Torben Palshof

Nationwide Quality Improvement in Lung Cancer Care: The Role of the Danish Lung Cancer Group and Registry

Introduction: To improve prognosis and quality of lung cancer care the Danish Lung Cancer Group has developed a strategy consisting of national clinical guidelines and a clinical quality and research database. The first edition of our guidelines was published in 1998 and our national lung cancer registry was opened for registrations in 2000. This article describes methods and results obtained by multidisciplinary collaboration and illustrates how quality of lung cancer care can be improved by establishing and monitoring result and process indicators. Methods: A wide range of indicators was established, validated, and monitored. By registration of all lung cancer patients since the year 2000, data on more than 40,000 patients have been included in the database. Results are reported periodically/quarterly and submitted to formal auditing on an annual basis. Results: Improvements in all outcome indicators are documented and statistically significant. Thus the 1-year overall survival rate has increased between 2003 and 2011 from 36.6% to 42.7%, the 2-year survival rate from 19.8% to 24.3%, and the 5-year survival rate from 9.8% to 12.1%. Five-year survival after surgical resection has increased from 39.5% to 48.1%. Improvements of waiting times, accordance between cTNM and pTNM, and resection rates are documented. Conclusion: The Danish experience shows that a national quality management system including national guidelines, a database with high data quality, frequent reports, audit and commitment from all stakeholders can contribute to improve clinical practice, improve core results, and reduce regional differences.

Data from a national lung cancer registry contributes to improve outcome and quality of surgery: Danish results

OBJECTIVE In 1998 The Danish Lung Cancer Group published the first edition of guidelines for diagnosis and treatment of lung cancer. A national registry was implemented in the year 2000 with the primary objective to monitor the implementation of these guidelines and nationwide to secure and improve the quality of the clinical management of lung cancer. The results of this effort are reported with special focus on surgery. METHODS Through systematic nationwide registration a total of 24,153 patients have been included in the period 2000-2007. Indicators describing staging, surgical procedures, complications and survival have been registered in those 5007 patients who underwent surgery. Using an Internet based closed circle with a safe program (firewall and encryptation) more than 95% of this subgroup of patients have been notified. Each year the results have been audited locally, regionally and nationally and improvements have been proposed, implemented, monitored and consecutively evaluated by the audit-plenary. RESULTS This strategy has been a contributory factor to significantly improve the results in mortality, survival and surgical procedures. Thus, the 30-days mortality following surgery has decreased from 5.2% to 3.6% and survival has increased from an overall 1- and 2-year survival of 69% and 50% in 2000 to 77% and 60% in 2007, respectively. A number of other key indicators were also improved: the lobectomy rate has increased from 54% to 73% and the pneumonectomy rate has decreased from 23% to 11%. The proportion of patients having surgery within 14 days from referral has increased from 69% to 87%. CONCLUSIONS Establishment of a national lung cancer group with the primary tasks to implement updated national guidelines and to secure valid registration of clinical baseline data and quality parameters has been a contributory factor to significantly improve the quality of lung cancer surgery.

MDR1 gene expression and drug resistance of AML cells

We investigated the cellular drug resistance to aclarubicin (Acla), cytosine arabinoside (Ara‐C), daunorubicin (Dau), doxorubicin (Dox), etoposide (Etop) and mitoxantrone (Mitox) using the MTT assay at time of disease presentation in 93 cases of acute myeloid leukaemia (AML). In 31 cases we concomitantly investigated MDR1 (multiple drug resistance 1 gene) expression (semi‐quantitative competitive RT‐PCR) of the leukaemic cells. Drug resistance towards Dau, Dox and Etop was correlated to the MDR1 expression of the AML cells (P < 0.05) with high MDR1 expression being associated with high drug resistance towards these drugs. Although the data did not allow firm conclusions to be drawn on the correlation between MDR1 expression and drug resistance towards Ara‐C and Mitox, the drug resistance towards Acla clearly was not correlated to, or dependent on, the MDR1 expression level of the AML blast cells. In addition, when examining the cross‐activities among the six drugs distinct patterns emerged. Thus, high to very high degrees of cross‐activity were found to exist between Dau, Dox, Etop and Mitox, whereas Ara‐C had moderate cross‐activity with the other drugs except Acla, which showed absent to moderate cross‐activity with the other drugs. We conclude that MDR1 gene expression is of significance for cellular drug resistance towards specific (MDR1‐related) drugs in AML, whereas it is not of significance regarding drug resistance towards other drugs, which is the case with the anthracycline Acla. We suggest that in the place of other more or less complicated ways to circumvent MDR1‐mediated drug resistance, Acla may be used to replace Dau, Dox and other MDR1‐related drugs if proven as potent as the drug it is to substitute.

