treated with conventional chemotherapy. The median LENT score and median survival was 5 (2-7) and 4.1 (0.13-34.3) months, respectively, in this group. The median survival and 6-month survival rate in patients in high-risk category and moderate-risk category by LENT score was 6.2 months and 52.7%, and 11.4 months and 70.5%, respectively.

CONCLUSION

LENT score underestimates prognosis in patients having MPE secondary to lung adenocarcinoma. This disparity particularly applies to the lung adenocarcinoma patients carrying EGFR mutation. Hence, LENT score may not be applicable to, or may need modification before applying to such patients.

Detection of epidermal growth factor receptor gene T790M mutation in cytology samples using the cobas® EGFR mutation test

OBJECTIVE

Detection of epidermal growth factor receptor (EGFR) gene mutations is essential in deciding therapeutic strategy in non-small cell lung cancer (NSCLC) patients at initial diagnosis. Moreover, in EGFR mutation-positive (EGFRm) NSCLC patients, re-biopsy at disease progression to clarify resistance mechanisms is also important. However, collecting histology samples is often difficult because of inaccessibility and invasiveness. In some cases, only cytology samples can be collected, and studies have reported that cytology samples are appropriate for EGFR gene mutation testing. The cobas^® EGFR Mutation Test (Roche Molecular Systems Inc., Branchburg, New Jersey, USA) is approved as a companion diagnostic for osimertinib, a third-generation EGFR-tyrosine kinase inhibitor approved in Japan. However, it is not clear whether the EGFR T790M mutation can be detected in cytology samples using this test. The primary objective of this study was to assess concordance of EGFR T790M gene mutation detection between histology and matched cytology samples using the cobas^® EGFR Mutation Test.

MATERIALS AND METHODS

We conducted a multicenter, observational study in Japan. Overall, 41 EGFRm NSCLC patients who had both histology and cytology samples collected at the same time at re-biopsy and with the results of EGFR mutation test using histology samples were enrolled. The EGFR mutation status of both sample types was tested using the cobas^® EGFR Mutation Test and the concordance rates were calculated.

RESULTS

The EGFR T790M mutation detection rate in histology and cytology samples was 42.5% and 37.5%, respectively. The overall percent agreement between the histology and cytology samples was 91.7%.

CONCLUSIONS

These data demonstrate that the cobas^® EGFR Mutation Test can detect the EGFR T790M mutation in both cytology and histology samples.

ECOG is as independent predictor of the response to chemotherapy, overall survival and progression-free survival in carcinoma of unknown primary site

The aim of the present study was to determine whether age, gender, functional status, histology, tumor location, number of metastases, and levels of the tumor markers, lactate dehydrogenase (LDH) and albumin, are poor prognostic factors for the response to chemotherapy in patients with carcinoma of unknown primary site. A total of 149 patients diagnosed with carcinoma of unknown primary site that was histologically confirmed, and treated with chemotherapy in the Oncology Hospital, National Medical Center, ‘Century XXI’ IMSS, Mexico City, Mexico during the period between January 2002 to December 2009, were carefully selected for the present study. The analysis of 149 patients diagnosed with carcinoma of unknown primary site revealed that the liver was the organ with the highest frequency of metastases (33.5%). The objective response rates to chemotherapy were ~30.2%. Notably, ECOG was an important predictor of response to chemotherapy (P=0.008). The median progression-free survival was 7.1 months. Upon multivariate analysis, the Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status was observed as an independent predictor of progression (P<0.0001). The median overall survival was 14.2 months. The ECOG was also an independent predictor of mortality (P<0.0001). In conclusion, the data from the present study have demonstrated that ECOG is an independent predictor of a poor response to chemotherapy, lower overall survival and progression-free survival in carcinoma of unknown primary site.

Phase I study investigating everolimus combined with sorafenib in patients with advanced hepatocellular carcinoma

BACKGROUND & AIMS

Sorafenib is the only therapy shown to improve overall survival in advanced hepatocellular carcinoma (HCC). Combination therapy targeting multiple signaling pathways may improve outcomes. This phase I study was designed to determine the maximum tolerated dose (MTD) of everolimus given with sorafenib 400mg twice daily in patients with advanced HCC of Child-Pugh class A liver function who were naive to systemic therapy.

