Lung Cancer

A new report offers more insight into the connection between cumulative smoking levels and lung cancer.

People who have smoked an average of 1 pack a day for 20-39 years tripled their tumor risk versus less-heavy smokers and 30-fold versus those who never smoked. For those who smoked the equivalent of 1 pack for 40-60 years, or 2 packs for 20-30 years, the risk levels grew by fourfold and 40-fold, respectively. For those who’ve smoked even more, the likelihood of developing lung cancer is high, but the risk remains stable and doesn’t grow more over time, according to the analysis.

The report, released at the annual European Lung Cancer Congress 2023 meeting, and an earlier related study “underscore the importance of smoking abstinence and early smoking cessation,” said study lead author J. Anthony Nations, MD, MBA, in an interview.

The earlier study, published in JAMA Oncology, relied on a “pack-year” analysis to evaluate the risk of lung cancer in smokers. A pack-year refers to the cigarette use of a person who smoked a pack a day for 1 year. It’s the equivalent of smoking half a pack for 2 years or 2 packs for 6 months.

By this measure, a smoker with 20 pack-years of cigarette use smoked the equivalent of a pack a day for 20 years or 2 packs a day for 10 years. U.S. guidelines recommend annual low-dose CT lung cancer screening in adults who are aged 50-80, have more than 20 pack-years of tobacco exposure, and either currently smoke or quit within the last 15 years.

The JAMA Oncology report “showed that, compared with never-smokers, current heavy and nonheavy smokers had [a] 40 and 10 times higher risk of lung cancer, respectively,” said Dr. Nations, who is also a pulmonologist with Washington D.C. Veterans Affairs Medical Center. “A smoking history of greater than 20 pack-years was considered heavy, but current heavy smokers had a median pack-year smoking history of 50 pack-years. This observation prompted us to want to look more closely at pack-year smoking history.”

For the new analysis, researchers tracked 2,505 older adults (mean age, 73 ± 5.7 years; 69% women, 17% African American) in the Cardiovascular Health Study. Of those, 532 were current smokers (18% less than 20 pack-years, 30% 20-39 pack-years, 34% 40–59 pack-years, and 18% greater than 60 pack-years).

Lung cancer occurred in 0.5% of those who never smoked, 5% of those who smoked less than 20 pack-years, 14.6% of those who smoked 20-39 pack-years, 17.7% of those who smoked 40-59 pack-years, and 16.0% for those who smoked more than 60 pack-years. In an analysis adjusted for age, sex, race, and competing risk of death, researchers found that those who smoked less than 20 pack-years were 9.73 times more likely to develop lung cancer than those who never smoked (hazard ratio, 9.73). The HRs of lung cancer versus never-smokers for the other groups were 30.33 (20-39 pack-years), 42.97 (40-59 pack-years), and 46.02 (greater than 60 pack-years.).

“While it was not surprising that the risk of lung cancer in current heavy smokers would be proportionately greater in smokers with higher pack-year smoking history, we were surprised to see that the risk almost plateaued in the heaviest current smokers,” Dr. Nations said.

As for the clinical message from the findings, Dr. Nations said they reveal that quitting smoking makes a difference in lung cancer risk, even after many years of heavy smoking. “Smokers who quit after a 30–pack-year smoking history will not incur the higher risk of those with a 40– or 50–pack-year smoking history.”

The previous JAMA Oncology paper also showed that quitting pays dividends by reducing lung cancer risk. Subjects with at least 20 pack-years of smoking who quit less than 15 years ago nearly halved their excess risk of lung cancer, compared with similar current smokers who didn’t quit.

In an interview, cancer researcher Robert J. Volk, PhD, of the University of Texas MD Anderson Cancer Center, Houston, praised the new analysis but noted that it has limitations: “The sample is fairly small – 532 adults who currently smoke – and the subgroups based on pack-years are even smaller.”

No study funding is reported. The study authors and Dr. Volk reported no disclosures.

*This article was updated on 4/17/23.

A new report offers more insight into the connection between cumulative smoking levels and lung cancer.

People who have smoked an average of 1 pack a day for 20-39 years tripled their tumor risk versus less-heavy smokers and 30-fold versus those who never smoked. For those who smoked the equivalent of 1 pack for 40-60 years, or 2 packs for 20-30 years, the risk levels grew by fourfold and 40-fold, respectively. For those who’ve smoked even more, the likelihood of developing lung cancer is high, but the risk remains stable and doesn’t grow more over time, according to the analysis.

The report, released at the annual European Lung Cancer Congress 2023 meeting, and an earlier related study “underscore the importance of smoking abstinence and early smoking cessation,” said study lead author J. Anthony Nations, MD, MBA, in an interview.

The earlier study, published in JAMA Oncology, relied on a “pack-year” analysis to evaluate the risk of lung cancer in smokers. A pack-year refers to the cigarette use of a person who smoked a pack a day for 1 year. It’s the equivalent of smoking half a pack for 2 years or 2 packs for 6 months.

By this measure, a smoker with 20 pack-years of cigarette use smoked the equivalent of a pack a day for 20 years or 2 packs a day for 10 years. U.S. guidelines recommend annual low-dose CT lung cancer screening in adults who are aged 50-80, have more than 20 pack-years of tobacco exposure, and either currently smoke or quit within the last 15 years.

The JAMA Oncology report “showed that, compared with never-smokers, current heavy and nonheavy smokers had [a] 40 and 10 times higher risk of lung cancer, respectively,” said Dr. Nations, who is also a pulmonologist with Washington D.C. Veterans Affairs Medical Center. “A smoking history of greater than 20 pack-years was considered heavy, but current heavy smokers had a median pack-year smoking history of 50 pack-years. This observation prompted us to want to look more closely at pack-year smoking history.”

For the new analysis, researchers tracked 2,505 older adults (mean age, 73 ± 5.7 years; 69% women, 17% African American) in the Cardiovascular Health Study. Of those, 532 were current smokers (18% less than 20 pack-years, 30% 20-39 pack-years, 34% 40–59 pack-years, and 18% greater than 60 pack-years).

Lung cancer occurred in 0.5% of those who never smoked, 5% of those who smoked less than 20 pack-years, 14.6% of those who smoked 20-39 pack-years, 17.7% of those who smoked 40-59 pack-years, and 16.0% for those who smoked more than 60 pack-years. In an analysis adjusted for age, sex, race, and competing risk of death, researchers found that those who smoked less than 20 pack-years were 9.73 times more likely to develop lung cancer than those who never smoked (hazard ratio, 9.73). The HRs of lung cancer versus never-smokers for the other groups were 30.33 (20-39 pack-years), 42.97 (40-59 pack-years), and 46.02 (greater than 60 pack-years.).

“While it was not surprising that the risk of lung cancer in current heavy smokers would be proportionately greater in smokers with higher pack-year smoking history, we were surprised to see that the risk almost plateaued in the heaviest current smokers,” Dr. Nations said.

As for the clinical message from the findings, Dr. Nations said they reveal that quitting smoking makes a difference in lung cancer risk, even after many years of heavy smoking. “Smokers who quit after a 30–pack-year smoking history will not incur the higher risk of those with a 40– or 50–pack-year smoking history.”

The previous JAMA Oncology paper also showed that quitting pays dividends by reducing lung cancer risk. Subjects with at least 20 pack-years of smoking who quit less than 15 years ago nearly halved their excess risk of lung cancer, compared with similar current smokers who didn’t quit.

In an interview, cancer researcher Robert J. Volk, PhD, of the University of Texas MD Anderson Cancer Center, Houston, praised the new analysis but noted that it has limitations: “The sample is fairly small – 532 adults who currently smoke – and the subgroups based on pack-years are even smaller.”

No study funding is reported. The study authors and Dr. Volk reported no disclosures.

*This article was updated on 4/17/23.

A new report offers more insight into the connection between cumulative smoking levels and lung cancer.

People who have smoked an average of 1 pack a day for 20-39 years tripled their tumor risk versus less-heavy smokers and 30-fold versus those who never smoked. For those who smoked the equivalent of 1 pack for 40-60 years, or 2 packs for 20-30 years, the risk levels grew by fourfold and 40-fold, respectively. For those who’ve smoked even more, the likelihood of developing lung cancer is high, but the risk remains stable and doesn’t grow more over time, according to the analysis.

The report, released at the annual European Lung Cancer Congress 2023 meeting, and an earlier related study “underscore the importance of smoking abstinence and early smoking cessation,” said study lead author J. Anthony Nations, MD, MBA, in an interview.

The earlier study, published in JAMA Oncology, relied on a “pack-year” analysis to evaluate the risk of lung cancer in smokers. A pack-year refers to the cigarette use of a person who smoked a pack a day for 1 year. It’s the equivalent of smoking half a pack for 2 years or 2 packs for 6 months.

By this measure, a smoker with 20 pack-years of cigarette use smoked the equivalent of a pack a day for 20 years or 2 packs a day for 10 years. U.S. guidelines recommend annual low-dose CT lung cancer screening in adults who are aged 50-80, have more than 20 pack-years of tobacco exposure, and either currently smoke or quit within the last 15 years.

The JAMA Oncology report “showed that, compared with never-smokers, current heavy and nonheavy smokers had [a] 40 and 10 times higher risk of lung cancer, respectively,” said Dr. Nations, who is also a pulmonologist with Washington D.C. Veterans Affairs Medical Center. “A smoking history of greater than 20 pack-years was considered heavy, but current heavy smokers had a median pack-year smoking history of 50 pack-years. This observation prompted us to want to look more closely at pack-year smoking history.”

For the new analysis, researchers tracked 2,505 older adults (mean age, 73 ± 5.7 years; 69% women, 17% African American) in the Cardiovascular Health Study. Of those, 532 were current smokers (18% less than 20 pack-years, 30% 20-39 pack-years, 34% 40–59 pack-years, and 18% greater than 60 pack-years).

Lung cancer occurred in 0.5% of those who never smoked, 5% of those who smoked less than 20 pack-years, 14.6% of those who smoked 20-39 pack-years, 17.7% of those who smoked 40-59 pack-years, and 16.0% for those who smoked more than 60 pack-years. In an analysis adjusted for age, sex, race, and competing risk of death, researchers found that those who smoked less than 20 pack-years were 9.73 times more likely to develop lung cancer than those who never smoked (hazard ratio, 9.73). The HRs of lung cancer versus never-smokers for the other groups were 30.33 (20-39 pack-years), 42.97 (40-59 pack-years), and 46.02 (greater than 60 pack-years.).

“While it was not surprising that the risk of lung cancer in current heavy smokers would be proportionately greater in smokers with higher pack-year smoking history, we were surprised to see that the risk almost plateaued in the heaviest current smokers,” Dr. Nations said.

As for the clinical message from the findings, Dr. Nations said they reveal that quitting smoking makes a difference in lung cancer risk, even after many years of heavy smoking. “Smokers who quit after a 30–pack-year smoking history will not incur the higher risk of those with a 40– or 50–pack-year smoking history.”

The previous JAMA Oncology paper also showed that quitting pays dividends by reducing lung cancer risk. Subjects with at least 20 pack-years of smoking who quit less than 15 years ago nearly halved their excess risk of lung cancer, compared with similar current smokers who didn’t quit.

In an interview, cancer researcher Robert J. Volk, PhD, of the University of Texas MD Anderson Cancer Center, Houston, praised the new analysis but noted that it has limitations: “The sample is fairly small – 532 adults who currently smoke – and the subgroups based on pack-years are even smaller.”

No study funding is reported. The study authors and Dr. Volk reported no disclosures.

*This article was updated on 4/17/23.

A new analysis suggests that the initial target of therapy – lung or brain – doesn’t affect overall survival rates in patients with non–small cell lung cancer that has spread to the brain.

“The findings of our study highlight the importance of adopting a personalized, case-based approach when treating each patient” instead of always treating the brain or lung first, lead author Arvind Kumar, a medical student at Icahn School of Medicine at Mount Sinai, New York, said in an interview.

The study was released at European Lung Cancer Congress 2023.

According to the author, current guidelines recommend treating the brain first in patients with non–small cell lung cancer and a tumor that has spread to the brain.

“Determining whether the brain or body gets treated first depends on where the symptoms are coming from, how severe the symptoms are, how bulky the disease is, and how long the treatment to each is expected to take,” radiation oncologist Henry S. Park, MD, MPH, chief of the thoracic radiotherapy program at Yale University, New Haven, Conn., said in an interview. “Often the brain is treated first since surgery is used for both diagnosis of metastatic disease as well as removal of the brain metastasis, especially if it is causing symptoms. The radiosurgery that follows tends to occur within a day or a few days.”

