Lung Cancer

Key clinical point: In a real-world cohort of patients with advanced non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitor (ICI) monotherapy, the 4-year overall survival (OS) was nearly 18%.

Major finding: The mean progression-free survival (PFS) was 3.4 months and OS was 13.0 months. The 4-year OS rate was 17.9%. The predictors of favorable OS and PFS included age >70 years, a good Eastern Cooperative Oncology Group Performance Status score, programmed cell death-ligand 1 tumor proportion score of ≥50%, absence of bone metastasis, and presence of immune-related skin toxicity.

Study details: The data come from a real-world retrospective cohort study of 435 patients diagnosed with advanced, metastatic, or recurrent NSCLC and treated with ICI monotherapy across seven Japanese centers (2015-2018).

Disclosures: No information on funding and disclosures was available.

Source: Yoneda T et al. Long-term survival of patients with non-small cell lung cancer treated with immune checkpoint inhibitor monotherapy in real-world settings. Clin Lung Cancer. 2022 (May 1). Doi: 10.1016/j.cllc.2022.03.008

Key clinical point: In a real-world cohort of patients with advanced non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitor (ICI) monotherapy, the 4-year overall survival (OS) was nearly 18%.

Major finding: The mean progression-free survival (PFS) was 3.4 months and OS was 13.0 months. The 4-year OS rate was 17.9%. The predictors of favorable OS and PFS included age >70 years, a good Eastern Cooperative Oncology Group Performance Status score, programmed cell death-ligand 1 tumor proportion score of ≥50%, absence of bone metastasis, and presence of immune-related skin toxicity.

Study details: The data come from a real-world retrospective cohort study of 435 patients diagnosed with advanced, metastatic, or recurrent NSCLC and treated with ICI monotherapy across seven Japanese centers (2015-2018).

Disclosures: No information on funding and disclosures was available.

Source: Yoneda T et al. Long-term survival of patients with non-small cell lung cancer treated with immune checkpoint inhibitor monotherapy in real-world settings. Clin Lung Cancer. 2022 (May 1). Doi: 10.1016/j.cllc.2022.03.008

Key clinical point: In a real-world cohort of patients with advanced non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitor (ICI) monotherapy, the 4-year overall survival (OS) was nearly 18%.

Major finding: The mean progression-free survival (PFS) was 3.4 months and OS was 13.0 months. The 4-year OS rate was 17.9%. The predictors of favorable OS and PFS included age >70 years, a good Eastern Cooperative Oncology Group Performance Status score, programmed cell death-ligand 1 tumor proportion score of ≥50%, absence of bone metastasis, and presence of immune-related skin toxicity.

Study details: The data come from a real-world retrospective cohort study of 435 patients diagnosed with advanced, metastatic, or recurrent NSCLC and treated with ICI monotherapy across seven Japanese centers (2015-2018).

Disclosures: No information on funding and disclosures was available.

Source: Yoneda T et al. Long-term survival of patients with non-small cell lung cancer treated with immune checkpoint inhibitor monotherapy in real-world settings. Clin Lung Cancer. 2022 (May 1). Doi: 10.1016/j.cllc.2022.03.008

Key clinical point: Anticoagulant use is linked to worse progression-free survival (PFS) and objective response rate (ORR) in patients with ALK- and ROS1-rearranged advanced nonsmall cell lung cancer (NSCLC) treated with crizotinib.

Major finding: In the ROS1-rearranged group, anticoagulant use vs no use was associated with a shorter median PFS (5.1 vs 29 months) and poorer ORR (41.7% vs 80.5%). Similarly, in the ALK-rearranged group, anticoagulant use vs no use was associated with a shorter median PFS (7.1 vs 12 months) and poorer ORR (41% vs 74.3%).

Study details: The data come from a retrospective analysis of patients with ROS1- and ALK-rearranged advanced NSCLC (n = 206) who received crizotinib in the phase 1 PROFILE 1001 trial.

Disclosures: The study was funded by Pfizer. The authors reported receiving grants or personal fees from one or more pharmaceutical companies, including Pfizer, outside this work.

Source: Ng TL, Tsui DCC, et al. Association of anticoagulant use with clinical outcomes from crizotinib in ALK- and ROS1-rearranged advanced non-small cell lung cancers: A retrospective analysis of PROFILE 1001. Cancer Med. 2022 (May 5). Doi: 10.1002/cam4.4789

Key clinical point: Anticoagulant use is linked to worse progression-free survival (PFS) and objective response rate (ORR) in patients with ALK- and ROS1-rearranged advanced nonsmall cell lung cancer (NSCLC) treated with crizotinib.

Major finding: In the ROS1-rearranged group, anticoagulant use vs no use was associated with a shorter median PFS (5.1 vs 29 months) and poorer ORR (41.7% vs 80.5%). Similarly, in the ALK-rearranged group, anticoagulant use vs no use was associated with a shorter median PFS (7.1 vs 12 months) and poorer ORR (41% vs 74.3%).

Study details: The data come from a retrospective analysis of patients with ROS1- and ALK-rearranged advanced NSCLC (n = 206) who received crizotinib in the phase 1 PROFILE 1001 trial.

Disclosures: The study was funded by Pfizer. The authors reported receiving grants or personal fees from one or more pharmaceutical companies, including Pfizer, outside this work.

Source: Ng TL, Tsui DCC, et al. Association of anticoagulant use with clinical outcomes from crizotinib in ALK- and ROS1-rearranged advanced non-small cell lung cancers: A retrospective analysis of PROFILE 1001. Cancer Med. 2022 (May 5). Doi: 10.1002/cam4.4789

Key clinical point: Anticoagulant use is linked to worse progression-free survival (PFS) and objective response rate (ORR) in patients with ALK- and ROS1-rearranged advanced nonsmall cell lung cancer (NSCLC) treated with crizotinib.

Major finding: In the ROS1-rearranged group, anticoagulant use vs no use was associated with a shorter median PFS (5.1 vs 29 months) and poorer ORR (41.7% vs 80.5%). Similarly, in the ALK-rearranged group, anticoagulant use vs no use was associated with a shorter median PFS (7.1 vs 12 months) and poorer ORR (41% vs 74.3%).

Study details: The data come from a retrospective analysis of patients with ROS1- and ALK-rearranged advanced NSCLC (n = 206) who received crizotinib in the phase 1 PROFILE 1001 trial.

Disclosures: The study was funded by Pfizer. The authors reported receiving grants or personal fees from one or more pharmaceutical companies, including Pfizer, outside this work.

Source: Ng TL, Tsui DCC, et al. Association of anticoagulant use with clinical outcomes from crizotinib in ALK- and ROS1-rearranged advanced non-small cell lung cancers: A retrospective analysis of PROFILE 1001. Cancer Med. 2022 (May 5). Doi: 10.1002/cam4.4789

Key clinical point: Noncachexic patients with advanced nonsmall cell lung cancer (NSCLC) and adipose tissue loss may respond more favorably to immunotherapy.

Major finding: Cachexic patients with loss and maintenance of adipose tissue showed no significant differences in the objective response rate (ORR) and progression-free survival (PFS). Noncachexic patients with loss vs maintenance of adipose tissue demonstrated a higher ORR (64.7% vs 23.5%; P < .05) and longer PFS (18.5 vs 2.86 months; P = .037) in response to immunotherapy.

Study details: The data come from a single-center retrospective cohort study involving patients with advanced NSCLC (40 with cachexia and 34 without cachexia) who received programmed cell death-1/programmed cell death-ligand 1 inhibitors (pembrolizumab, nivolumab, or atezolizumab).

Disclosures: The study was funded by the Japan Agency for Medical Research and Development. The authors reported ties with one or more pharmaceutical companies outside this work.

Source: Nishioka N et al. Impact of losing adipose tissue on outcomes from PD-1/PD-L1 inhibitor monotherapy in non-small cell lung cancer. Thorac Cancer. 2022;13(10):1496-1504 (Apr 14). Doi: 10.1111/1759-7714.14421

Key clinical point: Noncachexic patients with advanced nonsmall cell lung cancer (NSCLC) and adipose tissue loss may respond more favorably to immunotherapy.

Major finding: Cachexic patients with loss and maintenance of adipose tissue showed no significant differences in the objective response rate (ORR) and progression-free survival (PFS). Noncachexic patients with loss vs maintenance of adipose tissue demonstrated a higher ORR (64.7% vs 23.5%; P < .05) and longer PFS (18.5 vs 2.86 months; P = .037) in response to immunotherapy.

Study details: The data come from a single-center retrospective cohort study involving patients with advanced NSCLC (40 with cachexia and 34 without cachexia) who received programmed cell death-1/programmed cell death-ligand 1 inhibitors (pembrolizumab, nivolumab, or atezolizumab).

Disclosures: The study was funded by the Japan Agency for Medical Research and Development. The authors reported ties with one or more pharmaceutical companies outside this work.

Source: Nishioka N et al. Impact of losing adipose tissue on outcomes from PD-1/PD-L1 inhibitor monotherapy in non-small cell lung cancer. Thorac Cancer. 2022;13(10):1496-1504 (Apr 14). Doi: 10.1111/1759-7714.14421

Key clinical point: Noncachexic patients with advanced nonsmall cell lung cancer (NSCLC) and adipose tissue loss may respond more favorably to immunotherapy.

Major finding: Cachexic patients with loss and maintenance of adipose tissue showed no significant differences in the objective response rate (ORR) and progression-free survival (PFS). Noncachexic patients with loss vs maintenance of adipose tissue demonstrated a higher ORR (64.7% vs 23.5%; P < .05) and longer PFS (18.5 vs 2.86 months; P = .037) in response to immunotherapy.

Study details: The data come from a single-center retrospective cohort study involving patients with advanced NSCLC (40 with cachexia and 34 without cachexia) who received programmed cell death-1/programmed cell death-ligand 1 inhibitors (pembrolizumab, nivolumab, or atezolizumab).

Disclosures: The study was funded by the Japan Agency for Medical Research and Development. The authors reported ties with one or more pharmaceutical companies outside this work.

