Original ArticlePrediction of 90 Day and Overall Survival after Chemoradiotherapy for Lung Cancer: Role of Performance Status and Body Composition
Introduction
Lung cancer is the most common cause of cancer death worldwide. In the UK, a 10 year survival rate of 4.9% remains disappointingly low [1]. Given that most patients with lung cancer are incurable at diagnosis, with survival typically measured in ‘months’ [2], targeting treatments at improved quality of life, extended life or both is the priority [3]. In general, more radical treatment options carry more significant side-effects and a greater patient burden. An informed understanding of the probable outcomes following radical treatments is therefore important for clinicians and patients alike, ahead of treatment plans being made.
Clinical decision making in lung cancer in the UK is informed by national guidelines [4], [5], which are underpinned by an extensive evidence base. However, the lung cancer population is typically elderly and multimorbid [2], [4], [5], [6], and such patients are under-represented in clinical trials. Indeed, a recent review of international lung cancer guideline concordance questioned the generalisability of clinical guidelines to ‘real world’ patients [7].
In addition to cancer treatment modality, a number of factors are known to influence prognosis in lung cancer, including disease stage [2], [6], [8], [9], age [2], [6], [8], gender [2], [6], performance status [2], [6], [9], [10], systemic inflammation [10], [11], [12], [13], comorbidity [2], [6], muscle wasting [11], [14], [15] and weight loss [8], [15], [16], [17], [18]. Cachexia, a complex syndrome encompassing many of these poor prognostic factors (namely weight loss, muscle wasting and systemic inflammation), is responsible for numerous negative patient outcomes in cancer [19]. However, it is not currently assessed or managed in any systematic or consistent way in the lung cancer clinic.
There is a lack of understanding about which predictive factors relate to early mortality (presumed to be a consequence of anti-cancer treatment) and which to reduced overall survival as a result of progressive cancer. The potential for severe adverse outcomes due to cancer treatment toxicity is well recognised [4], [5] and death within 30 days of systemic anti-cancer treatment is now a commonly used proxy for quality of care [20]. Death within the 90 day post-treatment period is of interest in surgical cancer populations [21] and in Scotland lung cancer mortality within 30 or 90 days of the receipt of anti-cancer treatment is a routinely collected quality performance indicator [22].
Where evidence does exist around prognostic and predictive factors, assimilating this into clinical decision making can be a challenge. Furthermore, there can be a lack of understanding by some patients that cancer treatment has the potential to do more harm than good. Evidence is needed to inform discussions between lung cancer clinicians and their real world patients about the probable benefits and the potential harms of treatment. It is only with this evidence that cancer treatments can be targeted most appropriately.
The aim of this retrospective cohort study was to identify predictive factors for 30 and 90 day mortality after chemoradiotherapy (CRT) for lung cancer, and factors that were prognostic for overall survival.
Section snippets
Materials and Methods
All patients diagnosed with lung cancer between 2008 and 2010 in South East Scotland given CRT were included in the retrospective cohort study. National Caldicott approval was granted for the collation of existing patient data.
Patient Characteristics at Diagnosis
Demographic and clinical characteristics at diagnosis for all 194 patients who underwent CRT for lung cancer diagnosed in South East Scotland between 2008 and 2010 are outlined in Table 1, Table 2. Most patients had either stage III NSCLC or limited stage SCLC, and were treated with concurrent CRT. Ninety per cent of patients had an ECOG performance status of 0/1. The mean BMI for both men and women was in the overweight (BMI > 25) category, with over half of women and nearly two-thirds of men
Discussion
Treatment with CRT for lung cancer is lengthy and often burdensome. The expectation for most patients is of significantly extended survival. Current criteria for starting treatment include disease stage and performance status. In the present study, 98% and 89% of patients, respectively, survived more than 30 and 90 days after the completion of CRT, thereby suggesting that, for most, these criteria are fit for purpose. For the 22/194 (11.3%) patients who died within 90 days, BMI < 20 and ECOG
Conclusions
The present study has identified three clinical variables (low performance status, low BMI and low muscle attenuation) associated with significantly reduced survival (early and late) after CRT for lung cancer. Further work is needed to validate these findings and to examine the relationship between comorbid illness, frailty and cachexia. Understanding more about actual causes of early death, including the relationship with treatment toxicity, should also be a priority. Patient selection for
Acknowledgements
This work is dedicated to the memory of Ken Fearon, Professor of Colorectal Surgery and world leader in cachexia research. His academic expertise and mentorship were so greatly valued and he is very sadly missed. The authors also wish to acknowledge the Melville Charitable Trust (funded J. Bowden research fellowship), Professor Gerry Humpris and Dr Damien Williams, University of St Andrews (MD supervisors of J. Bowden), SCAN lung cancer team.
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Died September 2016.