Report on the Lung Cancer Treatment

Abstract of Lung Cancer Treatment

Background: Non-Small Cell Lung Cancer has different treatments related to the stage of the cancer.  Stage 1 will require surgery, while stage 2 and 3 require surgery and different levels of adjuvant chemotherapy post-operatively.  Physicians do limited resections of complex lung tumors so they can help patients preserve life function, this method has shown a lower life expectancy and unestablished medical guidelines are to blame.  This study aims to analyze if non-small cell lung cancer patients with major comorbid conditions will have higher complications after lung cancer treatment.  

Methods: Used the California State Registry of patients with non-small cell lung cancer and matched them with the California Medicaid system. ICD codes were used to assess comorbidities; 12 months prior diagnosis and 30 days post-op. We limited our analyses to the primary round of treatment; second- and third-line chemotherapy is reserved for patients with recurrent (i.e., advanced) disease and thus, outside the scope of the study. In our analyses, we assessed potential interactions between patient, tumor, and treatment outcomes.

Results: 25,961 patients were analyzed from the California State Registry, 3.1% (n=811) had non-small-cell lung cancer diagnosis with one or more a major comorbid diagnosis 12 months prior to first round of chemotherapy as follows: COPD, Heart Disease, Chronic Kidney Disease and/or HIV. 17.9% (n=145) were hospitalized within 30 days due to complications from chemotherapy and 82.1% (n=666) were not hospitalized.  On a multivariate analysis, stage of the tumor (stage 4) had the highest hospitalization rate within 30 days following first round chemotherapy. When adjusted for age, gender, site of primary cancer, and seer stage, the patients with high Charlson Comorbidity Index (CCI ≥ 3) had 2.3 higher hospitalization rate compared to low CCI group (< 3).

Conclusion: By developing and maintaining strong surgical guidelines based on tumor stage, Surgeons can help preserve life function by following stricter established guidelines. Patients who had COPD, Heart disease, and/ HIV, had higher risk of complications especially in stage 3 of tumor.

Table of Contents of Lung Cancer Treatment:

List of illustrations and diagrams  of Lung Cancer Treatment

Introduction of Lung Cancer Treatment

Non-small cell lung cancer accounts for about 85% off all lung cancer diagnosis.

Compared to a small cell, non-small cell is a lot more insensitive to chemotherapy. Since most

lung cancer patients were past and current cigarette smokers, cardiovascular and chronic

obstructive pulmonary disease are common comorbidities. Earlier research by Lembicz et al. has shown that comorbid diseases with lung cancer, increase the risk of post-operative

complications will require more pre- and post-operative care. Another study exploring

the survival benefit of lung cancer therapies, found that treatment does help lung cancer patients

regardless of comorbidities but helped patients the most with lower KCI scores. This study aims to analyze if non-small cell lung cancer patients with primary comorbid conditions will have higher complications after first round of chemotherapy.

Specific Aims of Lung Cancer Treatment: 

Hypothesis

Non-small cell lung cancer patients with significant comorbid condition (Chronic obstructive pulmonary disease, coronary artery disease, heart failure, chronic kidney disease, and HIV infection) will have higher complications during lung cancer treatment.

Background

 Non-Small Cell Lung Cancer has different treatments related to the stage of

cancer. Stage 1 will require surgery, while stages 2 and 3 require surgery and different levels of

adjuvant chemotherapy posts operatively. Physicians opt to do limited resections of some complex lung tumors so they can help patients preserve life function. This method has shown a lower life expectancy and unestablished medical guidelines are to blame. There has been no randomized control trial examining the treatment of lung cancer with comorbidities. This research can help inform patients and clinicians on treatment recommendations, which can get crafted into treatment guidelines and promote better patient outcomes with non-small cell lung cancer.

Research question

Do non-small cell lung cancer patients with primary comorbid conditions have higher hospitalization rates 30 or less after first round of Chemotherapy?

The topic is a question of public significance because various researches, as it will be discussed below, show Non-small cell lung cancer patients with comorbid conditions on the limelight as experiencing complications as they undergo treatments of lung cancer.