Source: Nishioka N et al. Impact of losing adipose tissue on outcomes from PD-1/PD-L1 inhibitor monotherapy in non-small cell lung cancer. Thorac Cancer. 2022;13(10):1496-1504 (Apr 14). Doi: 10.1111/1759-7714.14421

Key clinical point: The addition of nivolumab to neoadjuvant chemotherapy is more efficacious than and comparably safe compared to chemotherapy alone in patients with stage IB-IIIA resectable nonsmall cell lung cancer (NSCLC).

Major finding: The nivolumab plus chemotherapy vs chemotherapy-alone group demonstrated longer event-free survival (31.6 vs 20.8 months; hazard ratio 0.63; P = .005) and had a higher proportion of patients achieving pathological complete response (24.0% vs 2.2%; odds ratio 13.94; P < .001). The rates of grade 3/4 treatment-related adverse events were comparable between the groups (33.5% vs 36.9%).

Study details: The data come from an open-label phase 3 CheckMate 816 trial which included patients with resectable NSCLC who were randomly assigned to receive neoadjuvant nivolumab plus platinum-doublet chemotherapy (n = 179) or platinum-doublet chemotherapy alone (n = 179).

Disclosures: The trial was funded by Bristol Myers Squibb. The authors reported ties with one or more pharmaceutical companies outside this work, including Bristol Myers Squibb.

Source: Forde PM et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022 (Apr 11). Doi: 10.1056/NEJMoa2202170

Key clinical point: The addition of nivolumab to neoadjuvant chemotherapy is more efficacious than and comparably safe compared to chemotherapy alone in patients with stage IB-IIIA resectable nonsmall cell lung cancer (NSCLC).

Major finding: The nivolumab plus chemotherapy vs chemotherapy-alone group demonstrated longer event-free survival (31.6 vs 20.8 months; hazard ratio 0.63; P = .005) and had a higher proportion of patients achieving pathological complete response (24.0% vs 2.2%; odds ratio 13.94; P < .001). The rates of grade 3/4 treatment-related adverse events were comparable between the groups (33.5% vs 36.9%).

Study details: The data come from an open-label phase 3 CheckMate 816 trial which included patients with resectable NSCLC who were randomly assigned to receive neoadjuvant nivolumab plus platinum-doublet chemotherapy (n = 179) or platinum-doublet chemotherapy alone (n = 179).

Disclosures: The trial was funded by Bristol Myers Squibb. The authors reported ties with one or more pharmaceutical companies outside this work, including Bristol Myers Squibb.

Source: Forde PM et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022 (Apr 11). Doi: 10.1056/NEJMoa2202170

Key clinical point: The addition of nivolumab to neoadjuvant chemotherapy is more efficacious than and comparably safe compared to chemotherapy alone in patients with stage IB-IIIA resectable nonsmall cell lung cancer (NSCLC).

Major finding: The nivolumab plus chemotherapy vs chemotherapy-alone group demonstrated longer event-free survival (31.6 vs 20.8 months; hazard ratio 0.63; P = .005) and had a higher proportion of patients achieving pathological complete response (24.0% vs 2.2%; odds ratio 13.94; P < .001). The rates of grade 3/4 treatment-related adverse events were comparable between the groups (33.5% vs 36.9%).

Study details: The data come from an open-label phase 3 CheckMate 816 trial which included patients with resectable NSCLC who were randomly assigned to receive neoadjuvant nivolumab plus platinum-doublet chemotherapy (n = 179) or platinum-doublet chemotherapy alone (n = 179).

Disclosures: The trial was funded by Bristol Myers Squibb. The authors reported ties with one or more pharmaceutical companies outside this work, including Bristol Myers Squibb.

Source: Forde PM et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med. 2022 (Apr 11). Doi: 10.1056/NEJMoa2202170

Some smokers might not get lung cancer because of their DNA, researchers report in a new study.

These people have genes that help limit mutations to DNA that would turn cells malignant and make them grow into tumors, the researchers say.

Scientists have long suspected that smoking leads to lung cancer by triggering DNA mutations in healthy cells. But it was hard for them to identify the mutations in healthy cells that might help predict future cancer risk, Jan Vijg, PhD, a senior author of the study and researcher at the University School of Medicine, Shanghai, China, said in a statement.

His team used a process called single-cell whole genome sequencing to examine cells lining the lungs of 19 smokers and 14 nonsmokers ranging in age from their pre-teens to their mid-80s. The cells came from patients who had tissue samples collected from their lungs during diagnostic testing unrelated to cancer. The scientists reported their findings in Nature Genetics.

The researchers specifically looked at cells lining the lungs because these cells can survive for years and build up mutations over time that are linked to aging and smoking.

“Of all the lung’s cell types, these are among the most likely to become cancerous,” says Simon Spivack, MD, a senior author of the study and professor at the Albert Einstein College of Medicine, New York.

Smokers had far more gene mutations that can cause lung cancer than nonsmokers, the analysis found.

“This experimentally confirms that smoking increases lung cancer risk by increasing the frequency of mutations, as previously hypothesized,” says Dr. Spivack. “This is likely one reason why so few nonsmokers get lung cancer, while 10 to 20 percent of lifelong smokers do.”

Among the smokers, people had smoked a maximum of 116 pack-years. A pack-year is the equivalent of smoking one pack a day for a year. The number of mutations detected in smokers’ lung cells increased in direct proportion to the number of pack-years they smoked.

But after 23 pack-years, the lung cells in smokers didn’t appear to add more mutations, the researchers report, suggesting that some people’s genes might make them more likely to fight mutations.

“The heaviest smokers did not have the highest mutation burden,” says Dr. Spivack. “Our data suggest that these individuals may have survived for so long in spite of their heavy smoking because they managed to suppress further mutation accumulation.”

While it’s possible these findings could one day help doctors come up with better ways to screen for lung cancer and treat the disease, that’s still a long way off. Many more lab tests and larger studies will be needed to better pinpoint which smokers might be more prone to lung cancer and why.

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

Some smokers might not get lung cancer because of their DNA, researchers report in a new study.

These people have genes that help limit mutations to DNA that would turn cells malignant and make them grow into tumors, the researchers say.

Scientists have long suspected that smoking leads to lung cancer by triggering DNA mutations in healthy cells. But it was hard for them to identify the mutations in healthy cells that might help predict future cancer risk, Jan Vijg, PhD, a senior author of the study and researcher at the University School of Medicine, Shanghai, China, said in a statement.

His team used a process called single-cell whole genome sequencing to examine cells lining the lungs of 19 smokers and 14 nonsmokers ranging in age from their pre-teens to their mid-80s. The cells came from patients who had tissue samples collected from their lungs during diagnostic testing unrelated to cancer. The scientists reported their findings in Nature Genetics.

The researchers specifically looked at cells lining the lungs because these cells can survive for years and build up mutations over time that are linked to aging and smoking.

“Of all the lung’s cell types, these are among the most likely to become cancerous,” says Simon Spivack, MD, a senior author of the study and professor at the Albert Einstein College of Medicine, New York.

Smokers had far more gene mutations that can cause lung cancer than nonsmokers, the analysis found.

“This experimentally confirms that smoking increases lung cancer risk by increasing the frequency of mutations, as previously hypothesized,” says Dr. Spivack. “This is likely one reason why so few nonsmokers get lung cancer, while 10 to 20 percent of lifelong smokers do.”

Among the smokers, people had smoked a maximum of 116 pack-years. A pack-year is the equivalent of smoking one pack a day for a year. The number of mutations detected in smokers’ lung cells increased in direct proportion to the number of pack-years they smoked.

But after 23 pack-years, the lung cells in smokers didn’t appear to add more mutations, the researchers report, suggesting that some people’s genes might make them more likely to fight mutations.

“The heaviest smokers did not have the highest mutation burden,” says Dr. Spivack. “Our data suggest that these individuals may have survived for so long in spite of their heavy smoking because they managed to suppress further mutation accumulation.”

While it’s possible these findings could one day help doctors come up with better ways to screen for lung cancer and treat the disease, that’s still a long way off. Many more lab tests and larger studies will be needed to better pinpoint which smokers might be more prone to lung cancer and why.

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

Some smokers might not get lung cancer because of their DNA, researchers report in a new study.

These people have genes that help limit mutations to DNA that would turn cells malignant and make them grow into tumors, the researchers say.

Scientists have long suspected that smoking leads to lung cancer by triggering DNA mutations in healthy cells. But it was hard for them to identify the mutations in healthy cells that might help predict future cancer risk, Jan Vijg, PhD, a senior author of the study and researcher at the University School of Medicine, Shanghai, China, said in a statement.

His team used a process called single-cell whole genome sequencing to examine cells lining the lungs of 19 smokers and 14 nonsmokers ranging in age from their pre-teens to their mid-80s. The cells came from patients who had tissue samples collected from their lungs during diagnostic testing unrelated to cancer. The scientists reported their findings in Nature Genetics.

The researchers specifically looked at cells lining the lungs because these cells can survive for years and build up mutations over time that are linked to aging and smoking.

“Of all the lung’s cell types, these are among the most likely to become cancerous,” says Simon Spivack, MD, a senior author of the study and professor at the Albert Einstein College of Medicine, New York.

Smokers had far more gene mutations that can cause lung cancer than nonsmokers, the analysis found.

“This experimentally confirms that smoking increases lung cancer risk by increasing the frequency of mutations, as previously hypothesized,” says Dr. Spivack. “This is likely one reason why so few nonsmokers get lung cancer, while 10 to 20 percent of lifelong smokers do.”

Among the smokers, people had smoked a maximum of 116 pack-years. A pack-year is the equivalent of smoking one pack a day for a year. The number of mutations detected in smokers’ lung cells increased in direct proportion to the number of pack-years they smoked.

But after 23 pack-years, the lung cells in smokers didn’t appear to add more mutations, the researchers report, suggesting that some people’s genes might make them more likely to fight mutations.

“The heaviest smokers did not have the highest mutation burden,” says Dr. Spivack. “Our data suggest that these individuals may have survived for so long in spite of their heavy smoking because they managed to suppress further mutation accumulation.”

While it’s possible these findings could one day help doctors come up with better ways to screen for lung cancer and treat the disease, that’s still a long way off. Many more lab tests and larger studies will be needed to better pinpoint which smokers might be more prone to lung cancer and why.

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

In states that adopted Medicaid expansion following the implementation of the Affordable Care Act (ACA), patients with cancer have improved 2-year overall survival rates, compared with patients in states that did not adopt the expansion.