However, he said, “if the brain disease is small and not causing symptoms, and the lung disease is more problematic, then we will often treat the body first and fit in the brain treatment later.”

For the new study, researchers identified 1,044 patients in the National Cancer Database with non–small cell lung cancer and brain metastases who received systemic therapy plus surgery, brain stereotactic radiosurgery, or lung radiation. All were treated from 2010 to 2019; 79.0% received brain treatment first, and the other 21.0% received lung treatment first.

There was no statistically significant difference in overall survival between those whose brains were treated first and those whose lungs were treated first (hazard ratio, 1.24, 95% confidence interval [CI], 0.91-1.70, P = .17). A propensity score–matched analysis turned up no difference in 5-year survival (38.2% of those whose brains were treated first, 95% CI, 27.5-34.4, vs. 38.0% of those whose lungs were treated first, 95% CI, 29.9-44.7, P = .32.)

“These results were consistent regardless of which combination of treatment modalities the patient received – neurosurgery versus brain stereotactic radiosurgery, thoracic surgery versus thoracic radiation,” the author said.

He cautioned that “our study only included patients who were considered candidates for either surgery or radiation to both the brain and lung. The results of our study should therefore be cautiously interpreted for patients who may have contraindications to such treatment.”

Dr. Park, who didn’t take part in the study, said “the results are consistent with what I would generally expect.”

He added: “The take-home message for clinicians should be that there is no one correct answer in how to manage non–small cell lung cancer with synchronous limited metastatic disease in only the brain. If the brain disease is bulky and/or causes symptoms while the body disease isn’t – or if a biopsy or surgery is required to prove that the patient in fact has metastatic disease – then the brain disease should be treated first. On the other hand, if the body disease is bulky and/or causing symptoms while the brain disease isn’t – and there is no need for surgery but rather only a biopsy of the brain – then the body disease can be treated first.”

No funding was reported. The study authors and Dr. Park reported no financial conflicts or other disclosures.

A new analysis suggests that the initial target of therapy – lung or brain – doesn’t affect overall survival rates in patients with non–small cell lung cancer that has spread to the brain.

“The findings of our study highlight the importance of adopting a personalized, case-based approach when treating each patient” instead of always treating the brain or lung first, lead author Arvind Kumar, a medical student at Icahn School of Medicine at Mount Sinai, New York, said in an interview.

The study was released at European Lung Cancer Congress 2023.

According to the author, current guidelines recommend treating the brain first in patients with non–small cell lung cancer and a tumor that has spread to the brain.

“Determining whether the brain or body gets treated first depends on where the symptoms are coming from, how severe the symptoms are, how bulky the disease is, and how long the treatment to each is expected to take,” radiation oncologist Henry S. Park, MD, MPH, chief of the thoracic radiotherapy program at Yale University, New Haven, Conn., said in an interview. “Often the brain is treated first since surgery is used for both diagnosis of metastatic disease as well as removal of the brain metastasis, especially if it is causing symptoms. The radiosurgery that follows tends to occur within a day or a few days.”

However, he said, “if the brain disease is small and not causing symptoms, and the lung disease is more problematic, then we will often treat the body first and fit in the brain treatment later.”

For the new study, researchers identified 1,044 patients in the National Cancer Database with non–small cell lung cancer and brain metastases who received systemic therapy plus surgery, brain stereotactic radiosurgery, or lung radiation. All were treated from 2010 to 2019; 79.0% received brain treatment first, and the other 21.0% received lung treatment first.

There was no statistically significant difference in overall survival between those whose brains were treated first and those whose lungs were treated first (hazard ratio, 1.24, 95% confidence interval [CI], 0.91-1.70, P = .17). A propensity score–matched analysis turned up no difference in 5-year survival (38.2% of those whose brains were treated first, 95% CI, 27.5-34.4, vs. 38.0% of those whose lungs were treated first, 95% CI, 29.9-44.7, P = .32.)

“These results were consistent regardless of which combination of treatment modalities the patient received – neurosurgery versus brain stereotactic radiosurgery, thoracic surgery versus thoracic radiation,” the author said.

He cautioned that “our study only included patients who were considered candidates for either surgery or radiation to both the brain and lung. The results of our study should therefore be cautiously interpreted for patients who may have contraindications to such treatment.”

Dr. Park, who didn’t take part in the study, said “the results are consistent with what I would generally expect.”

He added: “The take-home message for clinicians should be that there is no one correct answer in how to manage non–small cell lung cancer with synchronous limited metastatic disease in only the brain. If the brain disease is bulky and/or causes symptoms while the body disease isn’t – or if a biopsy or surgery is required to prove that the patient in fact has metastatic disease – then the brain disease should be treated first. On the other hand, if the body disease is bulky and/or causing symptoms while the brain disease isn’t – and there is no need for surgery but rather only a biopsy of the brain – then the body disease can be treated first.”

No funding was reported. The study authors and Dr. Park reported no financial conflicts or other disclosures.

A new analysis suggests that the initial target of therapy – lung or brain – doesn’t affect overall survival rates in patients with non–small cell lung cancer that has spread to the brain.

“The findings of our study highlight the importance of adopting a personalized, case-based approach when treating each patient” instead of always treating the brain or lung first, lead author Arvind Kumar, a medical student at Icahn School of Medicine at Mount Sinai, New York, said in an interview.

The study was released at European Lung Cancer Congress 2023.

According to the author, current guidelines recommend treating the brain first in patients with non–small cell lung cancer and a tumor that has spread to the brain.

“Determining whether the brain or body gets treated first depends on where the symptoms are coming from, how severe the symptoms are, how bulky the disease is, and how long the treatment to each is expected to take,” radiation oncologist Henry S. Park, MD, MPH, chief of the thoracic radiotherapy program at Yale University, New Haven, Conn., said in an interview. “Often the brain is treated first since surgery is used for both diagnosis of metastatic disease as well as removal of the brain metastasis, especially if it is causing symptoms. The radiosurgery that follows tends to occur within a day or a few days.”

However, he said, “if the brain disease is small and not causing symptoms, and the lung disease is more problematic, then we will often treat the body first and fit in the brain treatment later.”

For the new study, researchers identified 1,044 patients in the National Cancer Database with non–small cell lung cancer and brain metastases who received systemic therapy plus surgery, brain stereotactic radiosurgery, or lung radiation. All were treated from 2010 to 2019; 79.0% received brain treatment first, and the other 21.0% received lung treatment first.

There was no statistically significant difference in overall survival between those whose brains were treated first and those whose lungs were treated first (hazard ratio, 1.24, 95% confidence interval [CI], 0.91-1.70, P = .17). A propensity score–matched analysis turned up no difference in 5-year survival (38.2% of those whose brains were treated first, 95% CI, 27.5-34.4, vs. 38.0% of those whose lungs were treated first, 95% CI, 29.9-44.7, P = .32.)

“These results were consistent regardless of which combination of treatment modalities the patient received – neurosurgery versus brain stereotactic radiosurgery, thoracic surgery versus thoracic radiation,” the author said.

He cautioned that “our study only included patients who were considered candidates for either surgery or radiation to both the brain and lung. The results of our study should therefore be cautiously interpreted for patients who may have contraindications to such treatment.”

Dr. Park, who didn’t take part in the study, said “the results are consistent with what I would generally expect.”

He added: “The take-home message for clinicians should be that there is no one correct answer in how to manage non–small cell lung cancer with synchronous limited metastatic disease in only the brain. If the brain disease is bulky and/or causes symptoms while the body disease isn’t – or if a biopsy or surgery is required to prove that the patient in fact has metastatic disease – then the brain disease should be treated first. On the other hand, if the body disease is bulky and/or causing symptoms while the brain disease isn’t – and there is no need for surgery but rather only a biopsy of the brain – then the body disease can be treated first.”

No funding was reported. The study authors and Dr. Park reported no financial conflicts or other disclosures.

At a single robotic-assisted pulmonary lobectomy center, patients with public insurance or combined public and private insurance fared worse than those with private insurance, according to a new retrospective analysis.

The study used public insurance status as a marker for low socioeconomic status (SES) and suggests that patients with combined insurance may constitute a separate population that deserves more attention.

Lower SES has been linked to later stage diagnoses and worse outcomes in NSCLC. Private insurance is a generally-accepted indicator of higher SES, while public insurance like Medicare or Medicaid, alone or in combination with private supplementary insurance, is an indicator of lower SES.

Although previous studies have found associations between patients having public health insurance and experiencing later-stage diagnoses and worse overall survival, there have been few studies of surgical outcomes, and almost no research has examined combination health insurance, according to Allison O. Dumitriu Carcoana, who presented the research during a poster session at the European Lung Cancer Congress 2023.

“This is an important insurance subgroup for us because the majority of our patients fall into this subgroup by being over 65 years old and thus qualifying for Medicare while also paying for a private supplement,” said Ms. Dumitriu Carcoana, who is a medical student at University of South Florida Health Morsani College of Medicine, Tampa.

A previous analysis by the group found an association between private insurance status and better discharge status, as well as higher 5-year overall survival. After accumulating an additional 278 patients, the researchers examined 10-year survival outcomes.

In the new analysis, 52% of 711 participants had combination insurance, while 28% had private insurance, and 20% had public insurance. The subgroups all had similar demographic and histological characteristics. The study was unique in that it found no between-group differences in higher stage at diagnosis, whereas previous studies have found a greater risk of higher stage diagnosis among individuals with public insurance. As expected, patients in the combined insurance group had a higher mean age (P less than .0001) and higher Charlson comorbidity index scores (P = .0014), which in turn was associated with lower 10-year survival. The group also had the highest percentage of former smokers, while the public insurance group had the highest percentage of current smokers (P = .0003).

At both 5 and 10 years, the private insurance group had better OS than the group with public (P less than .001) and the combination insurance group (P = .08). Public health insurance was associated with worse OS at 5 years (hazard ratio, 1.83; P less than .005) but not at 10 years (HR, 1.18; P = .51), while combination insurance was associated with worse OS at 10 years (HR, 1.72; P = .02).

“We think that patients with public health insurance having the worst 5-year overall survival, despite their lower ages and fewer comorbid conditions, compared with patients with combination insurance, highlights the impact of lower socioeconomic status on health outcomes. These patients had the same tumor characteristics, BMI, sex, and race as our patients in the other two insurance groups. The only other significant risk factor [the group had besides having a higher proportion of patients with lower socioeconomic status was that it had a higher proportion of current smokers]. But the multivariate analyses showed that insurance status was an independent predictor of survival, regardless of smoking status or other comorbidities,” said Ms. Dumitriu Carcoana.

“At 10 years post-operatively, the survival curves have shifted and the combination patients had the worst 10-year overall survival. We attribute this to their higher number of comorbid conditions and increased age. In practice, [this means that] the group of patients with public insurance type, but no supplement, should be identified clinically, and the clinical team can initiate a discussion,” Ms. Dumitriu Carcoana said.

“Do these patients feel that they can make follow-up appointments, keep up with medication costs, and make the right lifestyle decisions postoperatively on their current insurance plan? If not, can they afford a private supplement? In our cohort specifically, it may also be important to do more preoperative counseling on the importance of smoking cessation,” she added.

The study is interesting, but it has some important limitations, according to Raja Flores, MD, who was not involved with the study. The authors stated that there was no difference between the insurance groups with respect to mortality or cancer stage, which is the most important predictor of survival. However, the poster didn't include details of the authors' analysis, making it difficult to interpret, Dr. Flores said.

The fact that the study includes a single surgeon has some disadvantages in terms of broader applicability, but it also controls for surgical technique. “Different surgeons have different ways of doing things, so if you had the same surgeon doing it the same way every time, you can look at other variables like insurance (status) and stage,” said Dr. Flores.

The results may also provide an argument against using robotic surgery in patients who do not have insurance, especially since they have not been proven to be better than standard minimally invasive surgery with no robotic assistance. With uninsured patients, “you’re using taxpayer money for a more expensive procedure that isn’t proving to be any better,” Dr. Flores explained.

The study was performed at a single center and cannot prove causation due to its retrospective nature.

Ms. Dumitriu Carcoana and Dr. Flores have no relevant financial disclosures.

*This article was updated on 4/13/2023.

At a single robotic-assisted pulmonary lobectomy center, patients with public insurance or combined public and private insurance fared worse than those with private insurance, according to a new retrospective analysis.