METHODS

Everolimus was initiated at 2.5mg once daily and increased per a Bayesian sequential dose-escalation scheme based on the dose-limiting toxicities experienced within the first 28 days of treatment. Adverse events were assessed continuously. Efficacy was evaluated using the best overall response rate per RECIST.

RESULTS

Thirty patients were enrolled; 25 were evaluable for MTD determination. One out of 12 patients treated with everolimus 2.5mg once daily and 6 out of 13 patients treated with everolimus 5.0mg once daily experienced a dose-limiting toxicity, most commonly thrombocytopenia (n=5). All patients experienced 1 adverse event, most commonly diarrhea (66.7%), hand-foot skin reaction (66.7%), and thrombocytopenia (50.0%). Best overall response was stable disease (62.5% and 42.9% in the 2.5-mg and 5.0-mg cohorts, respectively). Median time to progression and overall survival in the 2.5-mg cohort were 4.5 months and 7.4 months, respectively, and 1.8 months and 11.7 months, respectively, in the 5.0-mg cohort.

CONCLUSIONS

In patients with advanced HCC, the everolimus MTD in combination with standard-dose sorafenib was 2.5mg once daily. The inability to achieve a biologically effective everolimus concentration at the MTD precluded phase II study of this combination.

Percutaneous microwave ablation of hepatic tumors: prospective evaluation of postablation syndrome and postprocedural pain

PURPOSE

To prospectively investigate the frequency and severity of postablation syndrome (PAS) and postprocedural pain in a cohort of patients undergoing hepatic microwave ablation.

MATERIALS AND METHODS

From March 2009 to November 2011, 54 consecutive patients undergoing microwave ablation for liver tumors were enrolled. A questionnaire was administered to investigate PAS and pain at 1, 7, and 40 days after ablation. Four patients did not complete all three questionnaires and were excluded from the analysis. Additionally, laboratory tests with results known to significantly increase or decrease after ablation were performed, and ablation parameters were recorded. Potential predictors of PAS and pain at 1 and 7 days were evaluated by a logistic regression model.

RESULTS

Fifty patients underwent a single microwave ablation session, 33 for hepatocellular carcinoma (HCC) and 17 for liver metastasis. Median ablation volumes on computed tomography were 31 cm(3) for HCC and 42 cm(3) for metastasis. Sixty percent of patients experienced PAS in the first week. Aspartate aminotransferase (AST) levels after ablation were significantly associated with PAS during postprocedure days 1-7. Median visual analog scale scores for pain at the puncture site were 1 and 0.24 at 1 and 7 days, respectively. The risk of having at least moderate pain in the first week was significantly related to ablation volume and time and postablation increase in AST level.

CONCLUSIONS

The incidence and severity of PAS with hepatic microwave ablation is similar to that reported for radiofrequency ablation, with the best predictive factor being postablation AST level elevation. Postablation pain was best predicted by total ablation volume and AST level.

Transcatheter arterial chemoembolization for advanced hepatocellular carcinoma with portal vein invasion: safety, efficacy, and prognostic factors

PURPOSE

To evaluate the safety and efficacy of transarterial chemoembolization and to identify the prognostic factors associated with survival in patients with hepatocellular carcinoma (HCC) and portal vein (PV) invasion.

MATERIALS AND METHODS

From January 2006 to March 2012, 50 patients with HCC invading into the PV (Barcelona Clinic Liver Cancer stage C) were treated with transarterial chemoembolization. The parenchymal tumor and PV tumor were confirmed by multidetector computed tomography (CT) and angiography. There were 14 patients with right PV tumor, 12 patients with left PV tumor, and 24 patients with main PV tumor. The response was evaluated by multidetector CT using Response Evaluation Criteria in Solid Tumors. Patients with residual tumors received repeated transarterial chemoembolization every 6-8 weeks unless the patients achieved complete remission or developed contraindications.