The finding comes from an American Cancer Society study of more than 2 million patients with newly diagnosed cancer, published online in the Journal of the National Cancer Institute.

The analysis also showed that the evidence was strongest for malignancies with poor prognosis such as lung, pancreatic, and liver cancer, and also for colorectal cancer.

Importantly, improvements in survival were larger in non-Hispanic Black patients and individuals residing in rural areas, suggesting there was a narrowing of disparities in cancer survival by race and rurality.

“Our findings provide further evidence of the importance of expanding Medicaid eligibility in all states, particularly considering the economic crisis and health care disruptions caused by the COVID-19 pandemic,” said lead author Xuesong Han, PhD, scientific director of health services research at the American Cancer Society, in a statement. “What’s encouraging is the American Rescue Plan Act of 2021 provides new incentives for Medicaid expansion in states that have yet to increase eligibility.”

The ACA provided states with incentives to expand Medicaid eligibility to all low-income adults under 138% federal poverty level, regardless of parental status.

As of last month, just 12 states have not yet opted for Medicaid expansion, even though the American Rescue Plan Act of 2021 provides new incentives for those remaining jurisdictions. But to date, none of the remaining states have taken advantage of these new incentives.

An interactive map showing the status of Medicare expansion by state is available here. The 12 states that have not adopted Medicare expansion (as of April) are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.  

The benefit of Medicaid expansion on cancer outcomes has already been observed in other studies. The first study to show a survival benefit was presented at the 2020 American Society of Clinical Oncology annual meeting. That analysis showed that cancer mortality declined by 29% in states that expanded Medicaid and by 25% in those that did not. The authors also noted that the greatest mortality benefit was observed in Hispanic patients.
 

Improved survival with expansion

In the current paper, Dr. Han and colleagues used population-based cancer registries from 42 states and compared data on patients aged 18-62 years who were diagnosed with cancer in a period of 2 years before (2010-2012) and after (2014-2016) ACA Medicaid expansion. They were followed through Sept. 30, 2013, and Dec. 31, 2017, respectively.

The analysis involved a total of 2.5 million patients, of whom 1.52 million lived in states that adopted Medicaid expansion and compared with 1 million patients were in states that did not.

Patients with grouped by sex, race and ethnicity, census tract-level poverty, and rurality. The authors note that non-Hispanic Black patients and those from high poverty areas and nonmetropolitan areas were disproportionately represented in nonexpansion states. 

During the 2-year follow-up period, a total of 453,487 deaths occurred (257,950 in expansion states and 195,537 in nonexpansion states).

Overall, patients in expansion states generally had better survival versus those in nonexpansion states, the authors comment. However, for most cancer types, overall survival improved after the ACA for both groups of states.

The 2-year overall survival increased from 80.6% before the ACA to 82.2% post ACA in expansion states and from 78.7% to 80% in nonexpansion states.

This extrapolated to net increase of 0.44 percentage points in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer, lung cancer, non-Hodgkin’s lymphoma, pancreatic cancer, and liver cancer.

For Hispanic patients, 2-year survival also increased but was similar in expansion and nonexpansion states, and little net change was associated with Medicaid expansion.

“Our study shows that the increase was largely driven by improvements in survival for cancer types with poor prognosis, suggesting improved access to timely and effective treatments,” said Dr. Han. “It adds to accumulating evidence of the multiple benefits of Medicaid expansion.”

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

In states that adopted Medicaid expansion following the implementation of the Affordable Care Act (ACA), patients with cancer have improved 2-year overall survival rates, compared with patients in states that did not adopt the expansion.

The finding comes from an American Cancer Society study of more than 2 million patients with newly diagnosed cancer, published online in the Journal of the National Cancer Institute.

The analysis also showed that the evidence was strongest for malignancies with poor prognosis such as lung, pancreatic, and liver cancer, and also for colorectal cancer.

Importantly, improvements in survival were larger in non-Hispanic Black patients and individuals residing in rural areas, suggesting there was a narrowing of disparities in cancer survival by race and rurality.

“Our findings provide further evidence of the importance of expanding Medicaid eligibility in all states, particularly considering the economic crisis and health care disruptions caused by the COVID-19 pandemic,” said lead author Xuesong Han, PhD, scientific director of health services research at the American Cancer Society, in a statement. “What’s encouraging is the American Rescue Plan Act of 2021 provides new incentives for Medicaid expansion in states that have yet to increase eligibility.”

The ACA provided states with incentives to expand Medicaid eligibility to all low-income adults under 138% federal poverty level, regardless of parental status.

As of last month, just 12 states have not yet opted for Medicaid expansion, even though the American Rescue Plan Act of 2021 provides new incentives for those remaining jurisdictions. But to date, none of the remaining states have taken advantage of these new incentives.

An interactive map showing the status of Medicare expansion by state is available here. The 12 states that have not adopted Medicare expansion (as of April) are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.  

The benefit of Medicaid expansion on cancer outcomes has already been observed in other studies. The first study to show a survival benefit was presented at the 2020 American Society of Clinical Oncology annual meeting. That analysis showed that cancer mortality declined by 29% in states that expanded Medicaid and by 25% in those that did not. The authors also noted that the greatest mortality benefit was observed in Hispanic patients.
 

Improved survival with expansion

In the current paper, Dr. Han and colleagues used population-based cancer registries from 42 states and compared data on patients aged 18-62 years who were diagnosed with cancer in a period of 2 years before (2010-2012) and after (2014-2016) ACA Medicaid expansion. They were followed through Sept. 30, 2013, and Dec. 31, 2017, respectively.

The analysis involved a total of 2.5 million patients, of whom 1.52 million lived in states that adopted Medicaid expansion and compared with 1 million patients were in states that did not.

Patients with grouped by sex, race and ethnicity, census tract-level poverty, and rurality. The authors note that non-Hispanic Black patients and those from high poverty areas and nonmetropolitan areas were disproportionately represented in nonexpansion states. 

During the 2-year follow-up period, a total of 453,487 deaths occurred (257,950 in expansion states and 195,537 in nonexpansion states).

Overall, patients in expansion states generally had better survival versus those in nonexpansion states, the authors comment. However, for most cancer types, overall survival improved after the ACA for both groups of states.

The 2-year overall survival increased from 80.6% before the ACA to 82.2% post ACA in expansion states and from 78.7% to 80% in nonexpansion states.

This extrapolated to net increase of 0.44 percentage points in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer, lung cancer, non-Hodgkin’s lymphoma, pancreatic cancer, and liver cancer.

For Hispanic patients, 2-year survival also increased but was similar in expansion and nonexpansion states, and little net change was associated with Medicaid expansion.

“Our study shows that the increase was largely driven by improvements in survival for cancer types with poor prognosis, suggesting improved access to timely and effective treatments,” said Dr. Han. “It adds to accumulating evidence of the multiple benefits of Medicaid expansion.”

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

In states that adopted Medicaid expansion following the implementation of the Affordable Care Act (ACA), patients with cancer have improved 2-year overall survival rates, compared with patients in states that did not adopt the expansion.

The finding comes from an American Cancer Society study of more than 2 million patients with newly diagnosed cancer, published online in the Journal of the National Cancer Institute.

The analysis also showed that the evidence was strongest for malignancies with poor prognosis such as lung, pancreatic, and liver cancer, and also for colorectal cancer.

Importantly, improvements in survival were larger in non-Hispanic Black patients and individuals residing in rural areas, suggesting there was a narrowing of disparities in cancer survival by race and rurality.

“Our findings provide further evidence of the importance of expanding Medicaid eligibility in all states, particularly considering the economic crisis and health care disruptions caused by the COVID-19 pandemic,” said lead author Xuesong Han, PhD, scientific director of health services research at the American Cancer Society, in a statement. “What’s encouraging is the American Rescue Plan Act of 2021 provides new incentives for Medicaid expansion in states that have yet to increase eligibility.”

The ACA provided states with incentives to expand Medicaid eligibility to all low-income adults under 138% federal poverty level, regardless of parental status.

As of last month, just 12 states have not yet opted for Medicaid expansion, even though the American Rescue Plan Act of 2021 provides new incentives for those remaining jurisdictions. But to date, none of the remaining states have taken advantage of these new incentives.

An interactive map showing the status of Medicare expansion by state is available here. The 12 states that have not adopted Medicare expansion (as of April) are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.  

The benefit of Medicaid expansion on cancer outcomes has already been observed in other studies. The first study to show a survival benefit was presented at the 2020 American Society of Clinical Oncology annual meeting. That analysis showed that cancer mortality declined by 29% in states that expanded Medicaid and by 25% in those that did not. The authors also noted that the greatest mortality benefit was observed in Hispanic patients.
 

Improved survival with expansion

In the current paper, Dr. Han and colleagues used population-based cancer registries from 42 states and compared data on patients aged 18-62 years who were diagnosed with cancer in a period of 2 years before (2010-2012) and after (2014-2016) ACA Medicaid expansion. They were followed through Sept. 30, 2013, and Dec. 31, 2017, respectively.

The analysis involved a total of 2.5 million patients, of whom 1.52 million lived in states that adopted Medicaid expansion and compared with 1 million patients were in states that did not.

Patients with grouped by sex, race and ethnicity, census tract-level poverty, and rurality. The authors note that non-Hispanic Black patients and those from high poverty areas and nonmetropolitan areas were disproportionately represented in nonexpansion states. 

During the 2-year follow-up period, a total of 453,487 deaths occurred (257,950 in expansion states and 195,537 in nonexpansion states).

Overall, patients in expansion states generally had better survival versus those in nonexpansion states, the authors comment. However, for most cancer types, overall survival improved after the ACA for both groups of states.

The 2-year overall survival increased from 80.6% before the ACA to 82.2% post ACA in expansion states and from 78.7% to 80% in nonexpansion states.

This extrapolated to net increase of 0.44 percentage points in expansion states after adjusting for sociodemographic factors. By cancer site, the net increase was greater for colorectal cancer, lung cancer, non-Hodgkin’s lymphoma, pancreatic cancer, and liver cancer.

For Hispanic patients, 2-year survival also increased but was similar in expansion and nonexpansion states, and little net change was associated with Medicaid expansion.