The study used public insurance status as a marker for low socioeconomic status (SES) and suggests that patients with combined insurance may constitute a separate population that deserves more attention.

Lower SES has been linked to later stage diagnoses and worse outcomes in NSCLC. Private insurance is a generally-accepted indicator of higher SES, while public insurance like Medicare or Medicaid, alone or in combination with private supplementary insurance, is an indicator of lower SES.

Although previous studies have found associations between patients having public health insurance and experiencing later-stage diagnoses and worse overall survival, there have been few studies of surgical outcomes, and almost no research has examined combination health insurance, according to Allison O. Dumitriu Carcoana, who presented the research during a poster session at the European Lung Cancer Congress 2023.

“This is an important insurance subgroup for us because the majority of our patients fall into this subgroup by being over 65 years old and thus qualifying for Medicare while also paying for a private supplement,” said Ms. Dumitriu Carcoana, who is a medical student at University of South Florida Health Morsani College of Medicine, Tampa.

A previous analysis by the group found an association between private insurance status and better discharge status, as well as higher 5-year overall survival. After accumulating an additional 278 patients, the researchers examined 10-year survival outcomes.

In the new analysis, 52% of 711 participants had combination insurance, while 28% had private insurance, and 20% had public insurance. The subgroups all had similar demographic and histological characteristics. The study was unique in that it found no between-group differences in higher stage at diagnosis, whereas previous studies have found a greater risk of higher stage diagnosis among individuals with public insurance. As expected, patients in the combined insurance group had a higher mean age (P less than .0001) and higher Charlson comorbidity index scores (P = .0014), which in turn was associated with lower 10-year survival. The group also had the highest percentage of former smokers, while the public insurance group had the highest percentage of current smokers (P = .0003).

At both 5 and 10 years, the private insurance group had better OS than the group with public (P less than .001) and the combination insurance group (P = .08). Public health insurance was associated with worse OS at 5 years (hazard ratio, 1.83; P less than .005) but not at 10 years (HR, 1.18; P = .51), while combination insurance was associated with worse OS at 10 years (HR, 1.72; P = .02).

“We think that patients with public health insurance having the worst 5-year overall survival, despite their lower ages and fewer comorbid conditions, compared with patients with combination insurance, highlights the impact of lower socioeconomic status on health outcomes. These patients had the same tumor characteristics, BMI, sex, and race as our patients in the other two insurance groups. The only other significant risk factor [the group had besides having a higher proportion of patients with lower socioeconomic status was that it had a higher proportion of current smokers]. But the multivariate analyses showed that insurance status was an independent predictor of survival, regardless of smoking status or other comorbidities,” said Ms. Dumitriu Carcoana.

“At 10 years post-operatively, the survival curves have shifted and the combination patients had the worst 10-year overall survival. We attribute this to their higher number of comorbid conditions and increased age. In practice, [this means that] the group of patients with public insurance type, but no supplement, should be identified clinically, and the clinical team can initiate a discussion,” Ms. Dumitriu Carcoana said.

“Do these patients feel that they can make follow-up appointments, keep up with medication costs, and make the right lifestyle decisions postoperatively on their current insurance plan? If not, can they afford a private supplement? In our cohort specifically, it may also be important to do more preoperative counseling on the importance of smoking cessation,” she added.

The study is interesting, but it has some important limitations, according to Raja Flores, MD, who was not involved with the study. The authors stated that there was no difference between the insurance groups with respect to mortality or cancer stage, which is the most important predictor of survival. However, the poster didn't include details of the authors' analysis, making it difficult to interpret, Dr. Flores said.

The fact that the study includes a single surgeon has some disadvantages in terms of broader applicability, but it also controls for surgical technique. “Different surgeons have different ways of doing things, so if you had the same surgeon doing it the same way every time, you can look at other variables like insurance (status) and stage,” said Dr. Flores.

The results may also provide an argument against using robotic surgery in patients who do not have insurance, especially since they have not been proven to be better than standard minimally invasive surgery with no robotic assistance. With uninsured patients, “you’re using taxpayer money for a more expensive procedure that isn’t proving to be any better,” Dr. Flores explained.

The study was performed at a single center and cannot prove causation due to its retrospective nature.

Ms. Dumitriu Carcoana and Dr. Flores have no relevant financial disclosures.

*This article was updated on 4/13/2023.

At a single robotic-assisted pulmonary lobectomy center, patients with public insurance or combined public and private insurance fared worse than those with private insurance, according to a new retrospective analysis.

The study used public insurance status as a marker for low socioeconomic status (SES) and suggests that patients with combined insurance may constitute a separate population that deserves more attention.

Lower SES has been linked to later stage diagnoses and worse outcomes in NSCLC. Private insurance is a generally-accepted indicator of higher SES, while public insurance like Medicare or Medicaid, alone or in combination with private supplementary insurance, is an indicator of lower SES.

Although previous studies have found associations between patients having public health insurance and experiencing later-stage diagnoses and worse overall survival, there have been few studies of surgical outcomes, and almost no research has examined combination health insurance, according to Allison O. Dumitriu Carcoana, who presented the research during a poster session at the European Lung Cancer Congress 2023.

“This is an important insurance subgroup for us because the majority of our patients fall into this subgroup by being over 65 years old and thus qualifying for Medicare while also paying for a private supplement,” said Ms. Dumitriu Carcoana, who is a medical student at University of South Florida Health Morsani College of Medicine, Tampa.

A previous analysis by the group found an association between private insurance status and better discharge status, as well as higher 5-year overall survival. After accumulating an additional 278 patients, the researchers examined 10-year survival outcomes.

In the new analysis, 52% of 711 participants had combination insurance, while 28% had private insurance, and 20% had public insurance. The subgroups all had similar demographic and histological characteristics. The study was unique in that it found no between-group differences in higher stage at diagnosis, whereas previous studies have found a greater risk of higher stage diagnosis among individuals with public insurance. As expected, patients in the combined insurance group had a higher mean age (P less than .0001) and higher Charlson comorbidity index scores (P = .0014), which in turn was associated with lower 10-year survival. The group also had the highest percentage of former smokers, while the public insurance group had the highest percentage of current smokers (P = .0003).

At both 5 and 10 years, the private insurance group had better OS than the group with public (P less than .001) and the combination insurance group (P = .08). Public health insurance was associated with worse OS at 5 years (hazard ratio, 1.83; P less than .005) but not at 10 years (HR, 1.18; P = .51), while combination insurance was associated with worse OS at 10 years (HR, 1.72; P = .02).

“We think that patients with public health insurance having the worst 5-year overall survival, despite their lower ages and fewer comorbid conditions, compared with patients with combination insurance, highlights the impact of lower socioeconomic status on health outcomes. These patients had the same tumor characteristics, BMI, sex, and race as our patients in the other two insurance groups. The only other significant risk factor [the group had besides having a higher proportion of patients with lower socioeconomic status was that it had a higher proportion of current smokers]. But the multivariate analyses showed that insurance status was an independent predictor of survival, regardless of smoking status or other comorbidities,” said Ms. Dumitriu Carcoana.

“At 10 years post-operatively, the survival curves have shifted and the combination patients had the worst 10-year overall survival. We attribute this to their higher number of comorbid conditions and increased age. In practice, [this means that] the group of patients with public insurance type, but no supplement, should be identified clinically, and the clinical team can initiate a discussion,” Ms. Dumitriu Carcoana said.

“Do these patients feel that they can make follow-up appointments, keep up with medication costs, and make the right lifestyle decisions postoperatively on their current insurance plan? If not, can they afford a private supplement? In our cohort specifically, it may also be important to do more preoperative counseling on the importance of smoking cessation,” she added.

The study is interesting, but it has some important limitations, according to Raja Flores, MD, who was not involved with the study. The authors stated that there was no difference between the insurance groups with respect to mortality or cancer stage, which is the most important predictor of survival. However, the poster didn't include details of the authors' analysis, making it difficult to interpret, Dr. Flores said.

The fact that the study includes a single surgeon has some disadvantages in terms of broader applicability, but it also controls for surgical technique. “Different surgeons have different ways of doing things, so if you had the same surgeon doing it the same way every time, you can look at other variables like insurance (status) and stage,” said Dr. Flores.

The results may also provide an argument against using robotic surgery in patients who do not have insurance, especially since they have not been proven to be better than standard minimally invasive surgery with no robotic assistance. With uninsured patients, “you’re using taxpayer money for a more expensive procedure that isn’t proving to be any better,” Dr. Flores explained.

The study was performed at a single center and cannot prove causation due to its retrospective nature.

Ms. Dumitriu Carcoana and Dr. Flores have no relevant financial disclosures.

*This article was updated on 4/13/2023.

A comparison of Food and Drug Administration and European Medicines Agency approvals of immune checkpoint inhibitors in the field of thoracic cancer found significantly longer approval times at the European agency, as well as some examples of different perspectives on biomarkers.

The findings of this new study suggest that patients in Europe may face delayed access to new therapies, the authors wrote in a poster presentation at the European Lung Cancer Congress 2023.

They also noted that some FDA approvals occurred before pivotal trial data became available, which can leave doubt about efficacy.

“Effective cancer management relies on availability of therapies which improve patient outcomes, such as immunotherapy. The two largest regulators involved in approving immunotherapies are the FDA and the EMA and therefore we aimed to compare the approval timings between both to see if a difference in approval timings was present,” coauthor Aakash Desai, MD, said in an interview.

Previously, the researchers conducted a study of cancer approval patterns at the FDA and EMA between 2010 and 2019, and found U.S. patients gain access to new cancer therapeutics more quickly than do European patients. Of 89 new therapies approved in that time span, the FDA approval occurred first in 85 cases (95%), though just 72% were submitted to FDA first. The median increased time it took for EMA approval compared with the FDA was 241 days. Thirty-nine percent of U.S. approvals came before the publication of the pivotal clinical trial, versus 9% of EMA approvals.

The new study focuses on thoracic oncology, where lung cancer is the leading cause of death. “As such, prompt approval timings for immunotherapies are crucial for effective treatment. Furthermore, lung cancer immunotherapies target certain biomarkers, of which, PD1 and PD-L1 are key,” said Dr. Desai, a fellow at Mayo Clinic, Rochester, Minn.

Still, Dr. Desai sounded a note of caution. “Just because a therapy is approved more quickly does not necessarily mean it is efficacious, as the clinical trials involving these drugs may not have been completed or fully reported at the time of authorization. [Drug developers] need to have a more global and coordinated approach to evaluating evidence and approval of drugs so the care received by a particular patient is not a factor of where they live,” he said.

The researchers surveyed approvals of seven immune checkpoint inhibitors (ICIs) approved by both the FDA and the EMA for thoracic malignancies, including non–small cell lung cancer (NSCLC), small cell lung cancer (SCLC), and mesothelioma. The FDA approved 22 indications for the novel ICIs in thoracic malignancies, compared with 16 indications at the EMA. The difference in median approval times was larger for SCLC (179 versus 308 days) and mesothelioma (39 versus 280 days) than for NSCLC (242 versus 272 days).

“There are two discrepancies in biomarker requirements between the FDA and EMA, whereby the FDA has a broader requirement, despite these being ranked fairly consistently in terms of evidence of benefit by [European Society for Medical Oncology Magnitude of Clinical Benefit Scale and National Comprehensive Cancer Network] frameworks,” said Dr. Desai. In the case of atezolizumab for adjuvant NSCLC, the FDA required PDL1 levels of 1% or higher, while the EMA required 50% or higher. For durvalumab in unresectable NSCLC, the FDA had no PDL1 requirement, while the EMA required 1% or higher.

Dr. Desai suggested a need for further investigation into the differences between the two agencies. Asked why the two agencies might have different views on the biomarkers, Dr. Desai responded: “That is the million-dollar question. My guess is [the] EMA weighs subgroup data more than [the] FDA.”

Dr. Desai has no relevant financial disclosures.

A comparison of Food and Drug Administration and European Medicines Agency approvals of immune checkpoint inhibitors in the field of thoracic cancer found significantly longer approval times at the European agency, as well as some examples of different perspectives on biomarkers.

The findings of this new study suggest that patients in Europe may face delayed access to new therapies, the authors wrote in a poster presentation at the European Lung Cancer Congress 2023.

They also noted that some FDA approvals occurred before pivotal trial data became available, which can leave doubt about efficacy.

“Effective cancer management relies on availability of therapies which improve patient outcomes, such as immunotherapy. The two largest regulators involved in approving immunotherapies are the FDA and the EMA and therefore we aimed to compare the approval timings between both to see if a difference in approval timings was present,” coauthor Aakash Desai, MD, said in an interview.

