Cardinale B. Smith

Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study

Objective To compare the survival and risk of serious adverse events in older patients with stages II-IIIA non-small cell lung cancer treated with or without postoperative platinum based chemotherapy. Design Observational cohort study. Setting Cases of lung cancer in Surveillance Epidemiology and End Results registry linked to Medicare files, 1992-2005, and follow-up data to December 2007. Participants 3324 patients aged more than 65 years with resected stages II-IIIA lung cancer. Main outcome measures Primary outcome was overall survival and secondary outcome was the rate of serious adverse events among older patients treated with or without adjuvant chemotherapy. Results Overall, 21% (n=684) of patients received platinum based chemotherapy. Analyses adjusted, stratified, or matched by propensity scores showed that chemotherapy was associated with improved survival (hazard ratio range 0.78-0.81). The beneficial effect of chemotherapy was also observed among patients treated with radiation therapy (0.75-0.77) or without radiation therapy (0.74-0.77); however, chemotherapy was not beneficial for patients aged 80 or more (1.32-1.46). Adjuvant chemotherapy was associated with an increased odds of serious adverse events (odds ratio 2.0, 95% confidence interval 1.5 to 2.6). Conclusions Platinum based adjuvant chemotherapy is associated with reduced mortality and increased risk of serious adverse events in older patients with stages II-IIIA lung cancer. The magnitude of the benefit is similar to that observed in randomised controlled trials carried out among selected patients.

Oncologist factors that influence referrals to subspecialty palliative care clinics.

PURPOSE Recent research and professional guidelines support expanded use of outpatient subspecialty palliative care in oncology, but provider referral practices vary widely. We sought to explore oncologist factors that influence referrals to outpatient palliative care. METHODS Multisite, qualitative interview study at three academic cancer centers in the United States with well-established palliative care clinics. Seventy-four medical oncologists participated in semistructured interviews between February and October 2012. The interview guide asked about experiences and decision making regarding outpatient palliative care use. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine themes related to palliative care referral decisions. RESULTS We identified three main oncologist barriers to subspecialty palliative care referrals at sites with comprehensive palliative care clinics: persistent conceptions of palliative care as an alternative philosophy of care incompatible with cancer therapy, a predominant belief that providing palliative care is an integral part of the oncologists role, and a lack of knowledge about locally available services. Participants described their views of subspecialty palliative care as evolving in response to increasing availability of services and positive referral experiences, but emphasized that views of palliative care as valuable in addition to standard oncology care were not universally shared by oncologists. CONCLUSIONS Improving provision of palliative care in oncology will likely require efforts beyond increasing service availability. Raising awareness of ways in which subspecialty palliative care complements standard oncology care and developing ways for oncologists and palliative care physicians to collaborate and integrate their respective skills may help.

Survival of patients with stage IV lung cancer with diabetes treated with metformin.

RATIONALE Prior studies have shown an anticancer effect of metformin in patients with breast and colorectal cancer. It is unclear, however, whether metformin has a mortality benefit in lung cancer. OBJECTIVES To compare overall survival of patients with diabetes with stage IV non-small cell lung cancer (NSCLC) taking metformin versus those not on metformin. METHODS Using data from the Surveillance, Epidemiology, and End Results registry linked to Medicare claims, we identified 750 patients with diabetes 65-80 years of age diagnosed with stage IV NSCLC between 2007 and 2009. We used propensity score methods to assess the association of metformin use with overall survival while controlling for potential confounders. MEASUREMENTS AND MAIN RESULTS Overall, 61% of patients were on metformin at the time of lung cancer diagnosis. Median survival in the metformin group was 5 months, compared with 3 months in patients not treated with metformin (P < 0.001). Propensity score analyses showed that metformin use was associated with a statistically significant improvement in survival (hazard ratio, 0.80; 95% confidence interval, 0.71-0.89), after controlling for sociodemographics, diabetes severity, other diabetes medications, cancer characteristics, and treatment. CONCLUSIONS Metformin is associated with improved survival among patients with diabetes with stage IV NSCLC, suggesting a potential anticancer effect. Further research should evaluate plausible biologic mechanisms and test the effect of metformin in prospective clinical trials.