“Our study shows that the increase was largely driven by improvements in survival for cancer types with poor prognosis, suggesting improved access to timely and effective treatments,” said Dr. Han. “It adds to accumulating evidence of the multiple benefits of Medicaid expansion.”

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

Lung cancer is the leading cause of cancer death in the United States.¹ The 2011 National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening provided a 20% relative reduction in lung cancer–specific mortality.² Based on these findings, the United States Preventive Services Task Force (USPSTF) published lung cancer screening guidelines in 2013 recommending an annual LDCT of the thorax in patients aged 55 to 80 years with a 30 pack-year smoking history and who currently smoke or quit within the past 15 years. 

In 2021, the USPSTF updated its recommendations by reducing the qualifications for annual screening to a 20 pack-year smoking history.³ The updated guidelines recognized the increased risk of lung cancer for Black individuals.^4,5 Evidence suggests the 2013 screening criteria was too conservative for this population.^6,7

Similarly, US Department of Veteran Affairs (VA) patients are a population at higher risk for lung cancer due to a male predominance, presence of comorbidities, exposure to carcinogenic agents, and possibly a higher prevalence of tobacco smoking.⁸ This study sought to examine the applicability of the USPSTF guidelines in a VA health care system with a predominantly Black population.

Methods

A retrospective chart review of adult patients who were diagnosed and treated with early-stage small cell or non–small cell lung cancer (stage I or II) was performed within the Southeast Louisiana Veterans Health Care System (SLVHCS) in New Orleans. The review used data from the VA Cancer Registry from January 1, 2005, through December 31, 2017. Patients were grouped by whether they met 2013 USPSTF screening criteria at time of diagnosis vs those that did not. Data collected included type and stage of lung cancer at time of diagnosis, context of diagnosis (incidental, screening, symptomatic), diagnostic method, smoking history, and presence of chronic obstructive pulmonary disease (COPD). Patients without a clear smoking history documented in the health record were excluded.

Statistical analyses were performed with GraphPad Prism 8.0. Student t test and Fischer exact test were performed for most of the statistical analyses, with differences between groups noted to be statistically significant at a P < .05.

Results

A total of 182 patient charts were reviewed and 13 patients were excluded for missing information related to the USPSTF screening criteria. Of the 169 patients included, 122 (72%) met USPSTF screening criteria while 47 (28%) patients did not. The reasons for not meeting screening criteria were 14 patients were too young at and 9 patients were too old at time of diagnosis, 7 had a < 20 pack-year smoking history, 7 patients had quit > 15 years previously, and 12 patients met multiple exclusion criteria. The study population was 96% male and there was an overall predominance of Black patients (58%) within the sample (Table).

There was a significantly higher proportion of Black patients in the group that did not meet screening criteria compared with the group that met screening criteria (68% vs 54%, P = .04). Cancer type and stage at diagnosis were similar in both patient populations. There was a statistically significant difference in COPD diagnosis between the groups, with a larger proportion of COPD patients in the met screening criteria group (74% vs 45%, P < .001). The mean smoking history was 61.4 pack-years in the met criteria group and 43.3 pack-years in the did not meet criteria group.  

Five additional patients in the group that did not meet the 2013 USPSTF screening criteria would have met criteria if the 2021 USPSTF guidelines were applied. All 5 were Black patients. Using the 2021 guidelines, Black patients would have made up 56% of the patients who met screening criteria and 54% of the patients who did not meet screening criteria at time of diagnosis.

Discussion

This study sought to determine the hypothetical effectiveness of national lung cancer screening guidelines in detecting early-stage lung cancer for a high-risk population. Patients diagnosed with early-stage lung cancer were selected as these patients have improved outcomes with treatment, and thus would theoretically benefit from early detection through screening. As expected, the study population had a majority of Black veterans (58%), with a higher proportion of Black patients in the did not meet screening criteria group compared with the met screening criteria group (68% vs 54%, P = .04). This difference highlights the concern that Black individuals were being underscreened with the 2013 USPSTF guidelines.⁷ This is not all surprising as the NLST, from which the initial screening guidelines were based, included a majority White population with only 4.4% of their population being Black.² The USPSTF also cites the NELSON trial as evidence to support annual lung cancer screening, a trial that was performed in the Netherlands with a very different population compared with that of southeast Louisiana.⁹

Given concern that the old criteria were underscreening certain populations, the updated 2021 USPSTF guidelines sought to expand the screening population. In this study, the implementation of these new guidelines resulted in more Black patients meeting screening criteria.

Racial and ethnic disparities in health care in the US are no secret, as Black individuals consistently have increased disease and death rates, higher rates of unemployment, and decreased access to preventive medical care compared to White individuals.¹⁰ Despite the updated USPSTF guidelines, additional modifications to the screening criteria could improve the ability to identify high-risk patients. A modified model using data from the Prostate, Lung, Colorectal, and Ovarian Screening Trial (PLCO) incorporating COPD history, race and ethnicity, and personal history of cancer increased the sensitivity for high-risk Black ever-smokers.¹¹ Additional models and analyses also support the utility of incorporating race and ethnicity in lung cancer screening criteria.^7,12 Using race and ethnicity to guide screening criteria for cancer is not unheard of; in 2017, the US Multi-Society Task Force recommended that Black individuals start colon cancer screening at age 45 years rather than the typical age of 50 years, before updating the guidelines again in 2021 to recommend that all adults start at age 45 years.^13,14

Limitations

This study had the inherent weakness of being a retrospective study at a single institution. Additionally, the 7th edition of the International Association for the Study of Lung Cancer was published in 2010, during the 2005 to 2017 time frame from which our data was collected, leading to possible inconsistencies in staging between patients before and after 2010.¹⁵ However, these changes in staging are unlikely to significantly impact the results for in this study, since the vast majority of the patients diagnosed with lung cancer stage I or II before 2010 would still be in the those 2 stages in the 2010 edition. Finally, specific to our patient population, it was often difficult to ascertain an accurate smoking history for each patient, especially in the early years of the data set, likely due to the disruption of care caused by Hurricane Katrina.

Conclusions

In this retrospective study performed at the SLVHCS in New Orleans, a significantly higher proportion of Black patients compared with White patients with early-stage lung cancer did not meet the 2013 USPSTF lung cancer screening guidelines at time of diagnosis, highlighting the concern that this population was being underscreened. These findings demonstrate the challenges and failures of applying national guidelines to a unique, high-risk population. An individualized, risk-based screening model incorporating race and ethnicity could be more effective at diagnosing early-stage lung cancer and requires more investigation. Centralized lung cancer screening programs within the VA system could also be beneficial for early detection and treatment, as well as provide insight into the increased risk within the veteran population.

Lung cancer is the leading cause of cancer death in the United States.¹ The 2011 National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening provided a 20% relative reduction in lung cancer–specific mortality.² Based on these findings, the United States Preventive Services Task Force (USPSTF) published lung cancer screening guidelines in 2013 recommending an annual LDCT of the thorax in patients aged 55 to 80 years with a 30 pack-year smoking history and who currently smoke or quit within the past 15 years. 

In 2021, the USPSTF updated its recommendations by reducing the qualifications for annual screening to a 20 pack-year smoking history.³ The updated guidelines recognized the increased risk of lung cancer for Black individuals.^4,5 Evidence suggests the 2013 screening criteria was too conservative for this population.^6,7

Similarly, US Department of Veteran Affairs (VA) patients are a population at higher risk for lung cancer due to a male predominance, presence of comorbidities, exposure to carcinogenic agents, and possibly a higher prevalence of tobacco smoking.⁸ This study sought to examine the applicability of the USPSTF guidelines in a VA health care system with a predominantly Black population.

Methods

A retrospective chart review of adult patients who were diagnosed and treated with early-stage small cell or non–small cell lung cancer (stage I or II) was performed within the Southeast Louisiana Veterans Health Care System (SLVHCS) in New Orleans. The review used data from the VA Cancer Registry from January 1, 2005, through December 31, 2017. Patients were grouped by whether they met 2013 USPSTF screening criteria at time of diagnosis vs those that did not. Data collected included type and stage of lung cancer at time of diagnosis, context of diagnosis (incidental, screening, symptomatic), diagnostic method, smoking history, and presence of chronic obstructive pulmonary disease (COPD). Patients without a clear smoking history documented in the health record were excluded.

Statistical analyses were performed with GraphPad Prism 8.0. Student t test and Fischer exact test were performed for most of the statistical analyses, with differences between groups noted to be statistically significant at a P < .05.

Results

A total of 182 patient charts were reviewed and 13 patients were excluded for missing information related to the USPSTF screening criteria. Of the 169 patients included, 122 (72%) met USPSTF screening criteria while 47 (28%) patients did not. The reasons for not meeting screening criteria were 14 patients were too young at and 9 patients were too old at time of diagnosis, 7 had a < 20 pack-year smoking history, 7 patients had quit > 15 years previously, and 12 patients met multiple exclusion criteria. The study population was 96% male and there was an overall predominance of Black patients (58%) within the sample (Table).

There was a significantly higher proportion of Black patients in the group that did not meet screening criteria compared with the group that met screening criteria (68% vs 54%, P = .04). Cancer type and stage at diagnosis were similar in both patient populations. There was a statistically significant difference in COPD diagnosis between the groups, with a larger proportion of COPD patients in the met screening criteria group (74% vs 45%, P < .001). The mean smoking history was 61.4 pack-years in the met criteria group and 43.3 pack-years in the did not meet criteria group.  

Five additional patients in the group that did not meet the 2013 USPSTF screening criteria would have met criteria if the 2021 USPSTF guidelines were applied. All 5 were Black patients. Using the 2021 guidelines, Black patients would have made up 56% of the patients who met screening criteria and 54% of the patients who did not meet screening criteria at time of diagnosis.