Relation of blast cell survival and proliferation to chemotherapy resistance in AML.

We have investigated the in vitro blast cell survival (viability) and drug resistance to cytosine arabinoside (Ara‐C), daunorubicin (Dau), mitoxantrone (Mitox) and aclarubicin (Acla) of fresh leukaemic blast cells from 80 patients with newly diagnosed acute myeloid leukaemia (AML) employing the semiautomated colourimetric MTT(3‐[4,5‐dimethylthiazol‐2‐yl]‐2,5‐diphenyl tetrazolium bromide)‐assay. In 15 cases we concurrently investigated the relation between in vitro blast cell survival (MTT assay) and blast cell proliferation (3H‐thymidine incorporation) in the presence and absence of myeloid growth factors (GFs) G‐CSF, GM‐CSF and IL‐3 (individually and in combination). A highly significant correlation was found between blast cell survival and blast cell proliferation (r = 0.87, P < 1 × 10−4). Furthermore, in 40 evaluable adult patients who completed intravenous induction chemotherapy and were evaluable for response to chemotherapy we found a positive correlation between in vitro blast survival (MTT assay) and response to chemotherapy with high blast survival being associated with poor response to chemotherapy (P = 0.05). Moreover, in a multivariate analysis, high blast cell survival was significantly associated with high CD13 expression and monocytic phenotype (P = 0.0003 and P = 0.02, respectively). Furthermore, we found an inverse relationship between the baseline proliferation of the blasts and the magnitude of response to the GFs (P < 0.02), indicating that cells with low baseline proliferation were more readily stimulated by growth factors. Finally, we found a significant correlation between leukaemic cell survival and cellular drug resistance towards Dau (P = 0.001) and Mitox (P = 0.03), but not towards Ara‐C (P = 0.68) and Acla (P = 0.13). We conclude that high in vitro leukaemic cell survival is associated with drug resistance in vivo and in vitro, and furthermore is correlated with high blast cell proliferation and some adverse prognostic factors previously identified in AML.

Pretreatment leukaemia cell drug resistance is correlated to clinical outcome in acute myeloid leukaemia

Abstract: In 85 adult patients diagnosed with acute myeloid leukaemia (AML) and treated at the same institution during a 5‐yr period, the clinical significance of in vitro cellular drug resistance to the anthracyclines aclarubicin (Acla) and daunorubicin (Dau) as well as the nucleoside analogue cytarabine (Ara‐C) was investigated using a 4‐d MTT (3‐[4,5‐dimethylthiazol‐2‐yl]‐2,5‐diphenyl tetrazolium bromide) assay. In 59 patients of whom 40 were treated by the combination of Acla and Ara‐C we found that leukaemia cell drug resistance towards Acla was higher (by a factor 2.80) in patients who failed to enter complete remission (CR) after the first cycle of induction chemotherapy as compared to patients who entered complete remission. The relationship was significant in univariate as well as multivariate analysis (p=0.02 and 0.03, respectively). By contrast, no in vitro single drug resistance values were consistently correlated to other parameters of clinical outcome (overall CR rate, overall survival (OS), or continuous complete remission (CCR)), whereas the combined Acla and Ara‐C drug resistance profile (Acla/Ara‐C DRP) was of prognostic significance to overall survival of all 85 patients (p=0.004) as well as to the CCR of 39 complete responders (p=0.04). These findings remained statistically significant in multivariate analyses correcting for other variables influencing clinical outcome including patient age, leukocyte count, karyotype, FAB‐subtype, and presence/absence of secondary AML. We conclude that the in vitro drug resistance of leukaemia cells at time of disease presentation appears to be independent of prognostic significance to short‐ and long‐term clinical outcome in AML.

