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Improving Early-Stage Lung Cancer Care

More than 80% of patients with lung cancer receive care in their communities, but this can leave them vulnerable to gaps in care quality and delivery.

More than 80% of patients with lung cancer receive care in their communities, but this can leave them vulnerable to gaps in care quality and delivery.

To better outcomes among patients diagnosed with early stage non–small cell lung cancer (NSCLC) who receive care in community settings, experts stress the importance of closing equity and efficiency gaps in testing, as well as optimizing comprehensive care delivery for long-term patient outcomes, according to data presented at the 2024 World Conference on Lung Cancer.1

Joseph Kim, MD, MPH, MBA, FACHEImage Credit: © Q Synthesis LLC

"I think the biggest improvement efforts are recognizing that there's really this opportunity not only to perform the testing as early as possible," said Joseph Kim, MD, MPH, MBA, FACHE, president, Q Synthesis LLC, and consultant, Xaf Solutions, who presented the data at WCLC on behalf of the Association of Cancer Care Centers (ACCC). "But using that information to then tailor treatment plans for patients who undergo surgery, they get resected, and then they may be eligible for adjuvant therapies."

NSCLC was the focus of the analysis because overall survival rates for it remain low despite recent treatment advances; in 2024, amivantamab alone has received 3 FDA approvals.2-4 Coupled with the fact that more than 80% of patients with this cancer are treated in their communities, ACCC was inspired to launch a 2-phase quality improvement initiative for patients with stage Ib to stage IIIa (early-stage) disease who receive treatment both within their communities and at academic cancer centers. Phase 1 comprised a provider survey that asked about barriers and facilitators to care, and in phase 2, the results from phase 1 were used to pinpoint target areas for improvement at 3 cancer centers. Information was collected on patient demographics, biomarker testing rates, multidisciplinary tumor board (MTB) use, and patterns of adjuvant and neoadjuvant therapy delivery.

Overall Findings

From the data they gathered for 2020 and 2021, there were 70 cases of lung cancer diagnosed, with 20 at site 1, 40 at site 2, and 10 at site 3. The corresponding ages of these patients were 69, 71, and 67 years, and female patients accounted for at least 50% of each patient group. The most common disease histologies were adenocarcinoma (site 1, 65%; site 2, 52%; site 3, 70%) and squamous cell (30%, 40%, and 30%, respectively).

Findings also show that a majority of the diagnosed cases were discussed during MTBs and that EGFR and PD-L1 testing were performed at high rates:

  • MTB:
  • Site 1: 65%
  • Site 2: 62%
  • Site 3: 90%
  • EGFR testing:
  • Site 1: 55%
  • Site 2: 45%
  • Site 3: 80%
  • PD-L1 testing:
  • Site 1: 55%
  • Site 2: 95%
  • Site 3: 80%
  • Marked for Improvement: Biomarker Testing

    At site 1, the above results demonstrate there are 45% of patients with early-stage disease not being tested for EGFR or PD-L1, when these tests are typically ordered 13 days after surgery. Potential causes were variations in what and when tests are ordered, as lack of testing protocol for these patients.

    At site 2, results show that 55% of patients were not tested for EGFR and 5% were not tested for PD-L1. Also, that just over half of patients with adenocarcinoma were tested for EGFR (59%), meaning 41% were not. Blames were placed on lack of an automatic testing protocol for early-stage NSCLC, lack of liquid biopsy, and no testing due to insufficient tumor tissue.

    At site 3, just 10% of patients underwent biomarker testing at initial diagnosis vs the 90% who were only tested at surgery or later. Reasons given for the subpar biomarker testing results were lack of a biomarker testing protocol at diagnosis and delayed testing due to hospitalization.

    The identified solution for all 3 sites was to implement a pathology-driven reflect biomarker testing protocol at diagnosis—for EGFR, PD-L1, and ALK alterations—to increase use of MTBs, and for everyone to contribute.

    "One of the biggest lessons is that when it comes to cancer care, a lot of clinicians have very strong opinions, and they may have their own ideas on what should be done. But if you gather everyone together and try to achieve consensus, that's often one of the biggest hurdles to overcome at the very beginning," Kim stated. "This project led these systems to achieve that type of consensus on when should testing occur, what type of testing are they going to be doing, tracking that information, and making sure that it's as consistent as possible."

    References

    1. Smeltzer M, Kim J, Alvarez B, et al. A quality improvement initiative to address biomarker testing and quality of care delivery for early-stage NSCLC at 3 cancer centers in the US. Presented at: World Conference on Lung Cancer; September 7-10, 2024; San Diego, CA.

