Management of patients with early stage lung cancer - why do some patients not receive treatment with curative intent?

BACKGROUNDS: This study aims to understand the factors that influence whether patients receive potentially curative treatment for early stage lung cancer. A key question was whether indigenous Maori patients were less likely to receive treatment. METHODS: Patients included those diagnosed with early stage lung cancer in 2011-2018 and resident in the New Zealand Midland Cancer Network region. Logistic regression model was used to estimate the odds ratios of having curative surgery/ treatment. The Kaplan Meier method was used to examine the all-cause survival and Cox proportional hazard model was used to estimate the hazard ratio of death. RESULTS: In total 419/583 (71.9%) of patients with Stage I and II disease were treated with curative intent - 272 (46.7%) patients had curative surgery. Patients not receiving potentially curative treatment were older, were less likely to have non-small cell lung cancer (NSCLC), had poorer lung function and were more likely to have an ECOG performance status of 2+. Current smokers were less likely to be treated with surgery and more likely to receive treatment with radiotherapy and chemotherapy. Those who were treated with surgery had a 2-year survival of 87.8% (95% CI: 83.8-91.8%) and 5-year survival of 69.6% (95% CI: 63.2-76.0%). Stereotactic ablative body radiotherapy (SABR) has equivalent effect on survival compared to curative surgery (hazard ratio: 0.77, 95% CI: 0.37-1.61). After adjustment we could find no difference in treatment and survival between Maori and non-Maori. CONCLUSIONS: The majority of patients with stage I and II lung cancer are managed with potentially curative treatment - mainly surgery and increasingly with SABR. The outcomes of those being diagnosed with stage I and II disease and receiving treatment is positive with 70% surviving 5 years.

Management dilemma in metastatic papillary thyroid carcinoma.

Papillary thyroid cancer is the most common type of well-differentiated thyroid cancer. It is associated with a survival rate greater than 95% with appropriate treatment, particularly in younger patients. We present the unique case of a 25-year-old male with severe Autistic spectrum disorder (ASD) with a right level V neck mass of several months. Due to his severe ASD, his first assessment was conducted in the hospital foyer, and every subsequent clinical assessment and blood test required a general anaesthetic (GA). He was subsequently diagnosed with T2 N1b M0 (Stage I) papillary thyroid cancer. He required extensive multidisciplinary team (MDT) input to determine the goal for his treatment whilst taking into consideration perioperative care, wound management, compliance with exam and blood tests, radioactive iodine administration and lifelong medication requirements if total thyroidectomy was considered. Following multiple MDT and family meetings, the decision was made to proceed with right hemi-thyroidectomy, right level I-V and central neck dissection. He required one-week stay in the intensive care unit under sedation post-operatively, and was discharged from hospital a further six days later with no complications. He is currently being followed-up every six months which presents its own challenges. This case highlights the extraordinary challenges and considerations that need to be made when dealing with surgical pathology in a patient with severe intellectual disability, even in the setting of a relatively common surgical pathology.

Stereotactic ablative radiotherapy for early stage lung cancer and lung metastases in a New Zealand population.

AIM: Stereotactic ablative radiotherapy (SABR) involves the delivery of high doses of precisely targeted radiation in a shorter time period than conventional radiotherapy. The aim of this study was to compare the outcomes of lung-based SABR in a New Zealand cohort to the global literature. METHODS: A single-institution retrospective analysis was performed on all patients who received lung-based SABR between May 2015 and September 2019 at Waikato Hospital, New Zealand. The study included both early stage lung cancer and lung oligometastases that measured less than 5cm. RESULTS: 102 patients received SABR to 116 lesions. Median follow-up was 19 months. The three-year rate of local control in the primary and metastatic cohorts was 85% and 82%, respectively. This reflects the three-year local control rate of 86% for primary lung cancer in the SPACE trial and the two-year local control rate of 81% for pulmonary oligometastases in a German study. Central primary lung cancer was associated with a higher risk of local recurrence (HR6.4 (1.3-31.5) p=0.02). The three-year progression-free survival rate in patients with early stage lung cancer and oligometastases was 56% and 26%, respectively. Maori patients with primary lung cancer had a significantly worse progression free survival (HR2.4 (1.1-5.1) p=0.03). There were no reported grade three toxicities. CONCLUSION: The use of lung-based SABR in a typical radiotherapy setting in New Zealand mirrors global outcomes.