Synergistic and antagonistic effects of myeloid growth factors on in vitro cellular killing by cytotoxic drugs.

The effect of stimulating acute myeloid leukemia blast cells with a combination of growth factors (G-CSF, GM-CSF, and IL-3) on cellular resistance to the antileukemia drugs Ara-C, daunorubicin, aclarubicin, and mitoxantrone was studied. For assessment of in vitro cellular drug resistance the MTT assay was employed. Stimulated cells showed enhanced sensitivity to Ara-C (p < 0.02), whereas a significant increase in cellular drug resistance to daunorubicin (p < 0.02) was observed. Variable and statistically non-significant changes in drug resistance to aclarubicin and mitoxantrone was induced by stimulation of the blast cells. We conclude on the basis of these observations that myeloid growth factors should be used with caution in combination with daunorubicin in AML treatment until further confirmatory evidence has been presented by other investigators.

Relevance of in Vitro Leukaemia Cell Survival to Short- and Long Term Clinical Outcome in AML

In ninety-three cases of newly diagnosed acute myeloid leukaemia (AML) we investigated the importance to short- and long term clinical outcome of the in vitro short term leukaemia cell survival as measured by a 4-day MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide)-assay. In 67 patients treated by intravenous remission induction therapy we found that patients who after the first induction cycle or after induction therapy overall achieved a complete remission (CR) had leukaemia cells with significantly lower in vitro cell survival ability than cells of non-responders (p = 0.02 and 0.06, respectively). These relations remained statistically significant in subsequent multivariate analyses. Likewise, a favourable effect of low in vitro leukaemia cell survival on overall survival of the patients was detected in the (largest) subgroup of adult patients treated uniformly by the same remission induction regimen as well as in all patients. However, in the 44 patients, who achieved CR, the in vitro leukaemia cell survival did not show significance to remission duration or time to first relapse. Furthermore, the leukaemia cell survival (MTT-assay) did not to correlate with the Bcl-2 expression level (quantitative flow cytometry) of the leukaemia cells (r = 0.18, n = 34, p = 0.32). In addition, in a cell line model employing the growth factor dependent MO7 human AML cell line, growth factor withdrawal was associated with rapid onset of cellular apoptosis as evaluated by morphology, occurrence of a subG1 peak in DNA histograms, and loss of cellular activity in the MTT-assay. In contrast, a more moderate decline in Bcl-2 expression and gradual loss of ability to exclude the trypan blue dye was seen in the leukaemia cells in response to growth factor withdrawal. We conclude, that the MTT-assay provides a simple and sensitive method for measuring in vitro cell survival. The differences in leukaemia cell survival seen in AML may well be clinically relevant and may help to provide a better understanding of clinical drug resistance.

Peripheral blood accessory cells modulate committed colony-forming units but not 5-week cobblestone-area-forming cell outgrowth from CD34+ cells.

Abstract: While cellular modulation in vitro of committed hematopoietic stem cell (HSC) growth has been known for some time, less is known about the effect of accessory cells (AC) on the growth of more immature HSC. We have examined the effect of peripheral blood (PB) AC on hematopoiesis by coculturing enriched PB CD34+ cells (> 96% pure) with different quantities of CD34− cells (< 1% contamination) harvested from 10 breast cancer patients. As expected colony growth was predominantly present in the CD34+ fractions, in which colony forming units granulocyte‐macrophage (CFU‐GM) varied between 89–3289/105 (median 1422/105 seeded cells) and week 5 cobblestone area forming cells (CAFC) between 64–1330/105 (median 427/105 seeded cells). Few CFU‐GM (0–27/105 seeded cells) and no week 5 CAFC (0–1/105 seeded cells) were present in the CD34− fractions. The addition of PB CD34− cells to cultures of CD34+ cells resulted in a considerable variation in the cloning efficiency at the CFU‐GM level, and the extent of modulation within the single patient was inconsistent between the different CD34+/CD34− cell mixtures. Overall the stimulatory effect was more pronounced than inhibition and on average the CFU‐GM formation per CD34+ cell seeded increased 3 fold (stimulatory effect ranged between 3–17 fold and decreases between 2–10 fold). In contrast, the cloning efficiency at the week 5 CAFC level of differentiation remained unaffected by the addition of different amounts of CD34− cells (the stimulatory effect was maximally 3‐fold and inhibition 3‐fold). We conclude that while the CFU assay is modulated by the presence of AC, the CAFC assay is more robust and can be employed as a reliable and reproducible tool for HSC measurement.

