To the Editor:
In the CheckMate 816 trial, Forde and colleagues (May 26 issue)
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concluded that neoadjuvant treatment with nivolumab did not impede the feasibility of surgery, which is the curative ...treatment for lung cancer. However, in the experimental group (in which patients received nivolumab plus platinum-based chemotherapy), surgery was canceled in 15.6% of the patients, owing mostly to disease progression after treatment. This result is worrisome because these patients could have been treated with up-front surgery and be cured of disease, had neoadjuvant therapy not been undertaken. More than one third of the enrolled patients were withdrawn from the . . .
•Thrombocytopenia in advanced non-small cell lung cancer (NSCLC) patients may indicate disseminated intravascular coagulation (DIC).•Paraneoplastic DIC is associated with adenocarcinoma and may cause ...thrombosis, bleeding, and thrombocytopenia.•We described a patient with EGFR-mutant adenocarcinoma who experienced severe thrombocytopenia due to DIC.•Osimertinib resulted in a rapid resolution of DIC and thrombocytopenia in this patient.•Among 17 cases of pulmonary adenocarcinoma with DIC treated with targeted therapy, the estimated 1-year survival rate was 69%.•For patients with advanced NSCLC, testing for actionable biomarkers is important, even in the presence of DIC.
Quality-of-care indicators are measurable elements of practice performance that can be used to assess the quality or change in quality of the care provided. To date, the literature on quality-of-care ...indicators for non-small cell lung cancer (NSCLC) has not been reviewed.
A search was performed to identify articles reporting on quality-of-care indicators specific for NSCLC published from January 2003 to May 2009 (using MEDLINE and American Society of Clinical Oncology abstract databases). Web sites of major quality care organizations were also searched. The identified indicators were then classified by their aspect of care provision (structure-of-care, process-of-care, or outcome-of-care indicator).
For structure-of-care quality indicators, the most cited indicators were related to the quality of lung surgery. These included being National Cancer Institute-designated cancer centers or high-volume hospitals. For process-of-care quality indicators, the most common indicators were the receipt of surgery for early-stage NSCLC and the administration of chemotherapy for advanced-stage NSCLC. For outcome-of-care quality indicators, the most cited indicators were related to postoperative morbidity or mortality after lung surgery.
Several quality-of-care indicators for NSCLC are available. Process-of-care indicators are the most studied. The use of these indicators to measure practice performance holds the promise of improving outcomes of patients with NSCLC.
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Background: TKIs are standard treatment for non-small cell lung cancer (NSCLC) which harbors an actionable mutation. TKIs have a unique toxicity profile, distinct from conventional ...chemotherapy. Although the manufacturer of each TKI often issues a specific safety precaution on its label, no set schedule has been widely adopted. We surveyed the safety monitoring practice at a large academic institution. Methods: Electronic medical records of patients with ROS1, ALK or EGFR-mutated NSCLC who began a TKI during 2017-2021 were retrospectively reviewed. For each patient, the observation period started from the date of TKI prescription and lasted through day 60. Safety metrics were formulated based on drug label recommendations of each TKI. For each treatment course, the occurrence of 2 index safety monitoring activities (Table) were recorded. Results: Analysis included 130 treatment courses: 82 osimertinib, 20 alectinib, 15 crizotinib and 13 lorlatinib. Median age was 64.3 years, with 66% female, 81% white, 91% ECOG 0/1, 28% zero comorbidity, and 99% non-smoker. For osimertinib, EKG was obtained at baseline (within 30 days of treatment initiation) in 69.5% of observations, and LVEF, in 26.8%. By 60 days, these numbers barely increased (Table). Overall, absence of any index safety monitoring activity occurred in 41 of 130 (32%) treatment courses. Multivariable logistic regression analysis found a trend toward less monitoring among non-white patients: Odds ratio 0.35 (95% CI 0.11-1.09, p = 0.07). No association was found between the number of cardiac risk factors and LVEF monitoring or the use of QT prolonging medication and QTc monitoring. Conclusions: We observed a wide variation in the safety monitoring practice during TKI initiation. Deviation from the manufacturer recommendation was most pronounced for CPK monitoring in alectinib. Future study is needed to define the clinical significance of deviation and to identify barriers to safety monitoring.Table: see text
•Ewing sarcoma, also known as peripheral neuroectodermal tumor, may closely resemble small cell lung cancer (SCLC) in its morphology and immunohistochemistry profile.•Ewing sarcoma typically affects ...pelvis and long bones; however, Ewing sarcoma of chest wall, known as Askin-Rosai tumor, and pulmonary Ewing sarcoma have been described in literature.•We reported a lifelong non-smoking patient with pulmonary Ewing sarcoma, initially misdiagnosed as SCLC.•-Subsequently, next generation sequencing (NGS) revealed a rearrangement in EWSR1, establishing the correct diagnosis.•-When SCLC is diagnosed in non-smokers, NGS can be useful to rule out the possibility of Ewing sarcoma.