Post-operative complications

According to Jeong, Choi, Yi, and Yoon (2017), the most preferred action for the individual patients having early-stage non-small cell lung cancer is radical surgical treatment (NSCLC). One of the qualifications for the above treatment should be a consideration of the associated risk of the comorbidity’s effects on the patient’s overall state. They also add that various risk factors are associated with the post-operative complications in a significant number of patients that undergo NSCLC. From their results section, Otake et al. (2016) found out that among the 39 % of the operated individual patients, a total of 151 patients was found to have experienced post-operative complications.  Belot et al. (2019) also found out that risk factors to post-operative complications included pneumonectomy, arrhythmias, and open thoracotomy during univariate analysis. They state that for significant complications, the risk factors for the patients included hypertension, arrhythmias, presence of comorbidities, and the age (65 years and above). On the other hand, during multivariant analysis, complications risk was higher among the patients who underwent pneumonectomy and having cardiac arrhythmias. This left the risk of severe complications among people with 65 or more years and suffering from comorbidities.

In their concluding remarks, Rios et al. (2018) note that the risk of post-operative complications is affected by the general health of the patients and the surgical factors of the patient. The population of the elderly individuals that have arrhythmias, hypertension, and chronic disease history have a very elevated risk of these complications (post-operative).  Having the knowledge of these factors will help in the identification of specific groups of patients that are in dire need of private consultation and optimization of both preoperative treatment and post-operative follow up.

Despite having an advancement in oncological treatments across the globe, lung cancer has still been found to be the leading cause of the depth from malignant neoplasia. The disease is usually because of long-term smoking, which results in a significant number of patients with coexisting diseases. The most preferred form of treatment of the diseases is Radical surgical treatment with the patients having early-stage non-small cell cancer. The determination for the therapy is that considerations should be put to identifying risks associated with general patient’s conditions. Kaniski et al. (2017) note that among the commonly accepted recommendations and the essential parameters regarded as the qualification of the treatment of the disease, is the stage of cancer and the functional parameters of the lungs. The impact of lung cancer patients on prognosis and oncological treatment has been among the top-notch discussions for many years. In some of the patients in their early stages of cancer, especially those that are candidates that have coexisting diseases play a significant role in determining the outcome.

On the other hand, patients who are in their early stages of cancer are candidates. Kanzaki et al. (2017) emphasize that there is a significant role that coexistence plays in determining the ultimate treatment of lung cancer. Some of the diseases that the patients may be having may prohibit the application of certain kinds of treatment methods like the original surgical method. Therefore, the existence of related illnesses acts as a significant factor of consideration in determining the treatment of the patient and the lung cancer stage. It thus remains a fact that among the non-small cell cancer patients with some of the existing diseases (comorbidity), are at a higher risk of experiencing a lot of complication s during the treatment. It is easy to treat a patient with associated diseases of the body. This is because, as Linden et al. (2019) state, it could pose many challenges in terms of solving a problem to create a more drastic one.

Linden et al. (2019) note that radical surgical treatment is the best method. It is a method of choice among early-stage patients with non-small cell lung cancer. However, they also argue that patients with lung cancer are usually the elderly with various comorbidities, especially the disease related to tobacco. The existence of the comorbidity, most of the time, affects the decisions of health specialists that qualify for the treatment of the patients who, in their professional judgment, prohibit aggressive therapy for the feat that it would result in a lot of complications. They also note that this has been and continues to be one of the significant clinical challenges for an internist or pulmonologist who majorly refers the patient for surgical treatment.

In the existing literature, there is an agreement that the disease severity and the extent of the surgery have a significant impact on the post-operative period. This was confirmed by the results from Shah et al. (2019) on non-small cell cancer patients.

Comorbidity profiles

 Shewale et al. (2020) argue that significant comorbidities (associated illnesses) are extremely prevalent among lung cancer patients because of the strong relationship between aging and smoking. The researchers state that cardiovascular diseases and pulmonary diseases are some of the dominant comorbid existing among patients. However, it is essential to note that patients having lung cancer are most likely to have several overlying states because of the shared risk factors. Sugarbaker, Haywood-Watson, and Wald (2016) acknowledge that comorbidity has a more significant effect on the management of lung cancer and has been authenticated as the more reliable predictor compared to the age for receipt of treatment of cancer. Several other studies on comorbidity impact on cancer of the lung have over time evaluated conditions considered as continuous estimations of burden illnesses. Tantraworasin et al. (2020) argue that since specific comorbidity has a probability of clustering within subgroups of specific patients, and have varying intercepting effects, promoted risk stratification might be deemed possible to help in exploring these relationships.

Non-small cell lung cancer patients often are likely to have a high profile. The proposed comorbidity profile might be used to provide an approach that would help in the risk stratification of patients with lung cancer disease for both research and clinical purposes (Kim et al., 2015). Patients who tend to have severe comorbidity conditions are most often not represented in the clinical trials of therapies. As a result, uncertainties in making decisions arise (Park et al. 2015). Therefore, the risk to benefit ratio is likely to be different in such individuals because of the risks associated with adverse surgical effects and complications.