Two years of tamoxifen or no adjuvant systemic therapy for patients with high-risk breast cancer: long-term follow-up of the Copenhagen breast cancer trial

Abstract Background: The Copenhagen Breast Cancer Trial (CBCT) randomly assigned patients with early breast cancer to two years of tamoxifen or placebo and we evaluated the effect over the following four decades. Patient and methods: Between 1975 and 1978, 327 patients with primary breast cancer were randomly assigned to two years of daily placebo or tamoxifen. Survival statistics was collected from the Danish Civil Registration System. Results: The five-year invasive breast cancer recurrence (BCR) rate was 43.2% in the placebo arm and 31.9% in the tamoxifen arm. Compared with the placebo arm the hazard ratio for a BCR event was 0.73 in the tamoxifen arm (p = .07). With an estimated median follow-up on overall survival of 40.9 years, 154 and 145 patients had died in the placebo and tamoxifen arm, respectively. After adjustment for baseline characteristics a significant reduction in mortality was obtained from tamoxifen (HR 0.79; p = .04). Conclusion: Two years of adjuvant tamoxifen resulted in a sustained reduction in mortality in pre- and postmenopausal high-risk breast cancer patients with long-term follow-up data.

The value of HRCT and Tc-depreotide in the evaluation of pulmonary lesions.

Lung cancer is one of the most common cancers worldwide, and the overall incidence continues to increase. Despite advances in treatment, the overall 5-year survival is still approximately 10% to 15%. A better therapeutic impact depends on the ability to diagnose the cancer in an early stage. When the suspicion of lung cancer is raised, a computed tomographic (CT) scan is necessary. A number of screening studies of lung cancer have been published.1–4 In these studies, the sub-centimeter, non-calcified lesions were identified in 30% to 60% of cases. However, only 1% to 3 % of these lesions turned out to be malignant. Thus, the final diagnosis can not rely on CT alone; invasive procedures are needed. Imaging-guided fine-needle aspirations have an overall accuracy of 64% to 100% for detecting malignancy,5,6 and bronchoscopy-guided biopsies of centrally located lesions have an accuracy of 70% to 90%.7 Follow-up CT is therefore still needed in a number of patients. Recently, new techniques for detecting lung cancer have become available. It seems that refinement of the CT technique with high-resolution CT (HRCT) in subgroups of lesions increases the specificity solely by morphological characterization, thereby reducing the need for invasive procedures.8,9 Thus, Furuya et al.8 found an accuracy for malignancy of more than 93% by using specific morphologic criteria on HRCT. Nuclear medicine methods have also emerged. The high level of somatostatin receptor expression on various tumor cells has provided the molecular basis for the successful use of radiolabeled somatostatin analogs as tumor tracers. Somatostatin-receptor scintigraphy is a well documented method of diagnosing neuroendocrine tumors10 and has been used since 1989. Furthermore, it has been shown to be able to detect both small cell lung cancer (SCLC), which possesses neuroendocrine characteristics, as well as non-small cell lung cancer (NSCLC).11 Until recently, an Indium-labeled somatostatin analogue, octreotide, was the only tracer used for imaging. However, in 2000, a Tc-labeled somatostatin analogue depreotide became commercially available for scintigraphic imaging of suspected malignant tumors in the lung. So far, studies have found that Tc-depreotide has a high sensitivity for detecting lung cancer (89% to 100 %) but low specificity (43% to 73%).12–19 F-fluoro-2-deoxy-D-glukose (FDG) positron emission tomography (PET) has an integral role in the management of many oncological tumors, including lung tumors, in regard to characterization and staging.20 However, compared with single emission computerized tomography (SPECT) scanners, PET scanners are still more costly, and availability is still rather limited, even in developed countries. The aim of this study was to assess the diagnostic impact of HRCT and Tc-depreotide separately and in combination among patients with pulmonary lesions demonstrated by conventional CT.