RESULTS

The median survival period of the entire group was 6.2 months (range, 1.7-50.9 mo), and the overall response rate was 42% (21 of 50 patients). The 6-month, 12-month, 24-month, and 36-month survival rates were 54%, 22%, 10%, and 8%. There were no instances of 30-day mortality or acute liver failure related to transarterial chemoembolization. The median survival of the 21 responders was 10.5 months, and the median survival of the 29 nonresponders was 5.5 months (P < .001). In both univariate and multivariate analyses, only the response to transarterial chemoembolization (hazard ratio = 0.25, P < .001) and the absence of ascites (hazard ratio = 0.24, P = .01) were significant prognostic factors.

CONCLUSIONS

Transarterial chemoembolization is a safe and effective treatment for HCC with major PV invasion. The response to transarterial chemoembolization and the ascites status were the most significant predictive factors for prolonged survival.

Downstaging disease in patients with hepatocellular carcinoma outside of Milan criteria: strategies using drug-eluting bead chemoembolization

PURPOSE

To assess downstaging rates in patients with United Network for Organ Sharing stage T3N0M0 hepatocellular carcinoma (HCC) treated with doxorubicin-eluting bead transarterial chemoembolization to meet Milan criteria for transplantation.

MATERIALS AND METHODS

A single-center retrospective review of 239 patients treated with doxorubicin-eluting bead (DEB) chemoembolization between September 2008 and December 2011 was undertaken. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed for response based on the longest enhancing axial dimension of each tumor (ie, modified Response Evaluation Criteria In Solid Tumors measurements), and medical records were reviewed. Fisher exact tests and exact logistic regression were used to test the association of patient and disease characteristics with downstaging.

RESULTS

After exclusions, 22 patients remained in the analysis, 17 of whom (77%) had their HCC downstaged to meet Milan criteria. Among those whose disease was downstaged, seven underwent transplantation, one remained listed for transplantation, six had disease progression beyond Milan criteria, two underwent conventional transarterial chemoembolization, and one underwent radiofrequency ablation. The seven patients who received transplants were still living, but recurrent HCC developed in two. Baseline age (P = .25), Model for End-stage Liver Disease score (P = .77), and α-fetoprotein (AFP) level (P = 1.00) were similar between patients with and without downstaged HCC. No associations were observed between the odds of downstaging and sex (P = .21), Child-Pugh class (P = .14), Child-Pugh class controlling for baseline tumor multiplicity (P = .15), Eastern Cooperative Oncology Group performance status (P = 1.00), tumor burden (P = .31), multiple tumors (P = .31), or hepatitis C virus infection (P = 1.00). Fifteen patients who did not receive transplants were alive at 1 year, with two progression-free. Baseline AFP levels differed between those who survived 1 year and those who did not (P = .02), but did not differ by progression-free survival status (P = .62).

CONCLUSIONS

T3N0M0 HCC treatment with DEB chemoembolization has a high likelihood (77%) of downstaging the disease to meet Milan criteria.

Dual intervention to improve pathologic staging of resectable lung cancer

BACKGROUND

Detection of lymph node metastasis is of immense prognostic value in patients with resectable non-small cell lung cancer (NSCLC), but routine pathologic nodal staging is suboptimal. To determine the impact on the rate of detection of nodal metastasis, we tested dual intervention with a prelabeled lymph node specimen collection kit to improve intraoperative node dissection and a fastidious gross dissection of the lung resection specimen for intrapulmonary lymph nodes.

METHODS

We matched dual-intervention cases with controls staged using standard surgical specimen collection and pathologic examination protocols. Controls were hierarchically matched for extent of resection, laterality, surgeon, pathologist, and T stage. All statistical comparisons were made with exact conditional logistic regression, to account for the matched case-control design.

RESULTS

One hundred dual-intervention cases were matched with 100 controls. The dual interventions resulted in approximately a 3-fold increase in the number of lymph nodes examined and the number of lymph nodes with metastasis detected; they also increased the proportion of patients with lymph node metastasis from 21% to 35% (p = 0.02). There were strong trends toward higher aggregate stage distribution, and eligibility for postoperative adjuvant chemotherapy in the dual-intervention cases.