Shibazaki et al. (2018) note that existing and possible interactions of comorbid conditions in their worst state are essential in the determination of optimal lung cancer treatment pathways. Some of the approaches to classify the grouping of the condition and their interactions with the outcomes of the disease like those described by Lembicz et al. (2018), may significantly allow for smooth prognostic evaluation and promote shared decision making.

Impact of comorbidities on lung cancer surgery

Zhao et al. (2017) argue that comorbidity has a significant association with increased perioperative mortality. In their research, Samson et al. (2016) identified that out of 15000 patients, those that had at least three comorbidities were found to have 2.5 times the risk of a patient who is hospitalized without any comorbidity. Some of the risks that accounted for 70 % were a history of cancer, smoking addiction, arterial hypertension, and disease of the heart. They also note that in another series of patients, a strong association was observed between the post-operative death and the charison index within 90 days.

Therefore, because of the progression of lung cancer, it is risky to delay surgery for many weeks. The short period, however, is meant to optimize the condition of the patient. Before the operation is carried out, therapeutic optimization of cardiac, renal diseases, respiratory and nutritional status is mandatory (Otake, Ohtsuka, Asakura, Kamiyama, and Kohno (2016). In the preoperative assessment, screening for obstructive sleep apnea should be carried out. Linden et al. (2019) note that pulmonary rehabilitation, physical therapy, and smoking cessation should be given out to reduce preoperative risks prolonged pulmonary disability. The researchers also note that complications are very early in non-small cell lung cancer patients that if no control is put, there can be very devastating effects of the treatment process, including the surgical treatment. For instance, they note that anticoagulant treatment should be progressed to reduce the risk of perioperative stroke. On the other hand, in patients with, for example, transient ischemic attack/ stroke following six months, there should be carotid revascularization before the real lung surgery.

Jeong et al. (2017) observe that a functional assessment should be carried out either before or after the demonstration of therapeutic optimization, which brings persistent high perioperative risk. They also note that the two exceptional circumstances that lead to consideration of the options of therapy are heart failure and lung function alteration. Long term functional disability from resection of lungs, perioperative morbidity, and mortality all depend on the resection extent as well as the preoperative lung function of the patients (Otake et al., 2016).

Impact of comorbidities on lung cancer radiotherapy

Radiation therapy helps in improving locoregional survival and control in patients having diagnosed with NSCLC. One of the most frequently used treatments, according to Belot et al. (2019) is the three-dimensional conformal radiation therapy in combination with surgery or chemotherapy. Stereotactic radiotherapy is a perfect alternative to the surgery from lung cancer stage T1T2A, of course, without involving those patients who are not eligible or refuse surgery. Rios et al. (2018) note that as these processes are compared, much care should be taken so that irradiation of the mediastinal tumors does not happen. Irradiated lung volume, the total dose, fractionation schedule, and dosimetric factors are all associated factors to the development of RP. Also, sequential and concurrent chemotherapy have been demonstrated as factors leading to increased RP risk. Some of the patient-specific risk factors could significantly influence the rate of symptomatic RP. Kaniski et al. (2017) showed that tumor location could have a significant influence on the risk of RP and that RP was more common among the patients who had a smoking history compared to those who never smoked. Nevertheless, the bottom line lies in the fact that sex and treatments, tumor location, age, and history of smoking are all factors that significantly influence the development of the complications among the NSCLC.

Lastly, Kanzaki et al. (2017) note that unlike other cancers like breast cancer, lung cancer, most of the time happens among the patients who have comorbid that could significantly prevent the realization of some symptomatic treatments and procedures. The high frequency of comorbidity is because there are no common risk factors. In some of the related situations, rehabilitations like the correction of metabolic disorders, could go ahead and allow treatments in most patients, including those who are frail.

Linden et al. (2019) state that lung cancer incident is much high in older individuals, and the prevalence of comorbidity is higher in this category of patients compared to younger patients. The impact of comorbid states on survival have attracted significant research interest, although there is inclusivity in their results. Some of the studies demonstrated that comorbidity is an independent prognostic factor for the survival of the NSCLC. However, the score does not consistently predetermine outcomes in patients, while some showing worse outcomes with increased comorbidities.

Shah et al. (2019) note that during the routine decision-making process and routine treatment selection process, comorbidity is overly not considered in cancer date sets design or included in the observational research. In many instances, many comorbid health issues are very severe that they affect directly individual survival and sometimes prohibit antineoplastic therapies of preference. Accurate comorbidity information alongside patent demographics, site for cancer, and tumor's morphological stage, are essential in cancer’s comprehensive risk adjustment. Effective risk adjustment is necessary for health service research and observation, including comparing outcomes of various treatments and quality assessment.