Previously, the researchers conducted a study of cancer approval patterns at the FDA and EMA between 2010 and 2019, and found U.S. patients gain access to new cancer therapeutics more quickly than do European patients. Of 89 new therapies approved in that time span, the FDA approval occurred first in 85 cases (95%), though just 72% were submitted to FDA first. The median increased time it took for EMA approval compared with the FDA was 241 days. Thirty-nine percent of U.S. approvals came before the publication of the pivotal clinical trial, versus 9% of EMA approvals.

The new study focuses on thoracic oncology, where lung cancer is the leading cause of death. “As such, prompt approval timings for immunotherapies are crucial for effective treatment. Furthermore, lung cancer immunotherapies target certain biomarkers, of which, PD1 and PD-L1 are key,” said Dr. Desai, a fellow at Mayo Clinic, Rochester, Minn.

Still, Dr. Desai sounded a note of caution. “Just because a therapy is approved more quickly does not necessarily mean it is efficacious, as the clinical trials involving these drugs may not have been completed or fully reported at the time of authorization. [Drug developers] need to have a more global and coordinated approach to evaluating evidence and approval of drugs so the care received by a particular patient is not a factor of where they live,” he said.

The researchers surveyed approvals of seven immune checkpoint inhibitors (ICIs) approved by both the FDA and the EMA for thoracic malignancies, including non–small cell lung cancer (NSCLC), small cell lung cancer (SCLC), and mesothelioma. The FDA approved 22 indications for the novel ICIs in thoracic malignancies, compared with 16 indications at the EMA. The difference in median approval times was larger for SCLC (179 versus 308 days) and mesothelioma (39 versus 280 days) than for NSCLC (242 versus 272 days).

“There are two discrepancies in biomarker requirements between the FDA and EMA, whereby the FDA has a broader requirement, despite these being ranked fairly consistently in terms of evidence of benefit by [European Society for Medical Oncology Magnitude of Clinical Benefit Scale and National Comprehensive Cancer Network] frameworks,” said Dr. Desai. In the case of atezolizumab for adjuvant NSCLC, the FDA required PDL1 levels of 1% or higher, while the EMA required 50% or higher. For durvalumab in unresectable NSCLC, the FDA had no PDL1 requirement, while the EMA required 1% or higher.

Dr. Desai suggested a need for further investigation into the differences between the two agencies. Asked why the two agencies might have different views on the biomarkers, Dr. Desai responded: “That is the million-dollar question. My guess is [the] EMA weighs subgroup data more than [the] FDA.”

Dr. Desai has no relevant financial disclosures.

A comparison of Food and Drug Administration and European Medicines Agency approvals of immune checkpoint inhibitors in the field of thoracic cancer found significantly longer approval times at the European agency, as well as some examples of different perspectives on biomarkers.

The findings of this new study suggest that patients in Europe may face delayed access to new therapies, the authors wrote in a poster presentation at the European Lung Cancer Congress 2023.

They also noted that some FDA approvals occurred before pivotal trial data became available, which can leave doubt about efficacy.

“Effective cancer management relies on availability of therapies which improve patient outcomes, such as immunotherapy. The two largest regulators involved in approving immunotherapies are the FDA and the EMA and therefore we aimed to compare the approval timings between both to see if a difference in approval timings was present,” coauthor Aakash Desai, MD, said in an interview.

Previously, the researchers conducted a study of cancer approval patterns at the FDA and EMA between 2010 and 2019, and found U.S. patients gain access to new cancer therapeutics more quickly than do European patients. Of 89 new therapies approved in that time span, the FDA approval occurred first in 85 cases (95%), though just 72% were submitted to FDA first. The median increased time it took for EMA approval compared with the FDA was 241 days. Thirty-nine percent of U.S. approvals came before the publication of the pivotal clinical trial, versus 9% of EMA approvals.

The new study focuses on thoracic oncology, where lung cancer is the leading cause of death. “As such, prompt approval timings for immunotherapies are crucial for effective treatment. Furthermore, lung cancer immunotherapies target certain biomarkers, of which, PD1 and PD-L1 are key,” said Dr. Desai, a fellow at Mayo Clinic, Rochester, Minn.

Still, Dr. Desai sounded a note of caution. “Just because a therapy is approved more quickly does not necessarily mean it is efficacious, as the clinical trials involving these drugs may not have been completed or fully reported at the time of authorization. [Drug developers] need to have a more global and coordinated approach to evaluating evidence and approval of drugs so the care received by a particular patient is not a factor of where they live,” he said.

The researchers surveyed approvals of seven immune checkpoint inhibitors (ICIs) approved by both the FDA and the EMA for thoracic malignancies, including non–small cell lung cancer (NSCLC), small cell lung cancer (SCLC), and mesothelioma. The FDA approved 22 indications for the novel ICIs in thoracic malignancies, compared with 16 indications at the EMA. The difference in median approval times was larger for SCLC (179 versus 308 days) and mesothelioma (39 versus 280 days) than for NSCLC (242 versus 272 days).

“There are two discrepancies in biomarker requirements between the FDA and EMA, whereby the FDA has a broader requirement, despite these being ranked fairly consistently in terms of evidence of benefit by [European Society for Medical Oncology Magnitude of Clinical Benefit Scale and National Comprehensive Cancer Network] frameworks,” said Dr. Desai. In the case of atezolizumab for adjuvant NSCLC, the FDA required PDL1 levels of 1% or higher, while the EMA required 50% or higher. For durvalumab in unresectable NSCLC, the FDA had no PDL1 requirement, while the EMA required 1% or higher.

Dr. Desai suggested a need for further investigation into the differences between the two agencies. Asked why the two agencies might have different views on the biomarkers, Dr. Desai responded: “That is the million-dollar question. My guess is [the] EMA weighs subgroup data more than [the] FDA.”

Dr. Desai has no relevant financial disclosures.

A large, systematic review of phase III randomized, controlled trials in metastatic non–small cell lung cancer found quality of life (QoL) improvements in progression-free survival (PFS), but not overall survival (OS), among patients treated with targeted therapy.

The authors, including Fabio Salomone of the University of Naples Federico II, department of clinical medicine and surgery, also observed trends toward an association between QoL improvement and PFS among patients treated with chemotherapy and immunotherapy.

The new research was presented during a poster session at European Lung Cancer Congress 2023.

“The findings of the study support the thesis that QoL and survival in patients with NSCLC are linked. Although this is documented in the literature, this study sums up the evidence of a large number of RCTs, and provides detail in the QoL/survival relationship by treatment type. The subgroup analysis by treatment type is a key strength of the study showing that the QoL/survival link is stronger and more reliable in target(ed) therapies,” George Kypriotakis, PhD, who was not involved with the study, said in an interview.

Combining efficacy and quality of life improvement is an important consideration in clinical practice. “It is important that clinicians provide therapies that are also palliative and improve QoL,” said Dr. Kypriotakis, assistant professor of behavioral sciences at University of Texas MD Anderson Cancer Center, Houston. He noted that the finding of a PFS benefit is a good indicator of overall benefit, which is important since OS outcomes require a larger number of patients and longer follow-up to determine.

“PFS can still be a valid surrogate for OS, especially when it is positively associated with QoL,” noted Dr. Kypriotakis.

The study included 81 trials. Sixteen of the studies investigated immunotherapy, 50 investigated targeted therapy, and 17 investigated chemotherapy regimens. Thirty-seven percent of the trials found an improvement in QoL in the treatment arm compared with the control arm, 59.3% found no difference between arms, and 3.7% found a worse QoL in the treatment arm. There was no statistically significant association between an improvement in OS and QoL among the trials (P = .368).
 

Improved QoL tied to improved PFS

The researchers found an association between improved QoL and improved PFS. Among 60 trials that showed improved PFS, 43.3% found a superior QoL in the treatment arm, 53.3% showed no difference, and 3.3% showed reduced QoL. Among 20 trials that found no improvement in PFS, 20% demonstrated an improved QoL, 75% found no change, and 5% showed worse QoL (P = .0473).

A subanalysis of 48 targeted therapy trials found a correlation between PFS and QoL improvement (P = .0196). Among 25 trials involving patients receiving epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) inhibitors showing an improved PFS, 60% showed improved QoL, 36% showed no difference, and 4% showed worsening (P = .0077). Seven of these trials showed no PFS benefit and no change in QoL.
 

Industry sponsorship may affect QOL results

The researchers found potential evidence that industry sponsorship may lead to a spin on QoL outcomes. Among 51 trials that showed no QoL benefit associated with treatment, the description of the QoL outcome in 37 industry-sponsored was judged to be neutral and coherent with the study findings in 26 cases, but unjustifiably favorable in 11 cases. Among 14 with nonprofit support, descriptions of QoL results were found to be neutral in all cases (P = .0232).

“Obviously, industry may be motivated to overemphasize treatment benefits, especially in measures that also have a qualitative/subjective dimension such as QoL. Assuming that the authors used a reliable criterion to evaluate “inappropriateness,” industry may be more likely to emphasize QoL improvements as a surrogate for OS, especially when seeking drug approval,” Dr. Kypriotakis said.

The study is retrospective and cannot prove causation.

Dr. Salomone and Dr. Kypriotakis have no relevant financial disclosures.

A large, systematic review of phase III randomized, controlled trials in metastatic non–small cell lung cancer found quality of life (QoL) improvements in progression-free survival (PFS), but not overall survival (OS), among patients treated with targeted therapy.

The authors, including Fabio Salomone of the University of Naples Federico II, department of clinical medicine and surgery, also observed trends toward an association between QoL improvement and PFS among patients treated with chemotherapy and immunotherapy.

The new research was presented during a poster session at European Lung Cancer Congress 2023.

“The findings of the study support the thesis that QoL and survival in patients with NSCLC are linked. Although this is documented in the literature, this study sums up the evidence of a large number of RCTs, and provides detail in the QoL/survival relationship by treatment type. The subgroup analysis by treatment type is a key strength of the study showing that the QoL/survival link is stronger and more reliable in target(ed) therapies,” George Kypriotakis, PhD, who was not involved with the study, said in an interview.

Combining efficacy and quality of life improvement is an important consideration in clinical practice. “It is important that clinicians provide therapies that are also palliative and improve QoL,” said Dr. Kypriotakis, assistant professor of behavioral sciences at University of Texas MD Anderson Cancer Center, Houston. He noted that the finding of a PFS benefit is a good indicator of overall benefit, which is important since OS outcomes require a larger number of patients and longer follow-up to determine.

“PFS can still be a valid surrogate for OS, especially when it is positively associated with QoL,” noted Dr. Kypriotakis.

The study included 81 trials. Sixteen of the studies investigated immunotherapy, 50 investigated targeted therapy, and 17 investigated chemotherapy regimens. Thirty-seven percent of the trials found an improvement in QoL in the treatment arm compared with the control arm, 59.3% found no difference between arms, and 3.7% found a worse QoL in the treatment arm. There was no statistically significant association between an improvement in OS and QoL among the trials (P = .368).
 

Improved QoL tied to improved PFS

The researchers found an association between improved QoL and improved PFS. Among 60 trials that showed improved PFS, 43.3% found a superior QoL in the treatment arm, 53.3% showed no difference, and 3.3% showed reduced QoL. Among 20 trials that found no improvement in PFS, 20% demonstrated an improved QoL, 75% found no change, and 5% showed worse QoL (P = .0473).

A subanalysis of 48 targeted therapy trials found a correlation between PFS and QoL improvement (P = .0196). Among 25 trials involving patients receiving epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) inhibitors showing an improved PFS, 60% showed improved QoL, 36% showed no difference, and 4% showed worsening (P = .0077). Seven of these trials showed no PFS benefit and no change in QoL.
 

Industry sponsorship may affect QOL results

The researchers found potential evidence that industry sponsorship may lead to a spin on QoL outcomes. Among 51 trials that showed no QoL benefit associated with treatment, the description of the QoL outcome in 37 industry-sponsored was judged to be neutral and coherent with the study findings in 26 cases, but unjustifiably favorable in 11 cases. Among 14 with nonprofit support, descriptions of QoL results were found to be neutral in all cases (P = .0232).

“Obviously, industry may be motivated to overemphasize treatment benefits, especially in measures that also have a qualitative/subjective dimension such as QoL. Assuming that the authors used a reliable criterion to evaluate “inappropriateness,” industry may be more likely to emphasize QoL improvements as a surrogate for OS, especially when seeking drug approval,” Dr. Kypriotakis said.