CONCLUSIONS

The combination of interventions improved the thoroughness and accuracy of pathologic nodal staging. A prospective randomized trial to test the survival impact of the dual interventions is warranted.

Intra-arterial infusion chemotherapy for advanced non-small-cell lung cancer: preliminary experience on the safety, efficacy, and clinical outcomes

PURPOSE

To investigate the effectiveness and toxicity of intra-arterial infusion chemotherapy as a therapeutic modality for advanced non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

In a retrospective study, 40 patients with stage III NSCLC received intra-arterial infusion chemotherapy with gemcitabine and cisplatin. Tumor staining was graded based on angiography, and the number of NSCLC feeding arteries detected was recorded. Toxicity was assessed according to National Cancer Institute Common Toxicity Criteria for Adverse Events. The response to treatment was evaluated per Response Evaluation Criteria In Solid Tumors (RECIST). Efficacy was assessed based on time to tumor progression (TTP), and survival was estimated by Kaplan-Meier analysis. Prognostic factors influencing TTP and overall survival rate were evaluated by Cox regression analysis.

RESULTS

The most frequent drug-related adverse events were cough (n = 17; 42.5%), anorexia (n = 14; 35%), and pain (n = 9; 22.5%). Evaluated per RECIST, a total of 47.5% of patients (n = 19) exhibited response to therapy after completion of the first three cycles of intra-arterial infusion chemotherapy. The median TTP was 5 months. Patients had a median life expectancy of 9 months. By Cox regression analysis, tumor staining was shown to be an independent prognostic factor for TTP (relative risk, 0.405; 95% confidence interval, 0.216-0.760) and overall survival (relative risk, 0.348; 95% confidence interval, 0.185-0.656).

CONCLUSIONS

Intra-arterial infusion chemotherapy for advanced lung cancer has the potential to reduce the size of tumors and has no severe adverse effects.

Cyclophosphamide, alvocidib (flavopiridol), and rituximab, a novel feasible chemoimmunotherapy regimen for patients with high-risk chronic lymphocytic leukemia

Alvocidib has demonstrated efficacy in high-risk chronic lymphocytic leukemia (CLL) patients. In this phase I study, we combined cyclophosphamide, alvocidib and rituximab (CAR) in a schema designed to mitigate tumor lysis syndrome (TLS) seen previously with alvocidib. Nine nucleoside analog-naïve, high-risk patients received escalating doses of CAR therapy. Dose limiting toxicity was not experienced. No instances of TLS were observed. Patient responses included three complete remissions and four partial remissions. CAR was tolerable and active in high-risk CLL patients without TLS toxicity. With continued monitoring of toxicities, a phase Ib/II study of this combination as frontline therapy is warranted.

Risk-scoring model for prediction of non-home discharge in epithelial ovarian cancer patients

BACKGROUND

Identification of preoperative factors predictive of non-home discharge after surgery for epithelial ovarian cancer (EOC) may aid counseling and optimize discharge planning. We aimed to determine the association between preoperative risk factors and non-home discharge.

STUDY DESIGN

Patients who underwent primary surgery for EOC at Mayo Clinic between January 2, 2003 and December 29, 2008 were included. Demographic, preoperative, and intraoperative factors were retrospectively abstracted. Logistic regression models were fit to identify preoperative factors associated with non-home discharge. Multivariable models were developed using stepwise and backward variable selection. A risk-scoring system was developed for use in preoperative counseling.

RESULTS

Within our cohort of 587 EOC patients, 12.8% were not discharged home (61 went to a skilled nursing facility, 1 to a rehabilitation facility, 1 to hospice, and there were 12 in-hospital deaths). Median length of stay was 7 days (interquartile range [IQR] 5, 10 days) for patients dismissed home compared with 11 days (IQR 7, 17 days) for those with non-home dismissals (p < 0.001). In multivariable analyses, patients with advanced age (odds ratio [OR] 3.75 95% CI [2.57, 5.48], p < 0.001), worse Eastern Cooperative Oncology Group (ECOG) performance status (OR 0.92 [95% CI 0.43, 1.97] for ECOG performance status 1 vs 0 and OR 5.40 (95% CI 2.42, 12.03) for score of 2+ vs 0; p < 0.001), greater American Society of Anesthesiologists (ASA) score (OR 2.03 [95% CI 1.02, 4.04] for score ≥3 vs < 3, p = 0.04), and higher CA-125 (OR 1.28 [95% CI 1.12, 1.46], p < 0.001) were less likely to be discharged home. The unbiased estimate of the c-index was excellent at 0.88, and the model had excellent calibration.