Nevertheless, Sugarbaker et al. (2016) note that survival among cancer patients is highly dependent on the characteristics of the patients, the pathology, and histology of the tumor. Diagnosis at the stages, comorbidity, and host tumor interactions are also additional factors. Every initial patient treatment is influenced by the comorbidity and the treatment effectiveness of patient care. Tantraworasin et al. (2020) demonstrate that less aggressive treatment of lung cancer is given to patients with lung cancer having existing comorbidity. Several diseases, such as the diseases in the question (comorbidity), are considered as having a substantial influence on the survival of patients who have lung cancer.

However, it is also essential to note that there is usually a significant problem in comorbidity issues. The coexistence of pulmonary disease before the diagnosis of the tumor of the lung may significantly delay lung cancer diagnosis. This is the reason why, supposedly, Kim et al. (2015) agree that estimating the risk of death among lung cancer patients has a significant role in choosing the type of oncological therapy. The Charlson Comorbidity Index is open of the commonly utilized comorbidity measures. It helps in the assessment of whether the patient will live long sufficiently to benefit from a certain measure of screening or medical intervention. Other comorbidity evaluation systems include mGPS and SCSS; they can also be utilized in evaluating various measurements.

Methods of Lung Cancer Treatment:

We retrospectively assembled a cohort from the California State Registry of patients with cancer diagnosis in 2018 (n=25,961) was matched with the California Medicaid system (22.1 million claims). The Medicaid system included demographic, clinical information (ICD-10 codes), and all consecutive information with lung cancer and specialized oncology data. The group was controlled for having comorbidities; ICD codes assessed the comorbidities for only COPD, Heart Disease, Chronic Kidney Disease and/or HIV; 12 months prior non-small lung cancer diagnosis (n=811) and hospitalization up to 30 days post first round chemotherapy were assessed. Multivariable logistic regression analysis was modeled to see the association between comorbidities and hospitalization after first round of Chemotherapy. During this cohort study, comorbidity is important in clinical prognosis, the Charlson Comorbidity Index (CCI) was used to separate the groups in the statistical models. The CCI predicts 1-year mortality for a patient for a total of 22 conditions, which included our control group conditions (COPD, Heart Disease, Chronic Kidney Disease and/or HIV). Each patient is assigned a score 1-6 depending on comorbidity and risk of dying. For the sake of the study we separated the groups that had ≥ 3 or < 3 CCI score.

Results of Lung Cancer Treatment:

25,961 patients were analyzed and controlled for comorbid diagnosis from 2018 California Cancer State Registry (COPD, Heart Disease, Chronic Kidney Disease and/or HIV). The criteria of study: comorbid conditions existed 12 months prior to small-cell lung cancer diagnosis and were given first round chemotherapy. 811 patients fit these characteristics and were eligible for this analysis. From the 811 patients, 145 (18%) were hospitalized within 30 after receiving first round of chemotherapy; the study group (n=145) demonstrated that hospitalization was higher at 30 days or less among patients with high Charlson score (≥ 3) compared to low CCI scores (< 3) 21% vs 13% (Graph1). 

 The stage of the cancer was significant in the determination if thEach patient was hospitalized, stage 4 in the admission group accounted for the 67% of the hospitalized group (n=145) (table1).  Stage 3 patients with comorbidities had the highest rate of hospitalization within 30 days of chemotherapy, and it is also worth noting that non-Hispanic white patients accounted from almost half all patients that were hospitalized within 30 days of first round chemotherapy (Table1). The admission and no admission group showed an age range from 54-73 years with 62 being the median. The multivariable analysis adjusted for age, gender, site of cancer, and SEER stage showed patients with more than a 3 CCI score were 2.3 likely to be hospitalized after first round of chemotherapy (table2).

Discussion of Lung Cancer Treatment

Individuals with non-small cell lung cancer with comorbidities face a tough time when it comes to the method of treatment of cancer. It is evident from all the researches mentioned above that the individuals are at a higher probability of experiencing a countless number of complications ranging from pre- to post-operative. Therefore, before any treatment method is administered to such individuals, many considerations are to be measured. Patients in this category are not eligible for any form of treatment available; many factors are considered. These factors consequentially to spread and increase. One of the most common comorbidities of respiration, which most of the time contributes to the delaying of the lung cancer diagnosis is pneumonia, silicosis, COPD, and residual tuberculosis. Shewale et al. (2018) argue that lung cancer is the most occurring malignancy on earth. It is one of the significant causes of death among a considerable number of individuals, especially those who smoke. It is the most common cancer identifiable in men and second in women, but because of the high mortality, it takes the first place across the two sexes. He wraps it all by stating that comorbidly like cardiovascular, pulmonary, and other systems may greatly influence lung cancer prognosis as well as complicate its treatment.