The study is retrospective and cannot prove causation.

Dr. Salomone and Dr. Kypriotakis have no relevant financial disclosures.

A large, systematic review of phase III randomized, controlled trials in metastatic non–small cell lung cancer found quality of life (QoL) improvements in progression-free survival (PFS), but not overall survival (OS), among patients treated with targeted therapy.

The authors, including Fabio Salomone of the University of Naples Federico II, department of clinical medicine and surgery, also observed trends toward an association between QoL improvement and PFS among patients treated with chemotherapy and immunotherapy.

The new research was presented during a poster session at European Lung Cancer Congress 2023.

“The findings of the study support the thesis that QoL and survival in patients with NSCLC are linked. Although this is documented in the literature, this study sums up the evidence of a large number of RCTs, and provides detail in the QoL/survival relationship by treatment type. The subgroup analysis by treatment type is a key strength of the study showing that the QoL/survival link is stronger and more reliable in target(ed) therapies,” George Kypriotakis, PhD, who was not involved with the study, said in an interview.

Combining efficacy and quality of life improvement is an important consideration in clinical practice. “It is important that clinicians provide therapies that are also palliative and improve QoL,” said Dr. Kypriotakis, assistant professor of behavioral sciences at University of Texas MD Anderson Cancer Center, Houston. He noted that the finding of a PFS benefit is a good indicator of overall benefit, which is important since OS outcomes require a larger number of patients and longer follow-up to determine.

“PFS can still be a valid surrogate for OS, especially when it is positively associated with QoL,” noted Dr. Kypriotakis.

The study included 81 trials. Sixteen of the studies investigated immunotherapy, 50 investigated targeted therapy, and 17 investigated chemotherapy regimens. Thirty-seven percent of the trials found an improvement in QoL in the treatment arm compared with the control arm, 59.3% found no difference between arms, and 3.7% found a worse QoL in the treatment arm. There was no statistically significant association between an improvement in OS and QoL among the trials (P = .368).
 

Improved QoL tied to improved PFS

The researchers found an association between improved QoL and improved PFS. Among 60 trials that showed improved PFS, 43.3% found a superior QoL in the treatment arm, 53.3% showed no difference, and 3.3% showed reduced QoL. Among 20 trials that found no improvement in PFS, 20% demonstrated an improved QoL, 75% found no change, and 5% showed worse QoL (P = .0473).

A subanalysis of 48 targeted therapy trials found a correlation between PFS and QoL improvement (P = .0196). Among 25 trials involving patients receiving epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) inhibitors showing an improved PFS, 60% showed improved QoL, 36% showed no difference, and 4% showed worsening (P = .0077). Seven of these trials showed no PFS benefit and no change in QoL.
 

Industry sponsorship may affect QOL results

The researchers found potential evidence that industry sponsorship may lead to a spin on QoL outcomes. Among 51 trials that showed no QoL benefit associated with treatment, the description of the QoL outcome in 37 industry-sponsored was judged to be neutral and coherent with the study findings in 26 cases, but unjustifiably favorable in 11 cases. Among 14 with nonprofit support, descriptions of QoL results were found to be neutral in all cases (P = .0232).

“Obviously, industry may be motivated to overemphasize treatment benefits, especially in measures that also have a qualitative/subjective dimension such as QoL. Assuming that the authors used a reliable criterion to evaluate “inappropriateness,” industry may be more likely to emphasize QoL improvements as a surrogate for OS, especially when seeking drug approval,” Dr. Kypriotakis said.

The study is retrospective and cannot prove causation.

Dr. Salomone and Dr. Kypriotakis have no relevant financial disclosures.

Stereotactic body radiation therapy (SBRT) and surgery offer nearly equal overall survival rates for patients with stage I and II non–small cell lung cancer (NSCLC), according to population-based data from a German cancer registry.

“From a public health perspective, SBRT is a good therapeutic option in terms of survival, especially for elderly and inoperable patients,” noted the study authors, led by Jörg Andreas Müller, MD, department of radiation oncology, University Hospital of Halle, Germany.

The analysis was published online in the journal Strahlentherapie Und Onkologie.

Surgery remains the standard of care for early stage NSCLC. However, many patients are not eligible for surgery because of the tumor’s location, age, frailty, or comorbidities.

Before the introduction of SBRT, conventional radiation therapy was the only reasonable option for inoperable patients, with study data showing only a small survival improvement in treated vs. untreated patients.

High-precision, image-guided SBRT offers better tumor control with limited toxicity. And while many radiation oncology centers in Germany adopted SBRT as an alternative treatment for surgery after 2000, few population-based studies evaluating SBRT’s impact on overall survival exist.

Using the German clinical cancer registry of Berlin-Brandenburg, Dr. Müller and colleagues assessed SBRT as an alternative to surgery in 558 patients with stage I and II NSCLC, diagnosed between 2000 and 2015.

More patients received surgery than SBRT (74% vs. 26%). Those who received SBRT were younger than those in the surgery group and had better Karnofsky performance status.

Among patients in the SBRT group, median survival was 19 months overall and 27 months in patients over age 75. In the surgery group, median survival was 22 months overall and 24 months in those over 75.

In a univariate survival model of a propensity-matched sample of 292 patients – half of whom received SBRT – survival rates were similar among those who underwent SBRT versus surgery (hazard ratio [HR], 1.2; P = .2).

Survival was also similar in the two treatment groups in a T1 subanalysis (HR, 1.12; P = .7) as well as in patients over age 75 (HR, 0.86; P = .5).

Better performance status scores were associated with improved survival, and higher histological grades and TNM stages were linked to higher mortality risk. The availability of histological data did not have a significant impact on survival outcomes.

Overall, the findings suggest that SBRT and surgery offer comparable survival outcomes in early stage NSCLC and “the availability of histological data might not be decisive for treatment planning,” Dr. Müller and colleagues said. 

Drew Moghanaki, MD, chief of the thoracic oncology service at UCLA Health Jonsson Comprehensive Cancer Center, Los Angeles, highlighted the findings on Twitter.

A thoracic surgeon from Germany responded with several concerns about the study, including the use of statistics with univariate modeling and undiagnosed lymph node (N) status.

Dr. Moghanaki replied that these “concerns summarize how we USED to think. It increasingly seems they aren’t as important as our teachers once thought they were.  As we move into the future we need to reassess the data that supported these recommendations as they seem more academic than patient centered.”

The study authors reported no specific funding, and no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Stereotactic body radiation therapy (SBRT) and surgery offer nearly equal overall survival rates for patients with stage I and II non–small cell lung cancer (NSCLC), according to population-based data from a German cancer registry.

“From a public health perspective, SBRT is a good therapeutic option in terms of survival, especially for elderly and inoperable patients,” noted the study authors, led by Jörg Andreas Müller, MD, department of radiation oncology, University Hospital of Halle, Germany.

The analysis was published online in the journal Strahlentherapie Und Onkologie.

Surgery remains the standard of care for early stage NSCLC. However, many patients are not eligible for surgery because of the tumor’s location, age, frailty, or comorbidities.

Before the introduction of SBRT, conventional radiation therapy was the only reasonable option for inoperable patients, with study data showing only a small survival improvement in treated vs. untreated patients.

High-precision, image-guided SBRT offers better tumor control with limited toxicity. And while many radiation oncology centers in Germany adopted SBRT as an alternative treatment for surgery after 2000, few population-based studies evaluating SBRT’s impact on overall survival exist.

Using the German clinical cancer registry of Berlin-Brandenburg, Dr. Müller and colleagues assessed SBRT as an alternative to surgery in 558 patients with stage I and II NSCLC, diagnosed between 2000 and 2015.

More patients received surgery than SBRT (74% vs. 26%). Those who received SBRT were younger than those in the surgery group and had better Karnofsky performance status.

Among patients in the SBRT group, median survival was 19 months overall and 27 months in patients over age 75. In the surgery group, median survival was 22 months overall and 24 months in those over 75.

In a univariate survival model of a propensity-matched sample of 292 patients – half of whom received SBRT – survival rates were similar among those who underwent SBRT versus surgery (hazard ratio [HR], 1.2; P = .2).

Survival was also similar in the two treatment groups in a T1 subanalysis (HR, 1.12; P = .7) as well as in patients over age 75 (HR, 0.86; P = .5).

Better performance status scores were associated with improved survival, and higher histological grades and TNM stages were linked to higher mortality risk. The availability of histological data did not have a significant impact on survival outcomes.

Overall, the findings suggest that SBRT and surgery offer comparable survival outcomes in early stage NSCLC and “the availability of histological data might not be decisive for treatment planning,” Dr. Müller and colleagues said. 

Drew Moghanaki, MD, chief of the thoracic oncology service at UCLA Health Jonsson Comprehensive Cancer Center, Los Angeles, highlighted the findings on Twitter.

A thoracic surgeon from Germany responded with several concerns about the study, including the use of statistics with univariate modeling and undiagnosed lymph node (N) status.

Dr. Moghanaki replied that these “concerns summarize how we USED to think. It increasingly seems they aren’t as important as our teachers once thought they were.  As we move into the future we need to reassess the data that supported these recommendations as they seem more academic than patient centered.”

The study authors reported no specific funding, and no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

Stereotactic body radiation therapy (SBRT) and surgery offer nearly equal overall survival rates for patients with stage I and II non–small cell lung cancer (NSCLC), according to population-based data from a German cancer registry.

“From a public health perspective, SBRT is a good therapeutic option in terms of survival, especially for elderly and inoperable patients,” noted the study authors, led by Jörg Andreas Müller, MD, department of radiation oncology, University Hospital of Halle, Germany.

The analysis was published online in the journal Strahlentherapie Und Onkologie.

Surgery remains the standard of care for early stage NSCLC. However, many patients are not eligible for surgery because of the tumor’s location, age, frailty, or comorbidities.

Before the introduction of SBRT, conventional radiation therapy was the only reasonable option for inoperable patients, with study data showing only a small survival improvement in treated vs. untreated patients.

High-precision, image-guided SBRT offers better tumor control with limited toxicity. And while many radiation oncology centers in Germany adopted SBRT as an alternative treatment for surgery after 2000, few population-based studies evaluating SBRT’s impact on overall survival exist.

Using the German clinical cancer registry of Berlin-Brandenburg, Dr. Müller and colleagues assessed SBRT as an alternative to surgery in 558 patients with stage I and II NSCLC, diagnosed between 2000 and 2015.

More patients received surgery than SBRT (74% vs. 26%). Those who received SBRT were younger than those in the surgery group and had better Karnofsky performance status.

Among patients in the SBRT group, median survival was 19 months overall and 27 months in patients over age 75. In the surgery group, median survival was 22 months overall and 24 months in those over 75.

In a univariate survival model of a propensity-matched sample of 292 patients – half of whom received SBRT – survival rates were similar among those who underwent SBRT versus surgery (hazard ratio [HR], 1.2; P = .2).

Survival was also similar in the two treatment groups in a T1 subanalysis (HR, 1.12; P = .7) as well as in patients over age 75 (HR, 0.86; P = .5).

Better performance status scores were associated with improved survival, and higher histological grades and TNM stages were linked to higher mortality risk. The availability of histological data did not have a significant impact on survival outcomes.

Overall, the findings suggest that SBRT and surgery offer comparable survival outcomes in early stage NSCLC and “the availability of histological data might not be decisive for treatment planning,” Dr. Müller and colleagues said. 

Drew Moghanaki, MD, chief of the thoracic oncology service at UCLA Health Jonsson Comprehensive Cancer Center, Los Angeles, highlighted the findings on Twitter.

A thoracic surgeon from Germany responded with several concerns about the study, including the use of statistics with univariate modeling and undiagnosed lymph node (N) status.

Dr. Moghanaki replied that these “concerns summarize how we USED to think. It increasingly seems they aren’t as important as our teachers once thought they were.  As we move into the future we need to reassess the data that supported these recommendations as they seem more academic than patient centered.”

The study authors reported no specific funding, and no relevant financial relationships.
 

A version of this article first appeared on Medscape.com.

A 2.5-mg dose of olanzapine once daily significantly improved appetite in patients undergoing chemotherapy for locally advanced or metastatic gastric, hepatopancreaticobiliary, or lung cancer.

Anorexia is a problem in approximately 50% of newly-diagnosed cancer patients, and can compromise survival, wrote study author Lakshmi Sandhya, MD, of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, and colleagues. In particular, patients with lung and gastrointestinal tract cancers are prone to anorexia during chemotherapy, they said. Olanzapine is a demonstrated appetite stimulant and has been used in cancer patients as a short-term antiemetic, but its use for long-term appetite stimulation has not been well-studied, they said.