CONCLUSIONS

Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.

The validity and utility of the M. D. Anderson Symptom Inventory in patients with breast cancer: evidence from the symptom outcomes and practice patterns data from the eastern cooperative oncology group

BACKGROUND

The M. D. Anderson Symptom Inventory (MDASI) is a psychometrically validated patient-reported outcome measurement that assesses the severity and impact of multiple symptoms related to cancer and its treatment. With the MDASI, patients rate 13 common "core" symptoms and 6 items that reflect symptom interference with functioning. Several MDASI modules (core symptom and interference items plus additional symptoms specific to a particular cancer type or treatment modality) have been developed. Although the original MDASI validation study encompassed various cancer types, the instrument's psychometric properties have not been examined in a homogenous sample of patients with breast cancer in a national multicenter study.

MATERIALS AND METHODS

We performed a secondary analysis of data from an Eastern Cooperative Oncology Group study to establish the reliability, validity, and sensitivity of the MDASI in a large sample of patients with breast cancer (n = 1544), 78% of whom were receiving treatment. The instrument was administered twice, approximately 1 month apart.

RESULTS

Internal consistency and test-retest reliability were adequate, with Cronbach α values ≥ 0.85 and intraclass correlations ≥ 0.76 for all subscales. Known-group validity was evaluated by using performance status, tumor response, and disease stage. Sensitivity to change in patient-reported quality of life was established.

CONCLUSION

The MDASI is a valid, reliable, and sensitive symptom-assessment instrument that can enhance descriptive and clinical studies of symptom status in patients with breast cancer. Future studies might include cognitive debriefing and qualitative interviews to identify additional disease-specific items for inclusion in a MDASI breast cancer module.

Prognostic factors after complete resection of pN2 non-small cell lung cancer

OBJECTIVES

This retrospective, multicenter study aimed to determine prognostic factors of completely resected pathologic N2 stage IIIA non-small cell cancer (NSCLC).

METHODS

From 25 participating hospitals, 496 patients (325 men and 171 women; median age, 65 years) who underwent complete resection without preoperative treatment for pT1-3 N2 M0, stage IIIA NSCLC between 2000 and 2004 were enrolled. Lobectomy/bilobectomy was performed in 462 patients and pneumonectomy in 34. Some kind of adjuvant chemotherapy was administered to 296 patients. Survivals were calculated using the Kaplan-Meier method, and prognostic factors were determined using the Cox proportional hazards model.

RESULTS

Five-year overall survival (OS) and disease-free survival (DFS) were 44.8% and 24.2%, respectively. pT classification (hazard ratio (HR), pT1/pT2/pT3 = 1/1.32/2.03), single or multiple N2 metastases (HR, single/multiple = 1/1.36), and skip or nonskip N2 metastasis (HR, skip/nonskip = 1/1.30) were found to be independent prognostic factors for DFS. Sex (HR, female/male = 1/1.36), performance status (HR, PS-0/PS-1 = 1/1.37), tumor diameter (HR, 1.12 per 1-cm increase), pT-factor (HR, pT1/pT2/pT3 = 1/1.37/2.22), and extent of N2 metastasis (HR, localized/extended = 1/1.39) were shown to be independent prognostic factors for OS.

CONCLUSIONS

We found that pT classification was a significant prognostic indicator for OS and DFS whereas tumor diameter, performance status, and sex were ones for OS. Single N2 metastasis and skip N2 metastasis were demonstrated as favorable prognostic factors for DFS, limited N2 metastasis was one for OS, and these should be considered as stratification factors for trial on adjuvant therapy.