Dyadic psychosocial intervention for advanced lung cancer patients and their family caregivers: Results of a randomized pilot trial

Advanced lung cancer (LC) patients and their families have reported low self‐efficacy for self‐care/caregiving and high rates of distress, yet few programs exist to address their supportive care needs during treatment. This pilot study examined the feasibility, acceptability, and preliminary efficacy of a 6‐session, telephone‐based dyadic psychosocial intervention that was developed for advanced LC patients and their caregivers. The program was grounded in self‐determination theory (SDT), which emphasizes the importance of competence (self‐efficacy), autonomy (sense of choice/volition), and relatedness (sense of belonging/connection) for psychological functioning. The primary outcomes were patient and caregiver psychological functioning (depression/anxiety) and caregiver burden. The secondary outcomes were the SDT constructs of competence, autonomy, and relatedness.

Survival After Segmentectomy and Wedge Resection in Stage I Non–Small-Cell Lung Cancer

Introduction: Although lobectomy is considered the standard surgical treatment for stage IA non–small-cell lung cancer (NSCLC), wedge resection or segmentectomy are frequently performed on patients who are not lobectomy candidates. The objective of this study was to compare survival among patients with stage IA NSCLC, who are undergoing these procedures. Methods: Using the Surveillance, Epidemiology and End Results registry, we identified 3525 patients. We used logistic regression to determine propensity scores for patients undergoing segmentectomy, based on the patient’s preoperative characteristics. Overall and lung cancer-specific survival of patients treated with wedge resection versus segmentectomy was compared after adjusting, stratifying, or matching patients based on propensity score. Results: Overall, 704 patients (20%) underwent segmentectomy. Analyses, adjusting for propensity scores, showed that segmentectomy was associated with significant improvement in overall (hazard ratio: 0.80, 95% confidence interval: 0.69–0.93) and lung cancer-specific survival (hazard ratio: 0.72, 95% confidence interval: 0.59–0.88) compared with wedge resection. Similar results were obtained when stratifying and matching by propensity score and when limiting analysis to patients with tumors sized less than or equal to 2 cm, or aged 70 years or younger. Conclusions: These results suggest that segmentectomy should be the preferred technique for limited resection of patients with stage IA NSCLC. The study findings should be confirmed in prospective studies.

Geritalk: Communication Skills Training for Geriatric and Palliative Medicine Fellows

Expert communication is essential to high‐quality care for older patients with serious illness. Although the importance of communication skills is widely recognized, formal curricula for teaching communication skills to geriatric and palliative medicine fellows is often inadequate or unavailable. The current study drew upon the educational principles and format of an evidence‐based, interactive teaching method to develop an intensive communication skills training course designed specifically to address the common communication challenges that geriatric and palliative medicine fellows face. The 2‐day retreat, held away from the hospital environment, included large‐group overview presentations, small‐group communication skills practice, and development of future skills practice commitment. Faculty received in‐depth training in small‐group facilitation techniques before the course. Geriatric and palliative medicine fellows were recruited to participate in the course and 100% (n = 18) enrolled. Overall satisfaction with the course was very high (mean 4.8 on a 5‐point scale). After the course, fellows reported an increase in self‐assessed preparedness for specific communication challenges (mean increase 1.4 on 5‐point scale, P < .001). Two months after the course, fellows reported a high level of sustained skills practice (mean 4.3 on 5‐point scale). In sum, the intensive communication skills program, customized for the specific needs of geriatric and palliative medicine fellows, improved fellows’ self‐assessed preparedness for challenging communication tasks and provided a model for ongoing deliberate practice of communication skills.