Discussion

This study sought to determine the hypothetical effectiveness of national lung cancer screening guidelines in detecting early-stage lung cancer for a high-risk population. Patients diagnosed with early-stage lung cancer were selected as these patients have improved outcomes with treatment, and thus would theoretically benefit from early detection through screening. As expected, the study population had a majority of Black veterans (58%), with a higher proportion of Black patients in the did not meet screening criteria group compared with the met screening criteria group (68% vs 54%, P = .04). This difference highlights the concern that Black individuals were being underscreened with the 2013 USPSTF guidelines.⁷ This is not all surprising as the NLST, from which the initial screening guidelines were based, included a majority White population with only 4.4% of their population being Black.² The USPSTF also cites the NELSON trial as evidence to support annual lung cancer screening, a trial that was performed in the Netherlands with a very different population compared with that of southeast Louisiana.⁹

Given concern that the old criteria were underscreening certain populations, the updated 2021 USPSTF guidelines sought to expand the screening population. In this study, the implementation of these new guidelines resulted in more Black patients meeting screening criteria.

Racial and ethnic disparities in health care in the US are no secret, as Black individuals consistently have increased disease and death rates, higher rates of unemployment, and decreased access to preventive medical care compared to White individuals.¹⁰ Despite the updated USPSTF guidelines, additional modifications to the screening criteria could improve the ability to identify high-risk patients. A modified model using data from the Prostate, Lung, Colorectal, and Ovarian Screening Trial (PLCO) incorporating COPD history, race and ethnicity, and personal history of cancer increased the sensitivity for high-risk Black ever-smokers.¹¹ Additional models and analyses also support the utility of incorporating race and ethnicity in lung cancer screening criteria.^7,12 Using race and ethnicity to guide screening criteria for cancer is not unheard of; in 2017, the US Multi-Society Task Force recommended that Black individuals start colon cancer screening at age 45 years rather than the typical age of 50 years, before updating the guidelines again in 2021 to recommend that all adults start at age 45 years.^13,14

Limitations

This study had the inherent weakness of being a retrospective study at a single institution. Additionally, the 7th edition of the International Association for the Study of Lung Cancer was published in 2010, during the 2005 to 2017 time frame from which our data was collected, leading to possible inconsistencies in staging between patients before and after 2010.¹⁵ However, these changes in staging are unlikely to significantly impact the results for in this study, since the vast majority of the patients diagnosed with lung cancer stage I or II before 2010 would still be in the those 2 stages in the 2010 edition. Finally, specific to our patient population, it was often difficult to ascertain an accurate smoking history for each patient, especially in the early years of the data set, likely due to the disruption of care caused by Hurricane Katrina.

Conclusions

In this retrospective study performed at the SLVHCS in New Orleans, a significantly higher proportion of Black patients compared with White patients with early-stage lung cancer did not meet the 2013 USPSTF lung cancer screening guidelines at time of diagnosis, highlighting the concern that this population was being underscreened. These findings demonstrate the challenges and failures of applying national guidelines to a unique, high-risk population. An individualized, risk-based screening model incorporating race and ethnicity could be more effective at diagnosing early-stage lung cancer and requires more investigation. Centralized lung cancer screening programs within the VA system could also be beneficial for early detection and treatment, as well as provide insight into the increased risk within the veteran population.

Lung cancer is the leading cause of cancer death in the United States.¹ The 2011 National Lung Screening Trial (NLST) demonstrated that low-dose computed tomography (LDCT) screening provided a 20% relative reduction in lung cancer–specific mortality.² Based on these findings, the United States Preventive Services Task Force (USPSTF) published lung cancer screening guidelines in 2013 recommending an annual LDCT of the thorax in patients aged 55 to 80 years with a 30 pack-year smoking history and who currently smoke or quit within the past 15 years. 

In 2021, the USPSTF updated its recommendations by reducing the qualifications for annual screening to a 20 pack-year smoking history.³ The updated guidelines recognized the increased risk of lung cancer for Black individuals.^4,5 Evidence suggests the 2013 screening criteria was too conservative for this population.^6,7

Similarly, US Department of Veteran Affairs (VA) patients are a population at higher risk for lung cancer due to a male predominance, presence of comorbidities, exposure to carcinogenic agents, and possibly a higher prevalence of tobacco smoking.⁸ This study sought to examine the applicability of the USPSTF guidelines in a VA health care system with a predominantly Black population.

Methods

A retrospective chart review of adult patients who were diagnosed and treated with early-stage small cell or non–small cell lung cancer (stage I or II) was performed within the Southeast Louisiana Veterans Health Care System (SLVHCS) in New Orleans. The review used data from the VA Cancer Registry from January 1, 2005, through December 31, 2017. Patients were grouped by whether they met 2013 USPSTF screening criteria at time of diagnosis vs those that did not. Data collected included type and stage of lung cancer at time of diagnosis, context of diagnosis (incidental, screening, symptomatic), diagnostic method, smoking history, and presence of chronic obstructive pulmonary disease (COPD). Patients without a clear smoking history documented in the health record were excluded.

Statistical analyses were performed with GraphPad Prism 8.0. Student t test and Fischer exact test were performed for most of the statistical analyses, with differences between groups noted to be statistically significant at a P < .05.

Results

A total of 182 patient charts were reviewed and 13 patients were excluded for missing information related to the USPSTF screening criteria. Of the 169 patients included, 122 (72%) met USPSTF screening criteria while 47 (28%) patients did not. The reasons for not meeting screening criteria were 14 patients were too young at and 9 patients were too old at time of diagnosis, 7 had a < 20 pack-year smoking history, 7 patients had quit > 15 years previously, and 12 patients met multiple exclusion criteria. The study population was 96% male and there was an overall predominance of Black patients (58%) within the sample (Table).

There was a significantly higher proportion of Black patients in the group that did not meet screening criteria compared with the group that met screening criteria (68% vs 54%, P = .04). Cancer type and stage at diagnosis were similar in both patient populations. There was a statistically significant difference in COPD diagnosis between the groups, with a larger proportion of COPD patients in the met screening criteria group (74% vs 45%, P < .001). The mean smoking history was 61.4 pack-years in the met criteria group and 43.3 pack-years in the did not meet criteria group.  

Five additional patients in the group that did not meet the 2013 USPSTF screening criteria would have met criteria if the 2021 USPSTF guidelines were applied. All 5 were Black patients. Using the 2021 guidelines, Black patients would have made up 56% of the patients who met screening criteria and 54% of the patients who did not meet screening criteria at time of diagnosis.

Discussion

This study sought to determine the hypothetical effectiveness of national lung cancer screening guidelines in detecting early-stage lung cancer for a high-risk population. Patients diagnosed with early-stage lung cancer were selected as these patients have improved outcomes with treatment, and thus would theoretically benefit from early detection through screening. As expected, the study population had a majority of Black veterans (58%), with a higher proportion of Black patients in the did not meet screening criteria group compared with the met screening criteria group (68% vs 54%, P = .04). This difference highlights the concern that Black individuals were being underscreened with the 2013 USPSTF guidelines.⁷ This is not all surprising as the NLST, from which the initial screening guidelines were based, included a majority White population with only 4.4% of their population being Black.² The USPSTF also cites the NELSON trial as evidence to support annual lung cancer screening, a trial that was performed in the Netherlands with a very different population compared with that of southeast Louisiana.⁹

Given concern that the old criteria were underscreening certain populations, the updated 2021 USPSTF guidelines sought to expand the screening population. In this study, the implementation of these new guidelines resulted in more Black patients meeting screening criteria.

Racial and ethnic disparities in health care in the US are no secret, as Black individuals consistently have increased disease and death rates, higher rates of unemployment, and decreased access to preventive medical care compared to White individuals.¹⁰ Despite the updated USPSTF guidelines, additional modifications to the screening criteria could improve the ability to identify high-risk patients. A modified model using data from the Prostate, Lung, Colorectal, and Ovarian Screening Trial (PLCO) incorporating COPD history, race and ethnicity, and personal history of cancer increased the sensitivity for high-risk Black ever-smokers.¹¹ Additional models and analyses also support the utility of incorporating race and ethnicity in lung cancer screening criteria.^7,12 Using race and ethnicity to guide screening criteria for cancer is not unheard of; in 2017, the US Multi-Society Task Force recommended that Black individuals start colon cancer screening at age 45 years rather than the typical age of 50 years, before updating the guidelines again in 2021 to recommend that all adults start at age 45 years.^13,14

Limitations

This study had the inherent weakness of being a retrospective study at a single institution. Additionally, the 7th edition of the International Association for the Study of Lung Cancer was published in 2010, during the 2005 to 2017 time frame from which our data was collected, leading to possible inconsistencies in staging between patients before and after 2010.¹⁵ However, these changes in staging are unlikely to significantly impact the results for in this study, since the vast majority of the patients diagnosed with lung cancer stage I or II before 2010 would still be in the those 2 stages in the 2010 edition. Finally, specific to our patient population, it was often difficult to ascertain an accurate smoking history for each patient, especially in the early years of the data set, likely due to the disruption of care caused by Hurricane Katrina.

Conclusions

In this retrospective study performed at the SLVHCS in New Orleans, a significantly higher proportion of Black patients compared with White patients with early-stage lung cancer did not meet the 2013 USPSTF lung cancer screening guidelines at time of diagnosis, highlighting the concern that this population was being underscreened. These findings demonstrate the challenges and failures of applying national guidelines to a unique, high-risk population. An individualized, risk-based screening model incorporating race and ethnicity could be more effective at diagnosing early-stage lung cancer and requires more investigation. Centralized lung cancer screening programs within the VA system could also be beneficial for early detection and treatment, as well as provide insight into the increased risk within the veteran population.

The observation that women with lung cancer seem to live longer than men can be explained by known prognostic factors, a new study suggests.

“In this first Australian prospective study of lung cancer survival comparing men and women, we found that men had a 43% greater risk of dying from their lung cancer than women,” comments lead author Xue Qin Yu, PhD, the Daffodil Centre, the University of Sydney, and colleagues.

“[However], when all prognostic factors were considered together, most of the survival differential disappeared,” they add.

“These results suggest that sex differences in lung cancer survival can be largely explained by known prognostic factors,” Dr. Yu and colleagues emphasize.

The study was published in the May issue of the Journal of Thoracic Oncology.
 

The ‘45 and up’ study

The findings come from the Sax Institute’s 45 and Up Study, an ongoing trial involving over 267,000 participants aged 45 years and older living in New South Wales, Australia. Patients were recruited to the study between 2006 and 2009. At the time of recruitment, patients were cancer free.

A total of 1,130 participants were diagnosed with having lung cancer during follow-up – 488 women and 642 men. Compared with men, women were, on average, younger at the time of diagnosis, had fewer comorbidities, and were more likely to be never-smokers or to have been exposed to passive smoke.