Yttrium-90 radioembolization for intrahepatic cholangiocarcinoma: safety, response, and survival analysis

PURPOSE

To present data on safety, antitumoral response, and survival following yttrium-90 ((90)Y) radioembolization for patients with unresectable intrahepatic cholangiocarcinoma (ICC).

MATERIALS AND METHODS

The present study expands on the cohort of 24 patients with ICC described in a pilot study, and includes 46 patients treated with (90)Y radioembolization at a single institution during an 8-year period. Via retrospective review of a prospectively collected database, patients were stratified by performance status, tumor distribution (solitary or multifocal), tumor morphology (infiltrative or peripheral), and presence/absence of portal vein thrombosis. Primary endpoints included biochemical and clinical toxicities, and secondary endpoints included imaging response (World Health Organization [WHO] and European Association for the Study of Liver Disease [EASL] criteria) and survival. Uni-/multivariate analyses were performed.

RESULTS

Ninety-two treatments were performed, with a mean of two per patient. Fatigue and transient abdominal pain occurred in 25 patients (54%) and 13 patients (28%), respectively. Treatment-related gastroduodenal ulcer developed in one patient (2%). WHO imaging findings included partial response (n = 11; 25%), stable disease (n = 33; 73%), and progressive disease (n = 1; 2%). EASL imaging findings included partial/complete response (n = 33; 73%) and stable disease (n = 12; 27%). Survival varied based on presence of multifocal (5.7 mo vs 14.6 mo), infiltrative (6.1 mo vs 15.6 mo), and bilobar disease (10.9 mo vs 11.7 mo). Disease was converted to resectable status in five patients, who successfully underwent curative (ie, R0) resection.

CONCLUSIONS

Radioembolization with (90)Y is safe and demonstrates antitumoral response and survival benefit in select patients with ICC. Results are most pronounced in patients with solitary tumors, for whom conversion to curative resection is possible.

Treatment of hepatocellular carcinoma combining sorafenib and transarterial locoregional therapy: state of the science

The potential for increased efficacy with combined transarterial chemoembolization and sorafenib is a topic of increased interest to specialists who care for patients with unresectable hepatocellular carcinoma. There is strong scientific rationale for combination therapy: transarterial chemoembolization produces ischemia and stimulates hypoxia-inducible factor-1α, resulting in a local and systemic upregulation of vascular endothelial growth factor (VEGF), which can increase tumor angiogenesis. This upregulation can theoretically be counteracted with the multikinase inhibitor sorafenib, which is thought to act directly on platelet-derived growth factor, Raf kinase, and VEGF receptors. The potential of this approach has not yet been fully realized in clinical trials, and many unanswered questions remain. This review article discusses the state of the science of arterial locoregional therapies and sorafenib.

A systematic review of trastuzumab and lapatinib in the treatment of women with brain metastases from HER2-positive breast cancer

Patients with HER2-positive breast cancer are living still longer and increasingly experiencing brain metastases. Current HER2-targeted therapies have limited potential to cross the blood-brain-barrier. We performed a systematic review to investigate data on HER2-targeting therapies in the treatment of brain metastases in breast cancer. We searched PUBMED for all human studies published 1998-2012 using the following search terms: breast neoplasm/cancer, human epidermal growth factor receptor 2/HER2, ErbB2, trastuzumab, lapatinib, brain/cerebral neoplasm/metastases and blood-brain barrier. We identified few and mostly small clinical studies. Study designs were very heterogeneous making comparisons on endpoints difficult. Overall survival for patients treated with trastuzumab varied from 8 to 25 months and 5.5 to 11 months for patients receiving lapatinib. The majority of studies were retrospective thus possibly biasing data. Only three studies were identified comparing trastuzumab to lapatinib. Conclusively, no solid data exist on how to treat patients with HER2-positive disease and brain metastases. Although continuous HER2-blockade is recommended by international consensus guidelines, it is still not evident which HER2-targeting agent should be preferred when brain metastases occur. The choice of chemotherapy to accompany the blockade is not obvious and we do not know if dual is better than single blockade. Further clinical trials are urgently needed.