Outcomes after primary intensity-modulated radiation therapy for oropharyngeal squamous cell carcinoma at a New Zealand regional cancer centre: Impact of p16 status.

INTRODUCTION: The rising incidence of oropharyngeal squamous cell carcinoma (OPSCC) in New Zealand is due to an increase in the numbers of human papilloma virus (HPV)-associated OPSCC. We evaluated the impact of positive p16 immunohistochemistry, as a surrogate for HPV positivity, on OPSCC outcomes after primary intensity-modulated radiotherapy (IMRT) with or without concurrent chemotherapy. METHODS: Retrospective review was undertaken of electronic medical records of 90 patients with OPSCC who received primary IMRT with or without chemotherapy between 2008 and mid-2015 at the Regional Cancer Centre, Waikato Hospital, Hamilton, New Zealand. RESULTS: Median age was 57.5 years. Immunohistochemistry for p16 was positive in 53 (59%) OPSCC while 37 (41%) had negative or unknown p16 status. Median radiotherapy dose was 70 Gy. Chemotherapy was administered to 78 (87%) patients, most receiving high-dose cisplatin. Nine patients had residual disease following treatment completion. Seven patients relapsed, and 26 died during the study period. Five patients with p16-positive OPSCC had persistent or recurrent disease. Actuarial 3-year locoregional control, disease-free survival, and overall survival for all patients were 80.7%, 74.7%, and 77.1%, respectively. Among p16-positive OPSCC patients, 3-year locoregional control, disease-free survival, and overall survival were 89.5%, 80.8%, and 90.9%, respectively. CONCLUSION: Outcomes after IMRT for OPSCC at Waikato Hospital are in line with the reported literature. Human papilloma virus-related OPSCC has better outcomes compared with patients with unknown or HPV-unrelated OPSCC. Trials are underway evaluating reduced intensity of treatment for HPV-related OPSCC.

The New Zealand PIPER Project: colorectal cancer survival according to rurality, ethnicity and socioeconomic deprivation-results from a retrospective cohort study.

AIM: To investigate differences in survival after diagnosis with colorectal cancer (CRC) by rurality, ethnicity and deprivation. METHODS: In this retrospective cohort study, clinical records and National Collections data were merged for all patients diagnosed with CRC in New Zealand in 2007-2008. Prioritised ethnicity was classified using New Zealand Cancer Registry data; meshblock of residence at diagnosis was used to determine rurality and socioeconomic deprivation. RESULTS: Of the 4,950 patients included, 1,938 had died of CRC by May 2014. The five-year risks of death from CRC were: Maori 47%; Pacific 59%; non-Maori-non-Pacific (nMnP) 38%. After adjustment for demographic characteristics, comorbidity and disease stage at diagnosis, compared to nMnP the relative risk (RR) for Maori was 1.1 (95%CI: 0.8-1.3) and for Pacific 1.8 (95% CI: 1.4-2.5). We found no differences in risk of death from CRC by rurality, but some differences by deprivation. CONCLUSIONS: Disparity in outcome following diagnosis with CRC exists in New Zealand. Much of this disparity can be explained by stage of disease at diagnosis for Maori, but for Pacific peoples and those in deprived areas other factors may influence outcome. Further analyses of the PIPER data will explore the impact of any differences in management.

Methods of a national colorectal cancer cohort study: the PIPER Project.