In the study, published in the Journal of Clinical Oncology, the researchers randomized 124 adults aged 18 years and older to a 2.5 grams of olanzapine or placebo for 12 weeks. The participants had untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), or lung cancers.

The median age of the participants was 55 years. The primary outcome was a weight gain greater than 5% and improved appetite based on the visual analog scale (VAS) and questionnaires. A change in nutritional status, quality of life (QOL), and chemotherapy toxicity, were secondary endpoints.

After 12 weeks, complete data were available for 58 patients in the olanzapine group and 54 in the placebo group. Of these, 60% of the olanzapine group and 9% of the placebo group met the primary endpoint of a weight gain greater than 5%. The proportion of patients with improved appetite based on VAS scores and questionnaire scores was significantly higher in olanzapine patients vs. placebo patients (43% vs. 13% and 22% vs. 4%, respectively).

In addition, 52% of the olanzapine group vs. 18% of the placebo group achieved more than 75% intake of recommended daily calories.

Most of the reported toxicities were not hematological and similar between the groups (85% for olanzapine vs. 88% for placebo). The proportion of patients with toxicities of grade 3 or higher was lower in the olanzapine group vs. the placebo group (12% vs. 37%, P = .002). Patients in the olanzapine group also reported significantly improved quality of life from baseline compared to the placebo patients.

The findings were limited by several factors including the heterogeneous cancers and treatment regimens, the lack of data on weight beyond 12 weeks, the relatively small study population, and the subjective nature of anorexia measurements, the researchers noted.

However, the results suggest that low-dose olanzapine is an effective and well-tolerated add-on intervention for the subset of patients at risk for anorexia at the start of chemotherapy, they said.

“Future studies could look at various cancers in a multicentric setting and long-term endpoints such as patient survival,” they concluded.

The study drug and placebo were funded by an intramural grant from Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). The researchers had no financial conflicts to disclose.

A 2.5-mg dose of olanzapine once daily significantly improved appetite in patients undergoing chemotherapy for locally advanced or metastatic gastric, hepatopancreaticobiliary, or lung cancer.

Anorexia is a problem in approximately 50% of newly-diagnosed cancer patients, and can compromise survival, wrote study author Lakshmi Sandhya, MD, of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, and colleagues. In particular, patients with lung and gastrointestinal tract cancers are prone to anorexia during chemotherapy, they said. Olanzapine is a demonstrated appetite stimulant and has been used in cancer patients as a short-term antiemetic, but its use for long-term appetite stimulation has not been well-studied, they said.

In the study, published in the Journal of Clinical Oncology, the researchers randomized 124 adults aged 18 years and older to a 2.5 grams of olanzapine or placebo for 12 weeks. The participants had untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), or lung cancers.

The median age of the participants was 55 years. The primary outcome was a weight gain greater than 5% and improved appetite based on the visual analog scale (VAS) and questionnaires. A change in nutritional status, quality of life (QOL), and chemotherapy toxicity, were secondary endpoints.

After 12 weeks, complete data were available for 58 patients in the olanzapine group and 54 in the placebo group. Of these, 60% of the olanzapine group and 9% of the placebo group met the primary endpoint of a weight gain greater than 5%. The proportion of patients with improved appetite based on VAS scores and questionnaire scores was significantly higher in olanzapine patients vs. placebo patients (43% vs. 13% and 22% vs. 4%, respectively).

In addition, 52% of the olanzapine group vs. 18% of the placebo group achieved more than 75% intake of recommended daily calories.

Most of the reported toxicities were not hematological and similar between the groups (85% for olanzapine vs. 88% for placebo). The proportion of patients with toxicities of grade 3 or higher was lower in the olanzapine group vs. the placebo group (12% vs. 37%, P = .002). Patients in the olanzapine group also reported significantly improved quality of life from baseline compared to the placebo patients.

The findings were limited by several factors including the heterogeneous cancers and treatment regimens, the lack of data on weight beyond 12 weeks, the relatively small study population, and the subjective nature of anorexia measurements, the researchers noted.

However, the results suggest that low-dose olanzapine is an effective and well-tolerated add-on intervention for the subset of patients at risk for anorexia at the start of chemotherapy, they said.

“Future studies could look at various cancers in a multicentric setting and long-term endpoints such as patient survival,” they concluded.

The study drug and placebo were funded by an intramural grant from Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). The researchers had no financial conflicts to disclose.

A 2.5-mg dose of olanzapine once daily significantly improved appetite in patients undergoing chemotherapy for locally advanced or metastatic gastric, hepatopancreaticobiliary, or lung cancer.

Anorexia is a problem in approximately 50% of newly-diagnosed cancer patients, and can compromise survival, wrote study author Lakshmi Sandhya, MD, of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, and colleagues. In particular, patients with lung and gastrointestinal tract cancers are prone to anorexia during chemotherapy, they said. Olanzapine is a demonstrated appetite stimulant and has been used in cancer patients as a short-term antiemetic, but its use for long-term appetite stimulation has not been well-studied, they said.

In the study, published in the Journal of Clinical Oncology, the researchers randomized 124 adults aged 18 years and older to a 2.5 grams of olanzapine or placebo for 12 weeks. The participants had untreated, locally advanced, or metastatic gastric, hepatopancreaticobiliary (HPB), or lung cancers.

The median age of the participants was 55 years. The primary outcome was a weight gain greater than 5% and improved appetite based on the visual analog scale (VAS) and questionnaires. A change in nutritional status, quality of life (QOL), and chemotherapy toxicity, were secondary endpoints.

After 12 weeks, complete data were available for 58 patients in the olanzapine group and 54 in the placebo group. Of these, 60% of the olanzapine group and 9% of the placebo group met the primary endpoint of a weight gain greater than 5%. The proportion of patients with improved appetite based on VAS scores and questionnaire scores was significantly higher in olanzapine patients vs. placebo patients (43% vs. 13% and 22% vs. 4%, respectively).

In addition, 52% of the olanzapine group vs. 18% of the placebo group achieved more than 75% intake of recommended daily calories.

Most of the reported toxicities were not hematological and similar between the groups (85% for olanzapine vs. 88% for placebo). The proportion of patients with toxicities of grade 3 or higher was lower in the olanzapine group vs. the placebo group (12% vs. 37%, P = .002). Patients in the olanzapine group also reported significantly improved quality of life from baseline compared to the placebo patients.

The findings were limited by several factors including the heterogeneous cancers and treatment regimens, the lack of data on weight beyond 12 weeks, the relatively small study population, and the subjective nature of anorexia measurements, the researchers noted.

However, the results suggest that low-dose olanzapine is an effective and well-tolerated add-on intervention for the subset of patients at risk for anorexia at the start of chemotherapy, they said.

“Future studies could look at various cancers in a multicentric setting and long-term endpoints such as patient survival,” they concluded.

The study drug and placebo were funded by an intramural grant from Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER). The researchers had no financial conflicts to disclose.

Younger people who experience stroke or intracerebral hemorrhage have about a three- to fivefold increased risk of being diagnosed with cancer in the next few years, new research shows.

In young people, stroke might be the first manifestation of an underlying cancer, according to the investigators, led by Jamie Verhoeven, MD, PhD, with the department of neurology, Radboud University Medical Centre, Nijmegen, the Netherlands.

The new study can be viewed as a “stepping stone for future studies investigating the usefulness of screening for cancer after stroke,” the researchers say.

The study was published online in JAMA Network Open.

Currently, the diagnostic workup for young people with stroke includes searching for rare clotting disorders, although screening for cancer is not regularly performed.

Some research suggests that stroke and cancer are linked, but the literature is limited. In prior studies among people of all ages, cancer incidence after stroke has been variable – from 1% to 5% at 1 year and from 11% to 30% after 10 years.

To the team’s knowledge, only two studies have described the incidence of cancer after stroke among younger patients. One put the risk at 0.5% for people aged 18-50 years in the first year after stroke; the other described a cumulative risk of 17.3% in the 10 years after stroke for patients aged 18-55 years.

Using Dutch data, Dr. Verhoeven and colleagues identified 27,616 young stroke patients (age, 15-49 years; median age, 45 years) and 362,782 older stroke patients (median age, 76 years).

The cumulative incidence of any new cancer at 10 years was 3.7% among the younger stroke patients and 8.5% among the older stroke patients.

The incidence of a new cancer after stroke among younger patients was higher among women than men, while the opposite was true for older stroke patients.

Compared with the general population, younger stroke patients had a more than 2.5-fold greater likelihood of being diagnosed with a new cancer in the first year after ischemic stroke (standardized incidence ratio, 2.6). The risk was highest for lung cancer (SIR, 6.9), followed by hematologic cancers (SIR, 5.2).

Compared with the general population, younger stroke patients had nearly a 5.5-fold greater likelihood of being diagnosed with a new cancer in the first year after intracerebral hemorrhage (SIR, 5.4), and the risk was highest for hematologic cancers (SIR, 14.2).

In younger patients, the cumulative incidence of any cancer decreased over the years but remained significantly higher for 8 years following a stroke.

For patients aged 50 years or older, the 1-year risk for any new cancer after either ischemic stroke or intracerebral hemorrhage was 1.2 times higher, compared with the general population.

“We typically think of occult cancer as being a cause of stroke in an older population, given that the incidence of cancer increases over time [but] what this study shows is that we probably do need to consider occult cancer as an underlying cause of stroke even in a younger population,” said Laura Gioia, MD, stroke neurologist at the University of Montreal, who was not involved in the research.

Dr. Verhoeven and colleagues conclude that their finding supports the hypothesis of a causal link between cancer and stroke. Given the timing between stroke and cancer diagnosis, cancer may have been present when the stroke occurred and possibly played a role in causing it, the authors note. However, conclusions on causal mechanisms cannot be drawn from the current study.

The question of whether young stroke patients should be screened for cancer is a tough one, Dr. Gioia noted. “Cancer represents a small percentage of causes of stroke. That means you would have to screen a lot of people with a benefit that is still uncertain for the moment,” Dr. Gioia said in an interview.

“I think we need to keep cancer in mind as a cause of stroke in our young patients, and that should probably guide our history-taking with the patient and consider imaging when it’s appropriate and when we think that there could be an underlying occult cancer,” Dr. Gioia suggested.

The study was funded in part through unrestricted funding by Stryker, Medtronic, and Cerenovus. Dr. Verhoeven and Dr. Gioia have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Younger people who experience stroke or intracerebral hemorrhage have about a three- to fivefold increased risk of being diagnosed with cancer in the next few years, new research shows.

In young people, stroke might be the first manifestation of an underlying cancer, according to the investigators, led by Jamie Verhoeven, MD, PhD, with the department of neurology, Radboud University Medical Centre, Nijmegen, the Netherlands.

The new study can be viewed as a “stepping stone for future studies investigating the usefulness of screening for cancer after stroke,” the researchers say.

The study was published online in JAMA Network Open.

Currently, the diagnostic workup for young people with stroke includes searching for rare clotting disorders, although screening for cancer is not regularly performed.

Some research suggests that stroke and cancer are linked, but the literature is limited. In prior studies among people of all ages, cancer incidence after stroke has been variable – from 1% to 5% at 1 year and from 11% to 30% after 10 years.

To the team’s knowledge, only two studies have described the incidence of cancer after stroke among younger patients. One put the risk at 0.5% for people aged 18-50 years in the first year after stroke; the other described a cumulative risk of 17.3% in the 10 years after stroke for patients aged 18-55 years.

Using Dutch data, Dr. Verhoeven and colleagues identified 27,616 young stroke patients (age, 15-49 years; median age, 45 years) and 362,782 older stroke patients (median age, 76 years).

The cumulative incidence of any new cancer at 10 years was 3.7% among the younger stroke patients and 8.5% among the older stroke patients.

The incidence of a new cancer after stroke among younger patients was higher among women than men, while the opposite was true for older stroke patients.

Compared with the general population, younger stroke patients had a more than 2.5-fold greater likelihood of being diagnosed with a new cancer in the first year after ischemic stroke (standardized incidence ratio, 2.6). The risk was highest for lung cancer (SIR, 6.9), followed by hematologic cancers (SIR, 5.2).

Compared with the general population, younger stroke patients had nearly a 5.5-fold greater likelihood of being diagnosed with a new cancer in the first year after intracerebral hemorrhage (SIR, 5.4), and the risk was highest for hematologic cancers (SIR, 14.2).