    2. Shaw M. Dr Joshua Sabari discusses amivantamab's first-line approval for NSCLC. AJMC®. March 4, 2024. Accessed October 30, 2024. Https://www.Ajmc.Com/view/dr-joshua-sabari-discusses-amivantamab-s-first-line-approval-for-nsclc

    3. Bonavitacola J. Lazertinib with amivantamab approved by FDA for use in NSCLC. AJMC. August 20, 2024. Accessed October 30, 2024. Https://www.Ajmc.Com/view/lazertinib-with-amivantamab-approved-by-fda-for-use-in-nsclc

    4. Shaw M. Amivantamab accolades add up for NSCLC. AJMC. September 27, 2024. Accessed October 30, 2024. Https://www.Ajmc.Com/view/amivantamab-accolades-add-up-for-nsclc


    A Decision-Making Model For Selecting Surgery Or Radiotherapy For Early-Stage Lung Cancer

    Minimally invasive surgery (MIS) and stereotactic body radiotherapy (SBRT) are both used to treat stage 1 non-small cell lung cancer (NSCLC). While MIS remains the standard of care for patients with operable disease, selecting which patients should be referred for SBRT has been challenging because there are many clinical factors affecting the decision-making process.

    A new study by a team of 12 thoracic surgeons at Memorial Sloan Kettering Cancer Center (MSK), published recently in the Annals of Surgery, (1) is the first to identify a comprehensive list of clinical factors significantly associated with referring patients with stage 1 NSCLC to SBRT. The factors included age, reduced performance status, previous pulmonary resection, MSK-Frailty score, forced expiratory volume in one second (FEV1), and diffusion capacity of the lung for carbon monoxide (DLCO).

    The investigators used these factors to create a prediction model for determining which patients with stage 1 NSCLC were most likely to benefit from referral to SBRT.  (1)

    "The clinical factors we identified are already collected by most thoracic surgeons and pulmonologists worldwide," said MSK thoracic surgeon Gaetano Rocco, MD, senior author of the study. "However, the model we created translates our clinical experience at MSK into a valuable tool for guiding referral decisions by categorizing patients into three distinct risk groups."

    Treatment Options for Early-Stage Lung Cancer

    Surgery remains the standard of care for operable patients, while SBRT is more frequently recommended for patients deemed high-risk for surgery or who decline surgery.

    Previous randomized clinical trials directly comparing surgical resection to SBRT were closed early due to poor accrual. (2) A pooled analysis among 58 patients from these studies showed a comparable recurrence-free survival but an improved overall survival (OS) for SBRT in patients with operable stage 1 NSCLC. However, the majority of patients in the surgical cohort had open surgery, not MIS, and 7% of patients had disease progression at the time of surgery.  (2) (3) 

    In prior studies based on real-world clinical settings, SBRT demonstrated that it provides excellent short-term morbidity, mortality, and tumor control. While the results showed recurrence-free survival and OS were worse after SBRT compared to surgery overall, treatment modality was no longer associated with survival after adjusting for age and performance status. (4) (5) (6) 

    Finally, while most patients tolerate MIS and SBRT well, postoperative complications or radiation-induced pneumonitis and esophagitis, respectively, can negatively affect the quality of life and should be considered when determining the optimal treatment modality.  (7) (8) (9) (10)

    Study Design

    Dr. Rocco and colleagues analyzed patient records for all consecutive patients who underwent MIS or SBRT for confirmed stage 1 NSCLC at MSK from January 2020 to July 2023. They excluded those who received neoadjuvant chemotherapy, open surgery, had cancer diagnosed preoperatively, or were surgical candidates who opted for SBRT. In total, their analysis included 1,291 patients. (1)

    The investigators included patient demographics and characteristics, disease stage, pathology results, post-procedural outcomes, survival, and recurrence data. They also looked at the MSK-Frailty Index, a composite measure of the following clinical risk factors: chronic obstructive pulmonary disease (COPD), acute myocardial infarction, congestive heart failure, hypertension, peripheral artery disease, coronary artery disease, stroke, transient ischemic attack, diabetes, cognitive impairment, and reduced activities of daily living.  (11)

    Post-procedural outcome data included 90-day mortality and surgical complication rates for surgical patients. For patients who received SBRT, the analysis included 90-day mortality as well as new-onset or treatment-induced toxicity, including cough, dyspnea, chest wall pain, pneumonitis, pulmonary fibrosis, bronchial stricture, esophagitis, dysphagia, myocardial infarction, pericarditis, and radiation dermatitis.  (8)

    The study's primary objective was to identify clinical factors that were significantly associated with SBRT referral. Dr. Rocco and colleagues then used these factors to develop a predictive model. They evaluated the model's performance and calculated two cutoff values for stratifying patients into three categories based on perioperative risk and postoperative complications. The first cutoff identified the low-risk patients most likely to be referred to MIS, and the second cutoff identified high-risk patients most likely to be referred to SBRT. Patients falling between these two cutoff values were categorized as intermediate-risk.  (1)