AIM: Colorectal cancer is one of the most common cancers, and second-leading cause of cancer-related death, in New Zealand. The PIPER (Presentations, Investigations, Pathways, Evaluation, Rx [treatment]) project was undertaken to compare presentation, investigations, management and outcomes by rurality, ethnicity and deprivation. This paper reports the methods of the project, a comparison of PIPER patient diagnoses to the New Zealand Cancer Registry (NZCR) data, and the characteristics of the PIPER cohort. METHOD: National, retrospective cohort review of secondary care medical records (public and private) of all cases of ICD-10-AM C18-C20 on the NZCR in the calendar years 2007 and 2008 (main cohort) and an extended sample of Maori and Pacific cases, and non-Maori non-Pacific controls in 2006 and 2009 (extended cohort). RESULTS: Of the 6,387 patients identified from the NZCR 5,610 (88%) were eligible for PIPER. Reasons for exclusion were non-adenocarcinoma histology (3%) and non-colorectal primary (2%). Data were collected on 3,695 patients with colon cancer, 1,385 with rectal cancer and 466 with cancer of the recto sigmoid junction. CONCLUSIONS: The PIPER Project has generated comprehensive population level data detailing the diagnosis and management of colorectal adenocarcinoma in New Zealand. This will be used to assess the care provided to patients, and the impact of variations in care occurring between patient groups.

Effects of selenomethionine on acute toxicities from concurrent chemoradiation for inoperable stage III non-small cell lung cancer.

AIM: To prospectively determine the safety and tolerability of oral L-selenomethionine (SLM) with concurrent chemoradiation (CCRT) for Stage III non-small cell lung cancer (NSCLC) and estimate if the incidence and/or severity of adverse events could be reduced by its use. METHODS: Sixteen patients with stage III NSCLC were accrued to this single arm, phase II study. CCRT consisted of radiation given at 2 Gy per fraction for 30-33 fractions, 5 d per week with concurrent weekly IV paclitaxel 50 mg/m(2) followed by carboplatin dosed at an area under the time-concentration curve of 2. SLM was dosed in a loading phase at 4800 µg twice daily for one week prior to CCRT followed by once daily dosing during treatment. RESULTS: No selenium-related toxicity was observed. Analysis revealed grade 3 or higher esophagitis in 3 of 16 patients (19%), pneumonitis in 0, leukopenia in 2 (12.5%), and anemia in 1 (6%); the latter two were significantly reduced when compared to the protocol-stated expected rate of 35% (P = 0.045 for leukopenia, and P < 0.01 for anemia). Median overall survival was 14.9 mo and median failure-free survival was 9 mo (95%CI: 3.3-21.5). CONCLUSION: There may be some protective benefit of selenium in the setting of CCRT for inoperable NSCLC. The data suggests decreased rates of myelosuppression when compared to similarly-treated historical and contemporary controls. Further evaluation of selenium in this setting may be warranted.

Treatment of regional cutaneous nodular metastases from melanoma using high-dose rate mould brachytherapy.

INTRODUCTION: The involvement of a wide body surface area by regional cutaneous nodular metastases (RCNM) from melanoma poses a significant therapeutic challenge. We report our experience from Waikato Hospital, Hamilton, New Zealand in successfully treating this condition with high-dose rate (HDR) surface mould brachytherapy (BT). METHODS: We analysed six patients who had surgery and then developed RCNM, which was treated in our department by HDR mould BT using Iridium 192. Five out of six patients were treated with a dose of 30 Gy in five fractions to wide field with a further 6 Gy boost to tumour nodules. Our first patient received a higher dose of 36 Gy in six fractions followed by 6 Gy boost to tumour nodules. RESULTS: All patients experienced a complete response (CR). Median follow up was 23 months and side effects were minimal, only Radiation Therapy Oncology Group (RTOG) grade I/II early and late toxicity. To date, no in-field recurrence has been observed. Two patients died from metastatic disease at 33 and 34 months of follow up. CONCLUSION: There was a CR in all cases without in-field recurrence. To our knowledge, this is the first reported experience in treating skin melanoma with a BT surface mould. We recommend that BT surface mould should be considered when treating patients with RCNM.