Women were also more likely to be diagnosed with adenocarcinoma than men and to receive surgery within 6 months of their diagnosis.

“Lung cancer survival was significantly higher for women,” the authors report, at a median of 1.28 years versus 0.77 years for men (P < .0001).

Within each subgroup of major prognostic factors – histologic subtype, cancer stage, cancer treatment, and smoking status – women again survived significantly longer than men.

Interestingly, the authors note that “women with adenocarcinoma had significantly better survival than men with adenocarcinoma independent of smoking status,” (P = .0009). This suggests that sex differences in tumor biology may play a role in explaining the sex survival differential between men and women, they commented. That said, never-smokers had a 16% lower risk for lung cancer death than ever-smokers after adjusting for age, the authors point out.

The authors also note that approximately half of the disparity in survival between the sexes could be explained by differences in the receipt of anticancer therapy within 6 months of the diagnosis. “This could partly be due to a lower proportion of men having surgery within 6 months than women,” investigators speculate, at 17% versus 25%, respectively.

Men were also older than women at the time of diagnosis, were less likely to be never-smokers, and had more comorbidities, all of which might also have prevented them from having surgery. Women with lung cancer may also respond better to chemotherapy than men, although the sex disparity in survival persisted even among patients who did not receive any treatment for their cancer within 6 months of their diagnosis, investigators point out.

Furthermore, “smoking history at baseline was identified as a significant contributing factor to the sex survival disparity, explaining approximately 28% of the overall disparity,” Dr. Yu and colleagues observe.

Only 8% of men diagnosed with lung cancer were never-smokers, compared with 23% of women. The authors note that never-smokers are more likely to receive aggressive or complete treatment and respond well to treatment.

Similarly, tumor-related factors together explained about one-quarter of the overall sex disparity in survival.
 

Screening guidelines

Commenting on the findings in an accompanying editorial, Claudia Poleri, MD, Hospital María Ferrer, Buenos Aires, says that this Australian study provides “valuable information.”

“The risk of dying from lung cancer was significantly higher for men than for women,” she writes. “Differences in treatment-related factors explained 50% of the sex survival differential, followed by lifestyle and tumor-related factors (28% and 26%, respectively).

“Nevertheless, these differences alone do not explain the higher survival in women,” she comments.

“Does it matter to analyze the differences by sex in lung cancer?” Dr. Poleri asks in the editorial, and then answers herself: “It matters.”

“It is necessary to implement screening programs and build artificial intelligence diagnostic algorithms considering the role of sex and gender equity to ensure that innovative technologies do not induce disparities in clinical care,” she writes.

“It is crucial to conduct education and health public programs that consider these differences, optimizing the use of available resources, [and] it is essential to improve the accuracy of research design and clinical trials,” she adds.

Dr. Yu and Dr. Poleri declared no relevant financial interests.

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

The observation that women with lung cancer seem to live longer than men can be explained by known prognostic factors, a new study suggests.

“In this first Australian prospective study of lung cancer survival comparing men and women, we found that men had a 43% greater risk of dying from their lung cancer than women,” comments lead author Xue Qin Yu, PhD, the Daffodil Centre, the University of Sydney, and colleagues.

“[However], when all prognostic factors were considered together, most of the survival differential disappeared,” they add.

“These results suggest that sex differences in lung cancer survival can be largely explained by known prognostic factors,” Dr. Yu and colleagues emphasize.

The study was published in the May issue of the Journal of Thoracic Oncology.
 

The ‘45 and up’ study

The findings come from the Sax Institute’s 45 and Up Study, an ongoing trial involving over 267,000 participants aged 45 years and older living in New South Wales, Australia. Patients were recruited to the study between 2006 and 2009. At the time of recruitment, patients were cancer free.

A total of 1,130 participants were diagnosed with having lung cancer during follow-up – 488 women and 642 men. Compared with men, women were, on average, younger at the time of diagnosis, had fewer comorbidities, and were more likely to be never-smokers or to have been exposed to passive smoke.

Women were also more likely to be diagnosed with adenocarcinoma than men and to receive surgery within 6 months of their diagnosis.

“Lung cancer survival was significantly higher for women,” the authors report, at a median of 1.28 years versus 0.77 years for men (P < .0001).

Within each subgroup of major prognostic factors – histologic subtype, cancer stage, cancer treatment, and smoking status – women again survived significantly longer than men.

Interestingly, the authors note that “women with adenocarcinoma had significantly better survival than men with adenocarcinoma independent of smoking status,” (P = .0009). This suggests that sex differences in tumor biology may play a role in explaining the sex survival differential between men and women, they commented. That said, never-smokers had a 16% lower risk for lung cancer death than ever-smokers after adjusting for age, the authors point out.

The authors also note that approximately half of the disparity in survival between the sexes could be explained by differences in the receipt of anticancer therapy within 6 months of the diagnosis. “This could partly be due to a lower proportion of men having surgery within 6 months than women,” investigators speculate, at 17% versus 25%, respectively.

Men were also older than women at the time of diagnosis, were less likely to be never-smokers, and had more comorbidities, all of which might also have prevented them from having surgery. Women with lung cancer may also respond better to chemotherapy than men, although the sex disparity in survival persisted even among patients who did not receive any treatment for their cancer within 6 months of their diagnosis, investigators point out.

Furthermore, “smoking history at baseline was identified as a significant contributing factor to the sex survival disparity, explaining approximately 28% of the overall disparity,” Dr. Yu and colleagues observe.

Only 8% of men diagnosed with lung cancer were never-smokers, compared with 23% of women. The authors note that never-smokers are more likely to receive aggressive or complete treatment and respond well to treatment.

Similarly, tumor-related factors together explained about one-quarter of the overall sex disparity in survival.
 

Screening guidelines

Commenting on the findings in an accompanying editorial, Claudia Poleri, MD, Hospital María Ferrer, Buenos Aires, says that this Australian study provides “valuable information.”

“The risk of dying from lung cancer was significantly higher for men than for women,” she writes. “Differences in treatment-related factors explained 50% of the sex survival differential, followed by lifestyle and tumor-related factors (28% and 26%, respectively).

“Nevertheless, these differences alone do not explain the higher survival in women,” she comments.

“Does it matter to analyze the differences by sex in lung cancer?” Dr. Poleri asks in the editorial, and then answers herself: “It matters.”

“It is necessary to implement screening programs and build artificial intelligence diagnostic algorithms considering the role of sex and gender equity to ensure that innovative technologies do not induce disparities in clinical care,” she writes.

“It is crucial to conduct education and health public programs that consider these differences, optimizing the use of available resources, [and] it is essential to improve the accuracy of research design and clinical trials,” she adds.

Dr. Yu and Dr. Poleri declared no relevant financial interests.

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

The observation that women with lung cancer seem to live longer than men can be explained by known prognostic factors, a new study suggests.

“In this first Australian prospective study of lung cancer survival comparing men and women, we found that men had a 43% greater risk of dying from their lung cancer than women,” comments lead author Xue Qin Yu, PhD, the Daffodil Centre, the University of Sydney, and colleagues.

“[However], when all prognostic factors were considered together, most of the survival differential disappeared,” they add.

“These results suggest that sex differences in lung cancer survival can be largely explained by known prognostic factors,” Dr. Yu and colleagues emphasize.

The study was published in the May issue of the Journal of Thoracic Oncology.
 

The ‘45 and up’ study

The findings come from the Sax Institute’s 45 and Up Study, an ongoing trial involving over 267,000 participants aged 45 years and older living in New South Wales, Australia. Patients were recruited to the study between 2006 and 2009. At the time of recruitment, patients were cancer free.

A total of 1,130 participants were diagnosed with having lung cancer during follow-up – 488 women and 642 men. Compared with men, women were, on average, younger at the time of diagnosis, had fewer comorbidities, and were more likely to be never-smokers or to have been exposed to passive smoke.

Women were also more likely to be diagnosed with adenocarcinoma than men and to receive surgery within 6 months of their diagnosis.

“Lung cancer survival was significantly higher for women,” the authors report, at a median of 1.28 years versus 0.77 years for men (P < .0001).

Within each subgroup of major prognostic factors – histologic subtype, cancer stage, cancer treatment, and smoking status – women again survived significantly longer than men.

Interestingly, the authors note that “women with adenocarcinoma had significantly better survival than men with adenocarcinoma independent of smoking status,” (P = .0009). This suggests that sex differences in tumor biology may play a role in explaining the sex survival differential between men and women, they commented. That said, never-smokers had a 16% lower risk for lung cancer death than ever-smokers after adjusting for age, the authors point out.

The authors also note that approximately half of the disparity in survival between the sexes could be explained by differences in the receipt of anticancer therapy within 6 months of the diagnosis. “This could partly be due to a lower proportion of men having surgery within 6 months than women,” investigators speculate, at 17% versus 25%, respectively.

Men were also older than women at the time of diagnosis, were less likely to be never-smokers, and had more comorbidities, all of which might also have prevented them from having surgery. Women with lung cancer may also respond better to chemotherapy than men, although the sex disparity in survival persisted even among patients who did not receive any treatment for their cancer within 6 months of their diagnosis, investigators point out.

Furthermore, “smoking history at baseline was identified as a significant contributing factor to the sex survival disparity, explaining approximately 28% of the overall disparity,” Dr. Yu and colleagues observe.

Only 8% of men diagnosed with lung cancer were never-smokers, compared with 23% of women. The authors note that never-smokers are more likely to receive aggressive or complete treatment and respond well to treatment.

Similarly, tumor-related factors together explained about one-quarter of the overall sex disparity in survival.
 

Screening guidelines

Commenting on the findings in an accompanying editorial, Claudia Poleri, MD, Hospital María Ferrer, Buenos Aires, says that this Australian study provides “valuable information.”

“The risk of dying from lung cancer was significantly higher for men than for women,” she writes. “Differences in treatment-related factors explained 50% of the sex survival differential, followed by lifestyle and tumor-related factors (28% and 26%, respectively).

“Nevertheless, these differences alone do not explain the higher survival in women,” she comments.

“Does it matter to analyze the differences by sex in lung cancer?” Dr. Poleri asks in the editorial, and then answers herself: “It matters.”