Discussion of Lung Cancer Treatment

As it has been explained in the previous sections of this study, there are a different treatment for non-small cell lung cancer related to cancer stages. Stage 1 seems to require surgery while both surgery and different levels of adjuvant chemotherapy post-operatively are required by stage 2 and 3. Although limited resections re performed by physicians for the preservation of life function, this method seems to have a lower life expectancy. Meanwhile, this research aimed to analyze if patients with non-small lung cancer have greater complications after the treatment of lung cancer.

            In this research, literature review was performed and California State Registry was used for patients with non-small cell lung cancer to match them with the California Medicaid system. Codes of ICD were utilized for assessing comorbidities. The analyses were limited to primary treatment round. Second and third-line chemotherapy was not considered in this study because it is for patients with advanced diseases. Thus, it was not included in this study.

            The literature review of different studies noted that with the treatment of non-small cell lung cancer, complications tend to arise. However, it is important to note that most studies indicated that there are several risk factors associated with post-operative complications. It has been determined that risk factors to these complications include arrhythmias, pneumonectomy, and even open thoracotomy during univariate analysis. In addition to these risk factors, some other risk factors include old age, presence of comorbidities. During multivariant analysis, it was determined that risk of complications was higher among patients who had cardiac arrhythmias and those patients who had undergone pneumonectomy.

            It is also important to note that survival among patients of cancer is dependent on the histology of tumor, pathology, and characteristics of patients with cancer. While treating these patients, some additional factors that need to be considered include host tumor interactions, comorbidity, and diagnosis. All initial treatments are affected by treatment effectiveness and comorbidity.

            Thus, it can be said that literature review suggests that the risk of post-operative complications is highly influenced by the general health of patients along with some surgical factors. Elderly individuals with a history of chronic diseases, hypertension, and arrhythmias have a high risk of post-operative complications. In terms of public health, these results will play an important role in the determination and identification of specific patients who require an efficient post-operative follow up and even private consultation.

            Meanwhile, when it comes to the results of this research, it has been determined that from 811 patients included, 18 percent were hospitalized within a month of receiving chemotherapy’s first round. It was demonstrated that hospitalization was quite higher for thirty days and it was less among patients who demonstrated high Charlson score. In addition to it, stage 3 patients had the highest hospitalization rate within thirty days as they had comorbidities. It was indicated by the multivariable analysis that patients with over 3 CCI score were twice as likely and possibly to be hospitalized after receiving the first routine of chemotherapy.

            Overall, the results determine that patients with non-small cell lung cancer tend to have higher rates of hospitalization as comorbid conditions are a risk factor. Other than just proving the hypothesis and answering the research question, the results of this research imply that for cancer patients with comorbidities, different treatment guidelines have to be considered. Other than just considering the guidelines, it is important to analyze and consider various risk factors that influence the rate of hospitalization and complexities. The consideration of these aspects can help in the treatment of cancer. In addition to it, it can serve to improve treatment results.

Conclusion of Lung Cancer Treatment

Patients who had COPD, Heart disease, and/ HIV had higher risk of complications especially in stage 3 of tumor. Different treatment guidelines are needed to treat patients with existing comorbidities to improve treatment outcomes.

Appendix of Lung Cancer Treatment

 References of Lung Cancer Treatment

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Otake, S., Ohtsuka, T., Asakura, K., Kamiyama, I., & Kohno, M. (2016). Impact of comorbidity index on morbidity and survival in non-small cell lung cancer. Asian Cardiovascular and Thoracic Annals, 24(1), 30-33.

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Otake, S., Ohtsuka, T., Asakura, K., Kamiyama, I., & Kohno, M. (2016). Impact of comorbidity index on morbidity and survival in non-small cell lung cancer. Asian Cardiovascular and Thoracic Annals, 24(1), 30-33.

Linden, S., Redig, J., Banos Hernaez, A., Nilsson, J., Bartels, D. B., & Justo, N. (2019). Comorbidities and relevant outcomes, commonly associated with cancer, of patients newly diagnosed with advanced non‐small‐cell lung cancer in Sweden. European Journal of Cancer Care, e13171.