    The study's secondary objective was to validate the model's performance by assessing post-procedural outcomes, recurrence, and OS and compare results for patients in the MIS and the SBRT groups.  (1)

    Study Results

    Among 1,291 patients treated for stage 1 NSCLC, 1,116 (86%) underwent MIS, and 175 (14%) received SBRT. Patients treated with SBRT were older (77 versus 70 years) and had worse performance status, lower pulmonary function, and higher MSK-Frailty scores than those in the MIS group.  (1)

    In the MIS group, 582 patients (52%) underwent lobectomy or bilobectomy, 260 (23%) underwent segmentectomy, and 274 (25%) underwent wedge resection. Also, 52 patients (5%) required conversion to open surgery, and 13 (1%) had an R1 resection upon final histopathology. In the SBRT group, the median total dose was 50 Gray (Gy), most often given as 10 Gy in five fractions. All SBRT patients completed their entire treatment courses.  (1)

    On multivariate analysis, factors associated with SBRT selection included in the decision-making model were as follows: age, performance status of 2 or 3, previous pulmonary resection, MSK-Frailty score, FEV1, and DLCO.  (1)

    The prediction model created with these variables demonstrated an area-under-the-curve (AUC) of 0.902. Dr. Rocco and colleagues used the model to stratify 1,197 patients with calculable probability scores into three risk categories as follows:  (1)

  • 998 patients in the low-risk category (MIS = 970, SBRT = 28),
  • 149 patients in the intermediate-risk group (MIS = 96, SBRT = 53), and
  • 50 patients in the high-risk group (MIS = 10, SBRT = 40).
  • Within the intermediate-risk group of 149 patients eligible for either treatment modality, factors significantly associated with SBRT selection on multivariate analysis included hypertension (odds ratio (OR) = 0.39, p = 0.042) and COPD (OR = 3.09, p = 0.009). However, only age was identified as a predictor of OS, with a hazard ratio of 1.2 (p = 0.021).  (1)

    Outcomes after MIS and SBRT reflected the distinct characteristics of patients in each group. The rate of postoperative complication after MIS was 28%, and the rate of radiation-induced toxicity was 29% (p = 0.71). Rates of grade 3 or higher complications were similar — 4% for MIS and 3% for SBRT. (1)

    90-day mortality rates were also similar at 0.4% for MIS and 0.6% for SBRT (p = 0.58). Notably, the majority of deaths in both the SBRT (23 of 31 or 74%) and MIS groups (30 of 42 or 71%) died from causes unrelated to lung cancer. Within the intermediate-risk group, three-year OS was comparable at 83% for SBRT and 91% for MIS (p = 0.60). (1)

    "While our study did not have sufficient power to elucidate specific clinical variables associated with SBRT selection for intermediate-risk patients, we are currently prospectively collecting data for this cohort to address this gap," said Dr. Rocco.

    Main Takeaway

    "The choice of MIS or SBRT was not associated with OS in the overall cohort or the intermediate-risk group, suggesting that comparable outcomes are achievable for either treatment modality with careful patient selection," Dr. Rocco said. "Determining optimal treatment plans for intermediate-risk patients requires collaboration between multidisciplinary experts at high-volume centers, like MSK."

    Learn more about lung cancer clinical trials at MSK.

    This study was partly supported by the National Institutes of Health/National Cancer Institute Cancer Center Support Grant (P30 CA008748), and MSK's Fiona and Stanley Druckenmiller Research Center for Lung Cancer Research. Access disclosures for Dr. Rocco.

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    From Adventure To Adversity: Facing Extensive-Stage Lung Cancer

    Sponsored

    Vickie, 76, lives in Atlantic Beach, Florida. She aims to make the most of each day and stay active as she lives with extensive-stage small cell lung cancer (ES-SCLC).

    November 1, 2024 • Sponsored By Amgen

    Until I was diagnosed with lung cancer, I couldn't imagine that anything was seriously wrong with me.

    Two years before receiving the news, I would sometimes get intense chest pains. Despite numerous X-rays, hospital visits and even a cardiac catheterization to test my heart, doctors assured me I was healthy. I didn't question it further as I was so focused on my husband, Larry's, health. I stayed very active and dismissed the pain, never considering that it could be related to a serious health condition.

    In the summer of 2022, Larry and I vacationed in Michigan, with me spending hours paddle boarding, kayaking, and hiking. One morning, I woke up and was struggling to breathe. I couldn't take three steps without pain. At the nearby hospital, the doctor insisted on a CT scan, which revealed a large tumor in my left lung.

    I was in shock, thinking we should have caught this earlier. I remember feeling so mentally numb as I asked, "Okay - where do we go from here?"