“It is necessary to implement screening programs and build artificial intelligence diagnostic algorithms considering the role of sex and gender equity to ensure that innovative technologies do not induce disparities in clinical care,” she writes.

“It is crucial to conduct education and health public programs that consider these differences, optimizing the use of available resources, [and] it is essential to improve the accuracy of research design and clinical trials,” she adds.

Dr. Yu and Dr. Poleri declared no relevant financial interests.

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

I’m often in the position of caring for patients after they’ve stopped active cancer treatments, but before they’ve made the decision to enroll in hospice. They remain under my care until they feel emotionally ready, or until their care needs have escalated to the point in which hospice is unavoidable.

Jenny, a mom in her 50s with metastatic pancreatic cancer, stopped coming to the clinic. She lived about 40 minutes away from the clinic and was no longer receiving treatment. The car rides were painful and difficult for her. I held weekly video visits with her for 2 months before she eventually went to hospice and passed away. Before she died, she shared with me her sadness that her oncologist – who had taken care of her for 3 years – had “washed his hands of [me].” She rarely heard from him after their final conversation in the clinic when he informed her that she was no longer a candidate for further therapy. The sense of abandonment Jenny described was visceral and devastating. With her permission, I let her oncology team know how she felt and they reached out to her just 1 week before her death. After she died, her husband told me how meaningful it had been for the whole family to hear from Jenny’s oncologist who told them that she had done everything possible to fight her cancer and that “no stone was left unturned.” Her husband felt this final conversation provided Jenny with the closure she needed to pass away peacefully.

Transitioning from active therapy to symptom management

Switching gears from an all-out pursuit of active therapy to focusing on cancer symptoms is often a scary transition for patients and their families. The transition is often viewed as a movement away from hope and optimism to “giving up the fight.” Whether you agree with the warrior language or not, many patients still describe their journey in these terms and thus, experience enrollment in hospice as a sense of having failed.

The sense of failure can be compounded by feelings of abandonment by oncology providers when they are referred without much guidance or continuity through the hospice enrollment process. Unfortunately, the consequences of suboptimal hospice transitions can be damaging, especially for the mental health and well-being of the patient and their surviving loved ones. Hospice transitions seem to reside in an area of clinical practice that is overlooked or, in my experience they are considered an afterthought by many oncologists.

When managed poorly, hospice transitions can easily lead to patient and family harm, which is a claim supported by research. A qualitative study published in 2019 included 92 caregivers of patients with terminal cancer. The authors found three common pathways for end-of-life transitions – a frictionless transition in which the patient and family are well prepared in advance by their oncologist; a more turbulent transition in which patient and family had direct conversations with their oncologist about the incurability of the disease and the lack of efficacy of further treatments, but were given no guidance on prognosis; and a third type of transition marked by abrupt shifts toward end-of-life care occurring in extremis and typically in the hospital.

In the latter two groups, caregivers felt their loved ones died very quickly after stopping treatment, taking them by surprise and leaving them rushing to put end-of-life care plans in place without much support from their oncologists. In the last group, caregivers shared they received their first prognostic information from the hospital or ICU doctor caring for their actively dying loved one, leaving them with a sense of anger and betrayal toward their oncologist for allowing them to be so ill-prepared.

A Japanese survey published in 2018 in The Oncologist of families of cancer patients who had passed away under hospice care over a 2-year period (2012-2014), found that about one-quarter felt abandoned by oncologists. Several factors that were associated with feeling either more or less abandonment. Spouses of patients, patients aged less than 60 years, and patients whose oncologists informed them that there was “nothing more to do” felt more abandoned by oncologists; whereas families for whom the oncologist provided reassurance about the trajectory of care, recommended hospice, and engaged with a palliative care team felt less abandoned by oncologists. Families who felt more abandoned had higher levels of depression and grief when measured with standardized instruments.
 

‘Don’t just put in the hospice order and walk away’

Fortunately, there are a few low-resource interventions that can improve the quality of care-to-hospice transitions and prevent the sense of abandonment felt by many patients and families.

First, don’t just put in the hospice order and walk away. Designate a staffer in your office to contact hospice directly, ensure all medical records are faxed and received, and update the patient and family on this progress throughout the transition. Taking care of details like these ensures the patient enrolls in hospice in a timely manner and reduces the chance the patient, who is likely to be quite sick at this point, will end up in the hospital despite your best efforts to get hospice involved.

Make sure the patient and family understand that you are still their oncologist and still available to them. If they want to continue care with you, have them name you as the “non–hospice-attending physician” so that you can continue to bill for telemedicine and office visits using the terminal diagnosis (with a billing modifier). This does not mean that you will be expected to manage the patient’s hospice problem list or respond to hospice nurse calls at 2 a.m. – the hospice doctor will still do this. It just ensures that patients do not receive a bill if you continue to see them.

If ongoing office or video visits are too much for the patient and family, consider assigning a member of your team to call the patient and family on a weekly basis to check in and offer support. A small 2018 pilot study aimed at improving communication found that when caregivers of advanced cancer patients transitioning to hospice received weekly supportive phone calls by a member of their oncology team (typically a nurse or nurse practitioner), they felt emotionally supported, had good continuity of care throughout the hospice enrollment, and appreciated the ability to have closure with their oncology team. In other words, a sense of abandonment was prevented and the patient-provider relationship was actually deepened through the transition.

These suggestions are not rocket science – they are simple, obvious ways to try to restore patient-centeredness to a transition that for providers can seem routine, but for patients and families is often the first time they have confronted the reality that death is approaching. That reality is terrifying and overwhelming. Patients and caregivers need our support more during hospice transitions than at any other point during their cancer journey – except perhaps at diagnosis.

As with Jenny, my patient who felt abandoned, all it took was a single call by her oncology team to restore the trust and heal the sense of feeling forsaken by the people who cared for her for years. Sometimes, even just one more phone call can feel like a lot to a chronically overburdened provider – but what a difference a simple call can make.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

I’m often in the position of caring for patients after they’ve stopped active cancer treatments, but before they’ve made the decision to enroll in hospice. They remain under my care until they feel emotionally ready, or until their care needs have escalated to the point in which hospice is unavoidable.

Jenny, a mom in her 50s with metastatic pancreatic cancer, stopped coming to the clinic. She lived about 40 minutes away from the clinic and was no longer receiving treatment. The car rides were painful and difficult for her. I held weekly video visits with her for 2 months before she eventually went to hospice and passed away. Before she died, she shared with me her sadness that her oncologist – who had taken care of her for 3 years – had “washed his hands of [me].” She rarely heard from him after their final conversation in the clinic when he informed her that she was no longer a candidate for further therapy. The sense of abandonment Jenny described was visceral and devastating. With her permission, I let her oncology team know how she felt and they reached out to her just 1 week before her death. After she died, her husband told me how meaningful it had been for the whole family to hear from Jenny’s oncologist who told them that she had done everything possible to fight her cancer and that “no stone was left unturned.” Her husband felt this final conversation provided Jenny with the closure she needed to pass away peacefully.

Transitioning from active therapy to symptom management

Switching gears from an all-out pursuit of active therapy to focusing on cancer symptoms is often a scary transition for patients and their families. The transition is often viewed as a movement away from hope and optimism to “giving up the fight.” Whether you agree with the warrior language or not, many patients still describe their journey in these terms and thus, experience enrollment in hospice as a sense of having failed.

The sense of failure can be compounded by feelings of abandonment by oncology providers when they are referred without much guidance or continuity through the hospice enrollment process. Unfortunately, the consequences of suboptimal hospice transitions can be damaging, especially for the mental health and well-being of the patient and their surviving loved ones. Hospice transitions seem to reside in an area of clinical practice that is overlooked or, in my experience they are considered an afterthought by many oncologists.

When managed poorly, hospice transitions can easily lead to patient and family harm, which is a claim supported by research. A qualitative study published in 2019 included 92 caregivers of patients with terminal cancer. The authors found three common pathways for end-of-life transitions – a frictionless transition in which the patient and family are well prepared in advance by their oncologist; a more turbulent transition in which patient and family had direct conversations with their oncologist about the incurability of the disease and the lack of efficacy of further treatments, but were given no guidance on prognosis; and a third type of transition marked by abrupt shifts toward end-of-life care occurring in extremis and typically in the hospital.

In the latter two groups, caregivers felt their loved ones died very quickly after stopping treatment, taking them by surprise and leaving them rushing to put end-of-life care plans in place without much support from their oncologists. In the last group, caregivers shared they received their first prognostic information from the hospital or ICU doctor caring for their actively dying loved one, leaving them with a sense of anger and betrayal toward their oncologist for allowing them to be so ill-prepared.

A Japanese survey published in 2018 in The Oncologist of families of cancer patients who had passed away under hospice care over a 2-year period (2012-2014), found that about one-quarter felt abandoned by oncologists. Several factors that were associated with feeling either more or less abandonment. Spouses of patients, patients aged less than 60 years, and patients whose oncologists informed them that there was “nothing more to do” felt more abandoned by oncologists; whereas families for whom the oncologist provided reassurance about the trajectory of care, recommended hospice, and engaged with a palliative care team felt less abandoned by oncologists. Families who felt more abandoned had higher levels of depression and grief when measured with standardized instruments.
 

‘Don’t just put in the hospice order and walk away’

Fortunately, there are a few low-resource interventions that can improve the quality of care-to-hospice transitions and prevent the sense of abandonment felt by many patients and families.

First, don’t just put in the hospice order and walk away. Designate a staffer in your office to contact hospice directly, ensure all medical records are faxed and received, and update the patient and family on this progress throughout the transition. Taking care of details like these ensures the patient enrolls in hospice in a timely manner and reduces the chance the patient, who is likely to be quite sick at this point, will end up in the hospital despite your best efforts to get hospice involved.

Make sure the patient and family understand that you are still their oncologist and still available to them. If they want to continue care with you, have them name you as the “non–hospice-attending physician” so that you can continue to bill for telemedicine and office visits using the terminal diagnosis (with a billing modifier). This does not mean that you will be expected to manage the patient’s hospice problem list or respond to hospice nurse calls at 2 a.m. – the hospice doctor will still do this. It just ensures that patients do not receive a bill if you continue to see them.