Introduction: Signaling through T-cell surface, an immune checkpoint protein such as PD-1 or CTLA-4 helps dampen or terminate unwanted immune responses. Blocking a single immune checkpoint or ...multiple checkpoints simultaneously can generate anti-tumor activity against a variety of cancers including lung cancer.
Area covered: This review highlights the results of recent clinical studies of single or combination checkpoint inhibitor immunotherapy in non-small cell lung cancer (NSCLC) or small cell lung cancer (SCLC). The authors discuss pembrolizumab and pembrolizumab plus ipilimumab, durvalumab and durvalumab plus tremelimumab, nivolumab and nivolumab plus ipilimumab for NSCLC as well as nivolumab and nivolumab plus ipilimumab for SCLC.
Expert opinion: Available data suggest that, in both metastatic NSCLC and SCLC, combined PD-1 and CTLA-4 blockade may produce a higher tumor response rate than PD-1 blockade alone. Nevertheless, combination therapy is associated with an increased toxicity. Several larger-scale studies are currently ongoing. For checkpoint inhibitor immunotherapy in SCLC and NSCLC, combination therapy is associated with a higher incidence of toxicities than single therapy; however, it appears to help increase tumor response rate. The increased response rate, if confirmed in larger scale studies, will likely make combination therapy another useful therapeutic approach for lung cancer.
ALK or EGFR inhibitor is an ideal frontline treatment for patients with advanced non-small cell lung cancer (NSCLC) harboring targetable alteration in ALK or EGFR. However, in the real-world setting, ...frontline treatment may be delayed or not ideal. For such patients, the benefit of initiating ALK or EGFR inhibitor at a later timepoint remains uninvestigated.
We utilized a nationwide electronic health record-derived, deidentified database collected from diverse oncology practices across the United States to investigate the timeliness of preferred targeted therapy (PTT). Individualized data obtained from patients with stage IV NSCLC at diagnosis treated with PTT from 2018 to 2023 were analyzed.
Data from 3250 patients were analyzed: 2640 patients (81%) with EGFR mutation and 610 patients (19%) with ALK rearrangement. The median time to PTT was 7 weeks from diagnosis with 26.4% of patients started PTT within 1 month. Landmark analyses using timepoints ranging from 1 to 12 months after diagnosis showed that at all timepoints, patients who had started on PTT had a significantly better survival than those who had not. In a multivariable analysis, time to PTT ≤ 1 month from diagnosis was an independent predictor of survival: HR 0.74 (95% CI: 0.62-0.89), P = .002. Time to PTT was significantly associated with age, smoking status and genomic class.
In this population-based analysis, an initiation of PTT occurring as late as at least 1 year from diagnosis still resulted in a significant survival benefit, though the magnitude of benefit appeared decreased as time passed.
The investigators analyzed data obtained from 3250 advanced lung cancer patients who initiated treatment with preferred targeted therapy for EGFR or ALK alterations. A significant survival benefit was observed among those who started treatment within 12 months of diagnosis.
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