    A biopsy of the tumor confirmed that it was small cell lung cancer, or SCLC. I didn't understand what that meant at first, but my doctor and care team explained that SCLC is a fast-growing and aggressive type of lung cancer.1

    As a former teacher, I appreciated how my doctor explained SCLC and provided guidance as we navigated treatment. When I was teaching, I always loved figuring out how to teach different students certain concepts because everyone learns differently. It can take a lot of patience, and I appreciate that my doctor took the time to make sure I understood my condition.

    After my diagnosis, I quickly began radiation and chemotherapy. During that time, a friend and I would walk a mile a day together, which gave me a goal and helped me to stay active. It was a really difficult time and those walks were challenging, but I felt good about myself that I accomplished them. My care team advised me that staying active could be good for me and those walks helped me through the most mentally challenging days.

    I finished treatment, and it appeared to be successful. My doctor explained that while many people with SCLC may respond initially to treatment, relapse is possible.1,2 A year later, I found out the cancer had metastasized when the doctors found a spot in my brain during a scan. This is also called "extensive stage" SCLC, or ES-SCLC, meaning the cancer has spread throughout one lung, both lungs or beyond the lungs to other parts of the body.3

    I underwent Gamma Knife radio surgery, which is a computer-guided form of radiation that delivers beams of energy on cancerous lesions in the brain, and they were able to remove the tumor which was in the balance area of my brain.4

    Of course, my first thought after that surgery was, "Can I still balance on my paddle board?" and I was happy to find I could still enjoy one of my favorite hobbies.

    In early 2024, I started chemotherapy again, because doctors continued to find nodules in my left lung. I worry about other spots appearing, but I trust my current care team and the treatment plan we have in place. I think of it as a whack-a-mole game – each time a new spot shows up, we quickly treat it.

    With this cancer, it would be easy to completely withdraw and pull into myself. I've made a conscious effort to stay active and connected with friends in my community and my family, who have been my greatest source of strength especially after my husband passed away earlier this year.

    My husband was my rock. We were married for 55 years, and he taught me the true meaning of love and perseverance. Despite the occasional moments of frustration, our love always saw us through. I'm blessed to be very close with our children, grandchildren, nieces and nephews, who have been my pillars of support. My daughter visits every weekend, and my son flies in from Texas for my treatments. My 14-year-old grandson writes me the sweetest cards. I cherish the times when everyone visits. I especially enjoy my time in Michigan where we gather around evening bonfires, roasting marshmallows and sharing stories. Going through cancer has shown me the importance of a strong support system like my friends and family that I can lean on throughout this journey.

    My advice is no matter how physically active and seemingly healthy one is; it is important to press for answers if you're experiencing any unexplained symptoms and find out what is happening. Looking back, I wish I had spoken up and advocated for myself earlier and taken those chest pains as a serious warning sign. I didn't know that an X-ray might not show lung cancer and that a CT scan was necessary for a more accurate picture.5 I advocate for every woman over the age of 50 who has ever smoked to receive a low dose CT scan as part of their yearly well checkups.6 Early detection has the potential to save lives!6

    I try to live in a bubble where I refuse to ruin this day with negative thoughts. I can make an appointment to deal with those thoughts and keep the feelings at bay until the appointment time when I can let my anger and frustrations out.

    To anyone who just received a lung cancer diagnosis or is undergoing their own journey, I'd encourage them to embrace it and be as open-minded as possible. Try to find joy and contentment every single day. Hang on to the things that you love dearly, the people you love dearly. Find your community and hold them close. 

    To learn more about ES-SCLC and information on a treatment option, visit SCLC-and-Me.Com.

    This information reflects the experience of one individual patient, Vickie. The experience of other patients may vary.

    ©2024 Amgen Inc. All rights reserved.

    References:

  • Sabari JK, et al. Nat Rev Clin Oncol. 2017;14:549-561.
  • Rudin CM, et al. Nat Rev Dis Primers. 2021;7:3.
  • American Cancer Society. Small Cell Lung Cancer Stages. Available at: https://www.Cancer.Org/cancer/types/lung-cancer/detection-diagnosis-staging/staging-sclc.Html. Accessed August 13, 2024.
  • Cleveland Clinic. Gamma Knife Surgery. Available at: https://my.Clevelandclinic.Org/health/procedures/16559-gamma-knife-surgery. Accessed August 13, 2024.
  • American Cancer Society. Tests for Lung Cancer. Available at: https://www.Cancer.Org/cancer/types/lung-cancer/detection-diagnosis-staging/how-diagnosed.Html. Accessed August 13, 2024.
  • American Cancer Society. Cancer Prevention & Early Detection Facts & Figures. Available at: https://www.Cancer.Org/research/cancer-facts-statistics/cancer-prevention-early-detection.Html. Accessed August 13, 2024.





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