In younger patients, the cumulative incidence of any cancer decreased over the years but remained significantly higher for 8 years following a stroke.

For patients aged 50 years or older, the 1-year risk for any new cancer after either ischemic stroke or intracerebral hemorrhage was 1.2 times higher, compared with the general population.

“We typically think of occult cancer as being a cause of stroke in an older population, given that the incidence of cancer increases over time [but] what this study shows is that we probably do need to consider occult cancer as an underlying cause of stroke even in a younger population,” said Laura Gioia, MD, stroke neurologist at the University of Montreal, who was not involved in the research.

Dr. Verhoeven and colleagues conclude that their finding supports the hypothesis of a causal link between cancer and stroke. Given the timing between stroke and cancer diagnosis, cancer may have been present when the stroke occurred and possibly played a role in causing it, the authors note. However, conclusions on causal mechanisms cannot be drawn from the current study.

The question of whether young stroke patients should be screened for cancer is a tough one, Dr. Gioia noted. “Cancer represents a small percentage of causes of stroke. That means you would have to screen a lot of people with a benefit that is still uncertain for the moment,” Dr. Gioia said in an interview.

“I think we need to keep cancer in mind as a cause of stroke in our young patients, and that should probably guide our history-taking with the patient and consider imaging when it’s appropriate and when we think that there could be an underlying occult cancer,” Dr. Gioia suggested.

The study was funded in part through unrestricted funding by Stryker, Medtronic, and Cerenovus. Dr. Verhoeven and Dr. Gioia have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Younger people who experience stroke or intracerebral hemorrhage have about a three- to fivefold increased risk of being diagnosed with cancer in the next few years, new research shows.

In young people, stroke might be the first manifestation of an underlying cancer, according to the investigators, led by Jamie Verhoeven, MD, PhD, with the department of neurology, Radboud University Medical Centre, Nijmegen, the Netherlands.

The new study can be viewed as a “stepping stone for future studies investigating the usefulness of screening for cancer after stroke,” the researchers say.

The study was published online in JAMA Network Open.

Currently, the diagnostic workup for young people with stroke includes searching for rare clotting disorders, although screening for cancer is not regularly performed.

Some research suggests that stroke and cancer are linked, but the literature is limited. In prior studies among people of all ages, cancer incidence after stroke has been variable – from 1% to 5% at 1 year and from 11% to 30% after 10 years.

To the team’s knowledge, only two studies have described the incidence of cancer after stroke among younger patients. One put the risk at 0.5% for people aged 18-50 years in the first year after stroke; the other described a cumulative risk of 17.3% in the 10 years after stroke for patients aged 18-55 years.

Using Dutch data, Dr. Verhoeven and colleagues identified 27,616 young stroke patients (age, 15-49 years; median age, 45 years) and 362,782 older stroke patients (median age, 76 years).

The cumulative incidence of any new cancer at 10 years was 3.7% among the younger stroke patients and 8.5% among the older stroke patients.

The incidence of a new cancer after stroke among younger patients was higher among women than men, while the opposite was true for older stroke patients.

Compared with the general population, younger stroke patients had a more than 2.5-fold greater likelihood of being diagnosed with a new cancer in the first year after ischemic stroke (standardized incidence ratio, 2.6). The risk was highest for lung cancer (SIR, 6.9), followed by hematologic cancers (SIR, 5.2).

Compared with the general population, younger stroke patients had nearly a 5.5-fold greater likelihood of being diagnosed with a new cancer in the first year after intracerebral hemorrhage (SIR, 5.4), and the risk was highest for hematologic cancers (SIR, 14.2).

In younger patients, the cumulative incidence of any cancer decreased over the years but remained significantly higher for 8 years following a stroke.

For patients aged 50 years or older, the 1-year risk for any new cancer after either ischemic stroke or intracerebral hemorrhage was 1.2 times higher, compared with the general population.

“We typically think of occult cancer as being a cause of stroke in an older population, given that the incidence of cancer increases over time [but] what this study shows is that we probably do need to consider occult cancer as an underlying cause of stroke even in a younger population,” said Laura Gioia, MD, stroke neurologist at the University of Montreal, who was not involved in the research.

Dr. Verhoeven and colleagues conclude that their finding supports the hypothesis of a causal link between cancer and stroke. Given the timing between stroke and cancer diagnosis, cancer may have been present when the stroke occurred and possibly played a role in causing it, the authors note. However, conclusions on causal mechanisms cannot be drawn from the current study.

The question of whether young stroke patients should be screened for cancer is a tough one, Dr. Gioia noted. “Cancer represents a small percentage of causes of stroke. That means you would have to screen a lot of people with a benefit that is still uncertain for the moment,” Dr. Gioia said in an interview.

“I think we need to keep cancer in mind as a cause of stroke in our young patients, and that should probably guide our history-taking with the patient and consider imaging when it’s appropriate and when we think that there could be an underlying occult cancer,” Dr. Gioia suggested.

The study was funded in part through unrestricted funding by Stryker, Medtronic, and Cerenovus. Dr. Verhoeven and Dr. Gioia have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The highly favorable results of the CheckMate 816 trial of neoadjuvant chemotherapy plus nivolumab for resectable stage IB-IIIA non–small cell lung cancer (NSCLC) were impressive enough to prompt a Food and Drug Administration approval of this combination in March 2022.

For many, this led to a marked shift in how we approached these patients. But in my conversations with many care teams, they have expressed ambivalence about using the chemoimmunotherapy regimen. Some have conveyed to me that the lack of statistically significant improvement in overall survival is a sticking point. Others have expressed uncertainty about the true benefit of neoadjuvant chemotherapy alongside nivolumab for patients with earlier-stage disease, given that 64% of patients in the trial had stage IIIA disease. The benefit of the neoadjuvant combination in patients with low or negative tumor programmed death–ligand 1 (PD-L1) expression also remains a question mark, though the trial found no significant differences in outcomes by PD-L1 subset.

But among many of my colleagues who favor adjuvant over neoadjuvant therapy, it isn’t necessarily the fine points of the data that present the real barrier: it’s the sentiment that “we just don’t favor a neoadjuvant approach at my place.”

If the worry is that a subset of patients who are eligible for up-front surgery may be derailed from the operating room if they experience significant disease progression or a complication during preoperative therapy or that surgery will more difficult after chemoimmunotherapy, those concerns are not supported by evidence. In fact, data on surgical outcomes from CheckMate 816 assessing these issues found that surgery after chemoimmunotherapy was approximately 30 minutes faster than it was after chemotherapy alone. In addition, the combination neoadjuvant chemoimmunotherapy approach was associated with less extensive surgeries, particularly for patients with stage IIIA NSCLC, and patients experienced measurably lower reports of pain and dyspnea as well.

Though postoperative systemic therapy has been our general approach for resectable NSCLC for nearly 2 decades, there are several reasons to focus on neoadjuvant therapy.

First, immunotherapy may work more effectively when the tumor antigens as well as lymph nodes and lymphatic system are present in situ at the time.

Second, patients may be eager to complete their treatment within a 3-month period of just three cycles of systemic therapy followed by surgery rather than receiving their treatment over a prolonged chapter of their lives, starting with surgery followed by four cycles of chemotherapy and 1 year of immunotherapy. 

Finally, we can’t ignore the fact that most neoadjuvant therapy is delivered exactly as intended, whereas planned adjuvant therapy is often not started or rarely completed as designed. At most, only about half of appropriate patients for adjuvant chemotherapy even start it, and far less complete a full four cycles or go on to complete prolonged adjuvant immunotherapy.

We also can’t underestimate the value of imaging and pathology findings after patients have completed neoadjuvant therapy. The pathologic complete response rate in CheckMate 816 is predictive of improved event-free survival over time.

And that isn’t just a binary variable of achieving a pathologic complete response or not. The degree of residual, viable tumor after surgery is a continuous variable associated along a spectrum with event-free survival. Our colleagues who treat breast cancer have been able to customize postoperative therapy to improve outcomes on the basis of the results achieved with neoadjuvant therapy. Multidisciplinary gastrointestinal oncology teams have revolutionized outcomes with rectal cancer by transitioning to total neoadjuvant therapy that makes it possible to deliver treatment more reliably and pursue organ-sparing approaches while achieving better survival.

Putting all of this together, I appreciate arguments against the generalizability or the maturity of the data supporting neoadjuvant chemoimmunotherapy for resectable NSCLC. However, sidestepping our most promising advances will harm our patients. Plus, what’s the point of generating practice-changing results if we don’t accept and implement them?

We owe it to our patients to follow the evolving evidence and not just stick to what we’ve always done.

Dr. West is an associate professor at City of Hope Comprehensive Cancer Center in Duarte, Calif., and vice president of network strategy at AccessHope in Los Angeles. Dr. West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing medical education and other educational programs.

A version of this article first appeared on Medscape.com.

The highly favorable results of the CheckMate 816 trial of neoadjuvant chemotherapy plus nivolumab for resectable stage IB-IIIA non–small cell lung cancer (NSCLC) were impressive enough to prompt a Food and Drug Administration approval of this combination in March 2022.

For many, this led to a marked shift in how we approached these patients. But in my conversations with many care teams, they have expressed ambivalence about using the chemoimmunotherapy regimen. Some have conveyed to me that the lack of statistically significant improvement in overall survival is a sticking point. Others have expressed uncertainty about the true benefit of neoadjuvant chemotherapy alongside nivolumab for patients with earlier-stage disease, given that 64% of patients in the trial had stage IIIA disease. The benefit of the neoadjuvant combination in patients with low or negative tumor programmed death–ligand 1 (PD-L1) expression also remains a question mark, though the trial found no significant differences in outcomes by PD-L1 subset.

But among many of my colleagues who favor adjuvant over neoadjuvant therapy, it isn’t necessarily the fine points of the data that present the real barrier: it’s the sentiment that “we just don’t favor a neoadjuvant approach at my place.”

If the worry is that a subset of patients who are eligible for up-front surgery may be derailed from the operating room if they experience significant disease progression or a complication during preoperative therapy or that surgery will more difficult after chemoimmunotherapy, those concerns are not supported by evidence. In fact, data on surgical outcomes from CheckMate 816 assessing these issues found that surgery after chemoimmunotherapy was approximately 30 minutes faster than it was after chemotherapy alone. In addition, the combination neoadjuvant chemoimmunotherapy approach was associated with less extensive surgeries, particularly for patients with stage IIIA NSCLC, and patients experienced measurably lower reports of pain and dyspnea as well.

Though postoperative systemic therapy has been our general approach for resectable NSCLC for nearly 2 decades, there are several reasons to focus on neoadjuvant therapy.

First, immunotherapy may work more effectively when the tumor antigens as well as lymph nodes and lymphatic system are present in situ at the time.

Second, patients may be eager to complete their treatment within a 3-month period of just three cycles of systemic therapy followed by surgery rather than receiving their treatment over a prolonged chapter of their lives, starting with surgery followed by four cycles of chemotherapy and 1 year of immunotherapy. 

Finally, we can’t ignore the fact that most neoadjuvant therapy is delivered exactly as intended, whereas planned adjuvant therapy is often not started or rarely completed as designed. At most, only about half of appropriate patients for adjuvant chemotherapy even start it, and far less complete a full four cycles or go on to complete prolonged adjuvant immunotherapy.

We also can’t underestimate the value of imaging and pathology findings after patients have completed neoadjuvant therapy. The pathologic complete response rate in CheckMate 816 is predictive of improved event-free survival over time.

And that isn’t just a binary variable of achieving a pathologic complete response or not. The degree of residual, viable tumor after surgery is a continuous variable associated along a spectrum with event-free survival. Our colleagues who treat breast cancer have been able to customize postoperative therapy to improve outcomes on the basis of the results achieved with neoadjuvant therapy. Multidisciplinary gastrointestinal oncology teams have revolutionized outcomes with rectal cancer by transitioning to total neoadjuvant therapy that makes it possible to deliver treatment more reliably and pursue organ-sparing approaches while achieving better survival.

Putting all of this together, I appreciate arguments against the generalizability or the maturity of the data supporting neoadjuvant chemoimmunotherapy for resectable NSCLC. However, sidestepping our most promising advances will harm our patients. Plus, what’s the point of generating practice-changing results if we don’t accept and implement them?

We owe it to our patients to follow the evolving evidence and not just stick to what we’ve always done.

Dr. West is an associate professor at City of Hope Comprehensive Cancer Center in Duarte, Calif., and vice president of network strategy at AccessHope in Los Angeles. Dr. West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing medical education and other educational programs.

