Small cell lung cancer Kalemkerian, Gregory P; Akerley, Wallace; Bogner, Paul ...
Journal of the National Comprehensive Cancer Network,
2013-Jan-01, Volume:
11, Issue:
1
Journal Article
Peer reviewed
Open access
Neuroendocrine tumors account for approximately 20% of lung cancers; most (≈15%) are small cell lung cancer (SCLC). These NCCN Clinical Practice Guidelines in Oncology for SCLC focus on ...extensive-stage SCLC because it occurs more frequently than limited-stage disease. SCLC is highly sensitive to initial therapy; however, most patients eventually die of recurrent disease. In patients with extensive-stage disease, chemotherapy alone can palliate symptoms and prolong survival in most patients; however, long-term survival is rare. Most cases of SCLC are attributable to cigarette smoking; therefore, smoking cessation should be strongly promoted.
To determine, in a randomized comparison, whether the addition of paclitaxel to etoposide and cisplatin improves the time to progression and overall survival in patients with extensive small-cell ...lung cancer (SCLC) compared with standard etoposide and cisplatin and to compare the regimens' toxicity.
Eligible patients (N=587) with untreated extensive SCLC were randomly assigned to receive either cisplatin 80 mg/m2 on day 1 and etoposide 80 mg/m2 on days 1 through 3 administered every 3 weeks for six cycles (EP) or cisplatin 80 mg/m2 on day 1, paclitaxel 175 mg/m2 over 4 hours on day 1, and etoposide 80 mg/m2 on days 1 to 3 followed by recombinant human granulocyte colony-stimulating factor on days 4 to 18 administered every 3 weeks for six cycles (PET).
Reporting of demographics, response, and survival included 565 patients, of whom 282 were randomly assigned to receive EP and 283 were assigned to receive PET. Overall response rates were 68% for the EP arm and 75% for the PET arm. Median failure-free survival time was 5.9 months for the EP arm and 6 months for the PET arm (P = .179). Median overall survival time was 9.9 months for patients on EP and 10.6 months for patients on PET (P = .169). Toxic deaths occurred in 2.4% of the patients on EP and 6.5% of patients on PET.
PET did not improve the time to progression or survival in patients with extensive SCLC compared with EP alone and was associated with unacceptable toxicity.
Among patients with small-cell lung carcinoma, African Americans have lower survival rates than non-African Americans. We investigated whether the disparity in survival would persist when patients ...were treated with similar therapies (ie, phase II/III Cancer and Leukemia Group B CALGB trials).
We assessed 995 patients (928 non-African American and 67 African American) receiving chemotherapy in CALGB studies for extensive-stage small-cell lung cancer (ES-SCLC). Clinical and demographic characteristics, treatment received, and survival data were obtained from the CALGB database. The Cox proportional hazards model was used to assess the effect of race/ethnicity on survival after adjustment for other known prognostic factors. All statistical tests were two sided.
The unadjusted survival distribution of African American patients was not significantly different from that of non-African American patients; median survival was 11.5 months (95% CI, 9.4 to 13.4 months) for African American patients versus 9.9 months (95% CI, 9.6 to 10.3 months) for non-African American patients. Multivariable adjustment for the effect of treatment arm, histology, and metastatic site at presentation did not alter the outcome for African American patients. Survival was similar even though African American patients were more likely to have a poorer performance status, present with significant weight loss, and be Medicaid recipients (20% v 6%), which is an indicator of lower socioeconomic status.
African American patients tended to present with prognostic features associated with a worse survival. However, when offered equivalent therapy, the outcome for African American patients was the same as that observed for non-African American patients.
Single-agent gemcitabine is a standard of care for elderly patients with advanced non-small cell lung cancer, but novel therapies are needed for this patient population.
We performed a noncomparative ...randomized phase II trial of gemcitabine, erlotinib, or the combination in elderly patients (age ≥70 years) with stage IIIB or IV non-small cell lung cancer. Patients were randomized to arms: A (gemcitabine 1200 mg/m2 on days 1 and 8 every 21 days), B (erlotinib 150 mg daily), or C (gemcitabine 1000 mg/m2 on days 1 and 8 every 21 days and erlotinib 100 mg daily). Arms B and C were considered investigational; the primary objective was 6-month progression-free survival.
Between March 2006 and May 2010, 146 eligible patients received protocol therapy. The majority of the patients (82%) had stage IV disease, 64% reported adenocarcinoma histology, 90% reported current or previous tobacco use, and 28% had a performance status of 2. The 6-month progression-free survival rate observed in arms A, B, and C was 22% (95% confidence interval CI 11–35), 24% (95% CI 13–36), and 25% (95% CI 15–38), respectively; the median overall survival observed was 6.8 months (95% CI 4.8–8.5), 5.8 months (95% CI 3.0–8.3), and 5.6 months (95% CI 3.5–8.4), respectively. The rate of grade ≥3 hematological and nonhematological toxicity observed was similar in all three arms. The best overall health-related quality of life response did not differ between treatment arms.
Erlotinib or erlotinib and gemcitabine do not warrant further investigation in an unselected elderly patient population.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
During the last 25 years, National Cancer Institute (NCI) cooperative trial groups have extended trial networks from academic centers to include certain community and Veterans Health Administration ...(VHA) centers. We compared trial patients' attributes and outcomes by these enrollment settings.
Studying 2,708 patients on one of 10 cooperative group, randomized lung trials at 272 institutions, we compared patient attributes by enrollment setting (ie, academic, community, and VHA affiliates). We used adjusted Cox regression to evaluate for survival differences by setting.