Perceptions of Palliative Care Among Hematologic Malignancy Specialists: A Mixed-Methods Study

PURPOSE Patients with hematologic malignancies are less likely to receive specialist palliative care services than patients with solid tumors. Reasons for this difference are poorly understood. METHODS This was a multisite, mixed-methods study to understand and contrast perceptions of palliative care among hematologic and solid tumor oncologists using surveys assessing referral practices and in-depth semistructured interviews exploring views of palliative care. We compared referral patterns using standard statistical methods. We analyzed qualitative interview data using constant comparative methods to explore reasons for observed differences. RESULTS Among 66 interviewees, 23 oncologists cared exclusively for patients with hematologic malignancies; 43 treated only patients with solid tumors. Seven (30%) of 23 hematologic oncologists reported never referring to palliative care; all solid tumor oncologists had previously referred. In qualitative analyses, most hematologic oncologists viewed palliative care as end-of-life care, whereas most solid tumor oncologists viewed palliative care as a subspecialty that could assist with complex patient cases. Solid tumor oncologists emphasized practical barriers to palliative care referral, such as appointment availability and reimbursement issues. Hematologic oncologists emphasized philosophic concerns about palliative care referrals, including different treatment goals, responsiveness to chemotherapy, and preference for controlling even palliative aspects of patient care. CONCLUSION Most hematologic oncologists view palliative care as end-of-life care, whereas solid tumor oncologists more often view palliative care as a subspecialty for comanaging patients with complex cases. Efforts to integrate palliative care into hematologic malignancy practices will require solutions that address unique barriers to palliative care referral experienced by hematologic malignancy specialists.

Validation of the lymph node ratio as a prognostic factor in patients with N1 nonsmall cell lung cancer

The number of positive lymph nodes (LNs) has been proposed as a prognostic indicator in N1 nonsmall cell lung cancer (NSCLC). However, the number of positive LNs is confounded by the number of LNs resected during surgery. The lymph node ratio (LNR) (the ratio of the number of positive LNs divided by the number of LNs resected) can circumvent this limitation. The prognostic significance of the LNR has been demonstrated in elderly patients with NSCLC. The objective of the current study was to evaluate whether a higher LNR is a marker of worse survival in patients with NSCLC aged ≤65 years who have N1 disease.

The Number of Lymph Node Metastases as a Prognostic Factor in Patients With N1 Non-small Cell Lung Cancer

BACKGROUND Lymph node (LN) status is an important component of staging; it provides valuable prognostic information and influences treatment decisions. However, the prognostic significance of the number of positive LNs in N1 non-small cell lung cancer (NSCLC) remains unclear. In this study we evaluated whether a higher number of positive LNs results in worse survival among patients with N1 disease. METHODS The Surveillance, Epidemiology, and End Results database was used to identify 3,399 patients who underwent resection for N1 NSCLC. Subjects were categorized into groups based on the number of positive nodes: one, two to three, four to eight, and more than eight positive LNs. The prognostic significance of the number of positive LNs in relation to survival was evaluated using the Kaplan-Meier method. Stratified and Cox regression analysis were used to evaluate the relationship between the number of positive LNs and survival after adjusting for potential confounders. RESULTS Unadjusted survival analysis showed that a greater number of N1 LNs was associated with worse lung cancer-specific (P < .0001) and overall (P < .0001) survival. Mean lung cancer-specific survival was 8.8, 8.2, 6.0, and 3.9 years for patients with one, two to three, four to eight, and more than eight positive LNs, respectively. Stratified and adjusted analysis also showed the number of N1 LNs was an independent predictor of survival after controlling for potential confounders. CONCLUSION The number of positive LNs is an independent prognostic factor of survival in patients with N1 NSCLC. This information may be used to further stratify patients with respect to risk of recurrence in order to determine postoperative management.

Postoperative radiotherapy for elderly patients with stage III lung cancer

The potential role of postoperative radiation therapy (PORT) for patients who have completely resected, stage III nonsmall cell lung cancer (NSCLC) with N2 disease remains controversial. By using population‐based data, the authors of this report compared the survival of a concurrent cohort of elderly patients who had N2 disease treated with and without PORT.