A version of this article first appeared on Medscape.com.

The highly favorable results of the CheckMate 816 trial of neoadjuvant chemotherapy plus nivolumab for resectable stage IB-IIIA non–small cell lung cancer (NSCLC) were impressive enough to prompt a Food and Drug Administration approval of this combination in March 2022.

For many, this led to a marked shift in how we approached these patients. But in my conversations with many care teams, they have expressed ambivalence about using the chemoimmunotherapy regimen. Some have conveyed to me that the lack of statistically significant improvement in overall survival is a sticking point. Others have expressed uncertainty about the true benefit of neoadjuvant chemotherapy alongside nivolumab for patients with earlier-stage disease, given that 64% of patients in the trial had stage IIIA disease. The benefit of the neoadjuvant combination in patients with low or negative tumor programmed death–ligand 1 (PD-L1) expression also remains a question mark, though the trial found no significant differences in outcomes by PD-L1 subset.

But among many of my colleagues who favor adjuvant over neoadjuvant therapy, it isn’t necessarily the fine points of the data that present the real barrier: it’s the sentiment that “we just don’t favor a neoadjuvant approach at my place.”

If the worry is that a subset of patients who are eligible for up-front surgery may be derailed from the operating room if they experience significant disease progression or a complication during preoperative therapy or that surgery will more difficult after chemoimmunotherapy, those concerns are not supported by evidence. In fact, data on surgical outcomes from CheckMate 816 assessing these issues found that surgery after chemoimmunotherapy was approximately 30 minutes faster than it was after chemotherapy alone. In addition, the combination neoadjuvant chemoimmunotherapy approach was associated with less extensive surgeries, particularly for patients with stage IIIA NSCLC, and patients experienced measurably lower reports of pain and dyspnea as well.

Though postoperative systemic therapy has been our general approach for resectable NSCLC for nearly 2 decades, there are several reasons to focus on neoadjuvant therapy.

First, immunotherapy may work more effectively when the tumor antigens as well as lymph nodes and lymphatic system are present in situ at the time.

Second, patients may be eager to complete their treatment within a 3-month period of just three cycles of systemic therapy followed by surgery rather than receiving their treatment over a prolonged chapter of their lives, starting with surgery followed by four cycles of chemotherapy and 1 year of immunotherapy. 

Finally, we can’t ignore the fact that most neoadjuvant therapy is delivered exactly as intended, whereas planned adjuvant therapy is often not started or rarely completed as designed. At most, only about half of appropriate patients for adjuvant chemotherapy even start it, and far less complete a full four cycles or go on to complete prolonged adjuvant immunotherapy.

We also can’t underestimate the value of imaging and pathology findings after patients have completed neoadjuvant therapy. The pathologic complete response rate in CheckMate 816 is predictive of improved event-free survival over time.

And that isn’t just a binary variable of achieving a pathologic complete response or not. The degree of residual, viable tumor after surgery is a continuous variable associated along a spectrum with event-free survival. Our colleagues who treat breast cancer have been able to customize postoperative therapy to improve outcomes on the basis of the results achieved with neoadjuvant therapy. Multidisciplinary gastrointestinal oncology teams have revolutionized outcomes with rectal cancer by transitioning to total neoadjuvant therapy that makes it possible to deliver treatment more reliably and pursue organ-sparing approaches while achieving better survival.

Putting all of this together, I appreciate arguments against the generalizability or the maturity of the data supporting neoadjuvant chemoimmunotherapy for resectable NSCLC. However, sidestepping our most promising advances will harm our patients. Plus, what’s the point of generating practice-changing results if we don’t accept and implement them?

We owe it to our patients to follow the evolving evidence and not just stick to what we’ve always done.

Dr. West is an associate professor at City of Hope Comprehensive Cancer Center in Duarte, Calif., and vice president of network strategy at AccessHope in Los Angeles. Dr. West serves as web editor for JAMA Oncology, edits and writes several sections on lung cancer for UpToDate, and leads a wide range of continuing medical education and other educational programs.

A version of this article first appeared on Medscape.com.

Patients who are already depressed before they receive a lung cancer diagnosis are more likely to have a worse overall survival (OS), and the driver for this may be inflammation, suggests a new study.

The findings underscore the importance of assessing and treating depression in patients with cancer, particularly given the high rate of depression among those with lung cancer versus other types of cancer, the investigators said.

The study involved 186 patients with newly diagnosed stage IV non–small cell lung cancer (NSCLC), of whom 35% had self-reported moderate to severe depressive symptoms.

Depression was reliably associated with lung-relevant systemic inflammation responses (SIRs), which included neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and Advanced Lung Cancer Inflammation Index (ALI) score.

These SIRs were prognostic for 2-year OS.

Overall mortality at 2 years was 61%. Higher NLRs and PLRs and lower ALI scores all predicted worse OS (hazard ratio, 1.91, 2.08, and 0.53, respectively).

The findings were published online in PLoS ONE (2023 Feb 24.

“These patients with high levels of depression are at much higher risk for poor outcomes,” but the key finding was that patients with the highest depression levels were driving the relationship, lead author Barbara Andersen, PhD, professor of psychology at Ohio State University, Columbus, stated in a press release.

“It was patients with high depression levels who had strikingly higher inflammation levels, and that is what really drove the correlation we saw,” she explained.

For example, 56% of patients with no depression symptoms or only mild depression symptoms had a PLR above the cutoff for dangerous levels of inflammation, compared with 42% whose PLR was below the cutoff. However, among those with high depression levels, 77% and 23% had a PLR above and below the cutoff, respectively.

“These highly depressed patients were 1.3-3 times more likely to have high inflammation levels, even after controlling for other factors related to inflammation biomarker levels, including demographics and smoking status,” Dr. Andersen noted.

“Depression levels may be as important or even more important than other factors that have been associated with how people fare with lung cancer,” she suggested.

In a previous study, the team controlled for baseline depression and found that “the trajectory of depression from diagnosis through 2 years (18 assessments) predicted NSCLC patients’ survival (HR, 1.09), above and beyond baseline depression, sociodemographics, smoking status, cell type, and receipt of targeted treatments and immunotherapies.”

“Taken together, data support psychological, behavioral, and biologic toxicities of depression capable of influencing treatment response and/or survival,” they wrote.

“The results may help explain why a substantial portion of lung cancer patients fail to respond to new immunotherapy and targeted treatments that have led to significantly longer survival for many people with the disease,” Dr. Andersen said.

The investigators concluded that “intensive study of depression among patients with NSCLC, combined with measures of cell biology, inflammation, and immunity, is needed to extend these findings and discover their mechanisms, with the long-term aim to improve patients’ quality of life, treatment responses, and longevity.”

This study was funded by the Ohio State University Comprehensive Cancer Center and Pelotonia through grants to individual authors. Dr. Andersen reported having no relevant disclosures.

A version of this article first appeared on Medscape.com.

Patients who are already depressed before they receive a lung cancer diagnosis are more likely to have a worse overall survival (OS), and the driver for this may be inflammation, suggests a new study.

The findings underscore the importance of assessing and treating depression in patients with cancer, particularly given the high rate of depression among those with lung cancer versus other types of cancer, the investigators said.

The study involved 186 patients with newly diagnosed stage IV non–small cell lung cancer (NSCLC), of whom 35% had self-reported moderate to severe depressive symptoms.

Depression was reliably associated with lung-relevant systemic inflammation responses (SIRs), which included neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and Advanced Lung Cancer Inflammation Index (ALI) score.

These SIRs were prognostic for 2-year OS.

Overall mortality at 2 years was 61%. Higher NLRs and PLRs and lower ALI scores all predicted worse OS (hazard ratio, 1.91, 2.08, and 0.53, respectively).

The findings were published online in PLoS ONE (2023 Feb 24.

“These patients with high levels of depression are at much higher risk for poor outcomes,” but the key finding was that patients with the highest depression levels were driving the relationship, lead author Barbara Andersen, PhD, professor of psychology at Ohio State University, Columbus, stated in a press release.

“It was patients with high depression levels who had strikingly higher inflammation levels, and that is what really drove the correlation we saw,” she explained.

For example, 56% of patients with no depression symptoms or only mild depression symptoms had a PLR above the cutoff for dangerous levels of inflammation, compared with 42% whose PLR was below the cutoff. However, among those with high depression levels, 77% and 23% had a PLR above and below the cutoff, respectively.

“These highly depressed patients were 1.3-3 times more likely to have high inflammation levels, even after controlling for other factors related to inflammation biomarker levels, including demographics and smoking status,” Dr. Andersen noted.

“Depression levels may be as important or even more important than other factors that have been associated with how people fare with lung cancer,” she suggested.

In a previous study, the team controlled for baseline depression and found that “the trajectory of depression from diagnosis through 2 years (18 assessments) predicted NSCLC patients’ survival (HR, 1.09), above and beyond baseline depression, sociodemographics, smoking status, cell type, and receipt of targeted treatments and immunotherapies.”

“Taken together, data support psychological, behavioral, and biologic toxicities of depression capable of influencing treatment response and/or survival,” they wrote.

“The results may help explain why a substantial portion of lung cancer patients fail to respond to new immunotherapy and targeted treatments that have led to significantly longer survival for many people with the disease,” Dr. Andersen said.

The investigators concluded that “intensive study of depression among patients with NSCLC, combined with measures of cell biology, inflammation, and immunity, is needed to extend these findings and discover their mechanisms, with the long-term aim to improve patients’ quality of life, treatment responses, and longevity.”

This study was funded by the Ohio State University Comprehensive Cancer Center and Pelotonia through grants to individual authors. Dr. Andersen reported having no relevant disclosures.

A version of this article first appeared on Medscape.com.

Patients who are already depressed before they receive a lung cancer diagnosis are more likely to have a worse overall survival (OS), and the driver for this may be inflammation, suggests a new study.

The findings underscore the importance of assessing and treating depression in patients with cancer, particularly given the high rate of depression among those with lung cancer versus other types of cancer, the investigators said.

The study involved 186 patients with newly diagnosed stage IV non–small cell lung cancer (NSCLC), of whom 35% had self-reported moderate to severe depressive symptoms.

Depression was reliably associated with lung-relevant systemic inflammation responses (SIRs), which included neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and Advanced Lung Cancer Inflammation Index (ALI) score.

These SIRs were prognostic for 2-year OS.

Overall mortality at 2 years was 61%. Higher NLRs and PLRs and lower ALI scores all predicted worse OS (hazard ratio, 1.91, 2.08, and 0.53, respectively).

The findings were published online in PLoS ONE (2023 Feb 24.

“These patients with high levels of depression are at much higher risk for poor outcomes,” but the key finding was that patients with the highest depression levels were driving the relationship, lead author Barbara Andersen, PhD, professor of psychology at Ohio State University, Columbus, stated in a press release.

“It was patients with high depression levels who had strikingly higher inflammation levels, and that is what really drove the correlation we saw,” she explained.

For example, 56% of patients with no depression symptoms or only mild depression symptoms had a PLR above the cutoff for dangerous levels of inflammation, compared with 42% whose PLR was below the cutoff. However, among those with high depression levels, 77% and 23% had a PLR above and below the cutoff, respectively.

“These highly depressed patients were 1.3-3 times more likely to have high inflammation levels, even after controlling for other factors related to inflammation biomarker levels, including demographics and smoking status,” Dr. Andersen noted.

“Depression levels may be as important or even more important than other factors that have been associated with how people fare with lung cancer,” she suggested.

In a previous study, the team controlled for baseline depression and found that “the trajectory of depression from diagnosis through 2 years (18 assessments) predicted NSCLC patients’ survival (HR, 1.09), above and beyond baseline depression, sociodemographics, smoking status, cell type, and receipt of targeted treatments and immunotherapies.”

“Taken together, data support psychological, behavioral, and biologic toxicities of depression capable of influencing treatment response and/or survival,” they wrote.

“The results may help explain why a substantial portion of lung cancer patients fail to respond to new immunotherapy and targeted treatments that have led to significantly longer survival for many people with the disease,” Dr. Andersen said.

The investigators concluded that “intensive study of depression among patients with NSCLC, combined with measures of cell biology, inflammation, and immunity, is needed to extend these findings and discover their mechanisms, with the long-term aim to improve patients’ quality of life, treatment responses, and longevity.”

This study was funded by the Ohio State University Comprehensive Cancer Center and Pelotonia through grants to individual authors. Dr. Andersen reported having no relevant disclosures.

A version of this article first appeared on Medscape.com.