Main member institutions enrolled 44% of patients; community affiliates enrolled 44%; and VHAs enrolled 12%. Patient attributes (ie, case-mix) of age, ethnicity, sex, and performance status varied by enrollment setting. After analysis was adjusted for patient case-mix, no mortality differences by enrollment setting were noted.
Although trial patients with primarily advanced-stage lung cancer from nonacademic centers were older and had worse performance statuses than those from academic centers, survival did not differ by enrollment setting after analysis accounted for patient heterogeneity. An answer for whether long-term outcomes for patients at community and VHA centers affiliated with cooperative trial groups are equivalent to those at academic centers when care is delivered through NCI trials requires additional research among patients with longer survival horizons.
In Cancer and Leukemia Group B 39801, we evaluated whether induction chemotherapy before concurrent chemoradiotherapy would result in improved survival and demonstrated no significant benefit from ...the addition of induction chemotherapy. The primary objective of this analysis was to dichotomize patients into prognostic groups using factors predictive of survival and to investigate whether induction chemotherapy was beneficial in either prognostic group.
A Cox proportional hazard model was used to assess the impact on survival of the following factors: (≥70 versus <70 years), gender, race, stage (IIIB versus IIIA), hemoglobin (hgb) (<13 versus ≥13 g/dl), performance status (PS) (1 versus 0), weight loss (≥5% versus <5%), treatment arm, and the interaction between weight loss and hgb.
Factors predictive of decreased survival were weight loss ≥5%, age ≥70 years, PS of 1, and hgb <13 g/dl (p < 0.05). Patients were classified as having ≥2 poor prognostic factors (n = 165) or ≤1 factor (n = 166). The hazard ratio (HR) for overall survival for the patients with ≥2 versus patients with ≤1 was 1.88 95% confidence interval (CI), 1.49–2.37; p = <0.0001; median survival times observed were 9 (95% CI, 8–11) and 18 (95% CI, 16–24) months, respectively. There was no significant difference in survival between treatment arms in patients with ≥2 factors (HR = 0.86, 95% CI, 0.63–1.17; p = 0.34) or ≤1 factor (HR = 0.97, 95% CI, 0.70–1.35; p = 0.87).
There is no evidence that induction chemotherapy is beneficial in either prognostic group.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
End-of-Life Care in Patients With Lung Cancer Griffin, John P.; Nelson, Judith E.; Koch, Kathryn A. ...
Chest,
January 2003, 20030101, 2003, 2003-Jan, 2003-01-00, Volume:
123, Issue:
1
Journal Article
Peer reviewed
Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has ...been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
8.
Small cell lung cancer Kalemkerian, Gregory P; Akerley, Wallace; Bogner, Paul ...
Journal of the National Comprehensive Cancer Network
9, Issue:
10
Journal Article
Guidelines recommend multiple types of cytologic and tissue samplings in the diagnosis of lung cancer by bronchoscopy, but differences of opinion exist as to the relative value of bronchial brushings ...and endobronchial or transbronchial biopsies. Our objective was to determine concordance of these procedures by a test of symmetry in a historical cohort referred to the pulmonary diagnostic laboratory.
From 1988 to 2001, patients with pathologic confirmation of primary lung cancer were examined by standard bronchoscopic techniques of that period. An electronic medical record system was used, with statistical analysis of symmetry between brushings and biopsies establishing the diagnosis.
Of 968 patients, 98% had bronchoscopy for 624 central and 322 peripheral suspect lesions. Bronchial brushings from 915 patients confirmed pulmonary malignancy in 811 (89%) patients. Endobronchial or transbronchial biopsies from 739 patients showed lung cancer in 603 (82%) cases. Bronchial washings in 16 patients and transthoracic needle biopsies in 30 patients established diagnosis. Transbronchial needle aspiration of mediastinal nodes identified metastases in 94 patients. Only 14 patients required a surgical procedure for diagnosis, but 188 received surgical excision as primary treatment. Statistical evaluation used only patients with both bronchial brushings and endobronchial or transbronchial biopsies. Analysis by a test of symmetry showed a significant difference (P<0.0001).
Positive, suspicious, and negative specimens were consistent, with bronchial brushings being more sensitive with a lower false-negative rate than endobronchial or transbronchial biopsies. Multiple techniques are recommended for bronchoscopic confirmation of lung cancer, but bronchial brushings should be collected initially, as technical or patient limitations might preclude diagnostic tissue biopsies.
Abstract only
199
Background: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information ...exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Methods: Previous evaluations of care and outcomes for cancer patients who die in intensive care (ICU) settings have been limited to large databases. Little detailed information exists regarding the decision making in these eventually futile efforts. Reasonableness of admission has not been evaluated in detail. Results: In our patients the mean duration of cancer awareness was 7.3 months. The majority (38) had expected duration of life prior to ICU of 6 months or less. Only 16 patients had documented discussions regarding treatment preferences or advanced directives prior to hospital admission. In establishing reasonableness of admission: 8 were post procedure complications; 21 had an ECOG performance status of 0-1 prior to admission; 14 had been notified of their incurable cancer for one month or less; an additional 3 patients had a life expectancy > 6 months. Of the 52 ICU deaths of patients with advanced cancers, 31 (60%) met our criteria for reasonableness of admission in spite of advanced cancer. Of the remaining 21 patients, 9 had advanced directives in place prior to hospitalization, but without specific decisions regarding ICU care. Only 23% of futile ICU admissions in advanced cancer patients lacked both advanced directives prior to hospital admission and reasonableness of ICU admission by the above criteria. Conclusions: The majority of patients with advanced cancer who die in the ICU in our medical center are reasonable admissions, as defined by recent diagnoses, good performance status, > 6 month life expectancy and admission for post procedure complications.
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