If ongoing office or video visits are too much for the patient and family, consider assigning a member of your team to call the patient and family on a weekly basis to check in and offer support. A small 2018 pilot study aimed at improving communication found that when caregivers of advanced cancer patients transitioning to hospice received weekly supportive phone calls by a member of their oncology team (typically a nurse or nurse practitioner), they felt emotionally supported, had good continuity of care throughout the hospice enrollment, and appreciated the ability to have closure with their oncology team. In other words, a sense of abandonment was prevented and the patient-provider relationship was actually deepened through the transition.

These suggestions are not rocket science – they are simple, obvious ways to try to restore patient-centeredness to a transition that for providers can seem routine, but for patients and families is often the first time they have confronted the reality that death is approaching. That reality is terrifying and overwhelming. Patients and caregivers need our support more during hospice transitions than at any other point during their cancer journey – except perhaps at diagnosis.

As with Jenny, my patient who felt abandoned, all it took was a single call by her oncology team to restore the trust and heal the sense of feeling forsaken by the people who cared for her for years. Sometimes, even just one more phone call can feel like a lot to a chronically overburdened provider – but what a difference a simple call can make.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

I’m often in the position of caring for patients after they’ve stopped active cancer treatments, but before they’ve made the decision to enroll in hospice. They remain under my care until they feel emotionally ready, or until their care needs have escalated to the point in which hospice is unavoidable.

Jenny, a mom in her 50s with metastatic pancreatic cancer, stopped coming to the clinic. She lived about 40 minutes away from the clinic and was no longer receiving treatment. The car rides were painful and difficult for her. I held weekly video visits with her for 2 months before she eventually went to hospice and passed away. Before she died, she shared with me her sadness that her oncologist – who had taken care of her for 3 years – had “washed his hands of [me].” She rarely heard from him after their final conversation in the clinic when he informed her that she was no longer a candidate for further therapy. The sense of abandonment Jenny described was visceral and devastating. With her permission, I let her oncology team know how she felt and they reached out to her just 1 week before her death. After she died, her husband told me how meaningful it had been for the whole family to hear from Jenny’s oncologist who told them that she had done everything possible to fight her cancer and that “no stone was left unturned.” Her husband felt this final conversation provided Jenny with the closure she needed to pass away peacefully.

Transitioning from active therapy to symptom management

Switching gears from an all-out pursuit of active therapy to focusing on cancer symptoms is often a scary transition for patients and their families. The transition is often viewed as a movement away from hope and optimism to “giving up the fight.” Whether you agree with the warrior language or not, many patients still describe their journey in these terms and thus, experience enrollment in hospice as a sense of having failed.

The sense of failure can be compounded by feelings of abandonment by oncology providers when they are referred without much guidance or continuity through the hospice enrollment process. Unfortunately, the consequences of suboptimal hospice transitions can be damaging, especially for the mental health and well-being of the patient and their surviving loved ones. Hospice transitions seem to reside in an area of clinical practice that is overlooked or, in my experience they are considered an afterthought by many oncologists.

When managed poorly, hospice transitions can easily lead to patient and family harm, which is a claim supported by research. A qualitative study published in 2019 included 92 caregivers of patients with terminal cancer. The authors found three common pathways for end-of-life transitions – a frictionless transition in which the patient and family are well prepared in advance by their oncologist; a more turbulent transition in which patient and family had direct conversations with their oncologist about the incurability of the disease and the lack of efficacy of further treatments, but were given no guidance on prognosis; and a third type of transition marked by abrupt shifts toward end-of-life care occurring in extremis and typically in the hospital.

In the latter two groups, caregivers felt their loved ones died very quickly after stopping treatment, taking them by surprise and leaving them rushing to put end-of-life care plans in place without much support from their oncologists. In the last group, caregivers shared they received their first prognostic information from the hospital or ICU doctor caring for their actively dying loved one, leaving them with a sense of anger and betrayal toward their oncologist for allowing them to be so ill-prepared.

A Japanese survey published in 2018 in The Oncologist of families of cancer patients who had passed away under hospice care over a 2-year period (2012-2014), found that about one-quarter felt abandoned by oncologists. Several factors that were associated with feeling either more or less abandonment. Spouses of patients, patients aged less than 60 years, and patients whose oncologists informed them that there was “nothing more to do” felt more abandoned by oncologists; whereas families for whom the oncologist provided reassurance about the trajectory of care, recommended hospice, and engaged with a palliative care team felt less abandoned by oncologists. Families who felt more abandoned had higher levels of depression and grief when measured with standardized instruments.
 

‘Don’t just put in the hospice order and walk away’

Fortunately, there are a few low-resource interventions that can improve the quality of care-to-hospice transitions and prevent the sense of abandonment felt by many patients and families.

First, don’t just put in the hospice order and walk away. Designate a staffer in your office to contact hospice directly, ensure all medical records are faxed and received, and update the patient and family on this progress throughout the transition. Taking care of details like these ensures the patient enrolls in hospice in a timely manner and reduces the chance the patient, who is likely to be quite sick at this point, will end up in the hospital despite your best efforts to get hospice involved.

Make sure the patient and family understand that you are still their oncologist and still available to them. If they want to continue care with you, have them name you as the “non–hospice-attending physician” so that you can continue to bill for telemedicine and office visits using the terminal diagnosis (with a billing modifier). This does not mean that you will be expected to manage the patient’s hospice problem list or respond to hospice nurse calls at 2 a.m. – the hospice doctor will still do this. It just ensures that patients do not receive a bill if you continue to see them.

If ongoing office or video visits are too much for the patient and family, consider assigning a member of your team to call the patient and family on a weekly basis to check in and offer support. A small 2018 pilot study aimed at improving communication found that when caregivers of advanced cancer patients transitioning to hospice received weekly supportive phone calls by a member of their oncology team (typically a nurse or nurse practitioner), they felt emotionally supported, had good continuity of care throughout the hospice enrollment, and appreciated the ability to have closure with their oncology team. In other words, a sense of abandonment was prevented and the patient-provider relationship was actually deepened through the transition.

These suggestions are not rocket science – they are simple, obvious ways to try to restore patient-centeredness to a transition that for providers can seem routine, but for patients and families is often the first time they have confronted the reality that death is approaching. That reality is terrifying and overwhelming. Patients and caregivers need our support more during hospice transitions than at any other point during their cancer journey – except perhaps at diagnosis.

As with Jenny, my patient who felt abandoned, all it took was a single call by her oncology team to restore the trust and heal the sense of feeling forsaken by the people who cared for her for years. Sometimes, even just one more phone call can feel like a lot to a chronically overburdened provider – but what a difference a simple call can make.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

In patients with stage I lung cancer, adding noncancerous features from CT chest imaging predicts overall survival better than clinical characteristics alone, according to a paper published online in the American Journal of Roentgenology.

Modeling that incorporates noncancerous imaging features captured on chest computed tomography (CT) along with clinical features, when calculated before stereotactic body radiation therapy (SBRT) is administered, improves survival prediction, compared with modeling that relies only on clinical features, the authors report.

“The focus of the study was to look at the environment in which the cancer lives,” said senior author Florian J. Fintelmann, MD, radiologist at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, both in Boston. “This is looking at parameters like the aortic diameter, body composition – that is, the quantification and characterization of adipose tissue and muscle – coronary artery calcifications, and emphysema quantification.”

CT images are used by radiation oncologists to determine where the radiation should be delivered. “There is more information from these images that we can utilize,” he said.

Survival estimates in patients with state I lung cancer now rely on biological age, ECOG (Eastern Cooperative Oncology Group) score, and the presence of comorbidities, Dr. Fintelmann said.

This retrospective investigation involved 282 patients with a median age of 75 years. There were 168 women and 114 men. All patients had stage I lung cancer and were treated with SBRT between January 2009 and June 2017.

Courtesy Florian J. Fintelman, MD

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

In patients with stage I lung cancer, adding noncancerous features from CT chest imaging predicts overall survival better than clinical characteristics alone, according to a paper published online in the American Journal of Roentgenology.

Modeling that incorporates noncancerous imaging features captured on chest computed tomography (CT) along with clinical features, when calculated before stereotactic body radiation therapy (SBRT) is administered, improves survival prediction, compared with modeling that relies only on clinical features, the authors report.

“The focus of the study was to look at the environment in which the cancer lives,” said senior author Florian J. Fintelmann, MD, radiologist at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, both in Boston. “This is looking at parameters like the aortic diameter, body composition – that is, the quantification and characterization of adipose tissue and muscle – coronary artery calcifications, and emphysema quantification.”

CT images are used by radiation oncologists to determine where the radiation should be delivered. “There is more information from these images that we can utilize,” he said.

Survival estimates in patients with state I lung cancer now rely on biological age, ECOG (Eastern Cooperative Oncology Group) score, and the presence of comorbidities, Dr. Fintelmann said.

This retrospective investigation involved 282 patients with a median age of 75 years. There were 168 women and 114 men. All patients had stage I lung cancer and were treated with SBRT between January 2009 and June 2017.

Courtesy Florian J. Fintelman, MD

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

In patients with stage I lung cancer, adding noncancerous features from CT chest imaging predicts overall survival better than clinical characteristics alone, according to a paper published online in the American Journal of Roentgenology.

Modeling that incorporates noncancerous imaging features captured on chest computed tomography (CT) along with clinical features, when calculated before stereotactic body radiation therapy (SBRT) is administered, improves survival prediction, compared with modeling that relies only on clinical features, the authors report.

“The focus of the study was to look at the environment in which the cancer lives,” said senior author Florian J. Fintelmann, MD, radiologist at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School, both in Boston. “This is looking at parameters like the aortic diameter, body composition – that is, the quantification and characterization of adipose tissue and muscle – coronary artery calcifications, and emphysema quantification.”

CT images are used by radiation oncologists to determine where the radiation should be delivered. “There is more information from these images that we can utilize,” he said.

Survival estimates in patients with state I lung cancer now rely on biological age, ECOG (Eastern Cooperative Oncology Group) score, and the presence of comorbidities, Dr. Fintelmann said.

This retrospective investigation involved 282 patients with a median age of 75 years. There were 168 women and 114 men. All patients had stage I lung cancer and were treated with SBRT between January 2009 and June 2017.

Courtesy Florian J. Fintelman, MD

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