Routine Lung Cancer Research Articles

P4.15E.02 Acceptability and Feasibility of Integrating A Chatbot into Routine Lung Cancer Care: Patient and Clinician Perspectives

P4.15E.02 Acceptability and Feasibility of Integrating A Chatbot into Routine Lung Cancer Care: Patient and Clinician Perspectives

Clinician perspectives on delivering primary and specialty palliative care in community oncology practices.

Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities. Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment. Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%). Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.

AI-based diagnosis of chronic obstructive pulmonary disease from low-dose CT images

Background: Chronic obstructive pulmonary disease (COPD) is a group of diseases characterized by airflow blockage. It is one of the leading causes of global mortality and is primarily attributed to smoking. COPD patients are usually diagnosed by spirometry test. Although regarded as the gold standard for COPD diagnosis, the spirometry test carries contraindications, thus prompting the development of low-dose computed tomography (low-dose CT) scan as an alternative for COPD screening. However, a practical limitation of diagnosing COPD from CT images is its reliance on the expertise of a skilled radiologist. Objective: To address this limitation, we aimed to develop a deep-learning model for the automated classification of COPD and non-COPD from low-dose CT images. Materials and methods: We examined the potential of a convolutional neural network for identifying COPD. Our dataset consisted of 10,000 low-dose CT images obtained from a lung cancer screening program, involving both ex-smokers and current smokers deemed at high risk of lung cancer. Spirometry data served as the ground truth for defining COPD. We used 90% of the datasets for training and 10% for testing. Results: Our developed model achieved notable performance metrics: an area under the receiver operating characteristic curve (AUC) of 0.97, an accuracy of 0.89, a precision of 0.85, a recall of 0.96, and an F1-score of 0.90. Conclusion: Our study demonstrates the potential of deep learning models to augment clinical assessments and improve the diagnosis of COPD, thereby enhancing diagnostic accuracy and efficiency. The findings suggest the feasibility of integrating this technology into routine lung cancer screening programs for COPD detection.

Deep learning analysis of epicardial adipose tissue to predict cardiovascular risk in heavy smokers

BackgroundHeavy smokers are at increased risk for cardiovascular disease and may benefit from individualized risk quantification using routine lung cancer screening chest computed tomography. We investigated the prognostic value of deep learning-based automated epicardial adipose tissue quantification and compared it to established cardiovascular risk factors and coronary artery calcium.MethodsWe investigated the prognostic value of automated epicardial adipose tissue quantification in heavy smokers enrolled in the National Lung Screening Trial and followed for 12.3 (11.9–12.8) years. The epicardial adipose tissue was segmented and quantified on non-ECG-synchronized, non-contrast low-dose chest computed tomography scans using a validated deep-learning algorithm. Multivariable survival regression analyses were then utilized to determine the associations of epicardial adipose tissue volume and density with all-cause and cardiovascular mortality (myocardial infarction and stroke).ResultsHere we show in 24,090 adult heavy smokers (59% men; 61 ± 5 years) that epicardial adipose tissue volume and density are independently associated with all-cause (adjusted hazard ratios: 1.10 and 1.38; P < 0.001) and cardiovascular mortality (adjusted hazard ratios: 1.14 and 1.78; P < 0.001) beyond demographics, clinical risk factors, body habitus, level of education, and coronary artery calcium score.ConclusionsOur findings suggest that automated assessment of epicardial adipose tissue from low-dose lung cancer screening images offers prognostic value in heavy smokers, with potential implications for cardiovascular risk stratification in this high-risk population.

SAT199 Intrathyroidal Parathyroid Adenomas: A Case Series

Abstract Disclosure: B.K. Bowens: None. D. LaChance: None. M.K. Shakir: None. T.D. Hoang: None. Background: Primary hyperparathyroidism (PHPT) is a relatively common condition which affects 1-7 people per 1000. However, intrathyroidal parathyroid adenomas (ITPA) have a prevalence of 1.3% to 6.7%. In this case series, we report 3 cases of ITPA. Case 1: 66-year-old male with a history of PHTP without intervention at initial diagnosis presented to Endocrinology several years after initial diagnosis due to an incidental thyroid nodule on routine CT lung cancer screening. Parathyroid hormone (PTH) level found to be 109.3 from a previous level of 80 (ref 10-55pg/mL) in the setting of mild hypercalcemia and osteopenia. Initial bedside thyroid ultrasound was suggestive of a right ITPA. Parathyroid scan, formal thyroid US and CT gated scan revealed a 1.5cm parathyroid adenoma (PA) posterior to the right superior aspect of the thyroid gland. Fine Needle Aspiration (FNA) was completed with PTH washout of 399.40 pg/mL. Right superior parathyroidectomy confirmed ITPA due to an intrathyroidal parathyroid adenoma Case 2: 44-year-old female presented with 9 months of fatigue and was diagnosed with PHPT. Her PTH level was 167 with a serum calcium of 10.9 (ref 8.5-10.4 mg/dL). CT SPECT with tech-99M sestamibi was positive for a right parathyroid adenoma. Explorative surgery did not localize parathyroid adenoma. Thyroid ultrasound revealed a 9mm hypoechoic lesion in the right inferior lobe with polar artery. FNA of this lesion was completed with PTH washout of 4737 pg/mL. Right hemi-thyroidectomy was completed with resolution of PHTP. Case 3: 54-year-old male with history of PHPT and carcinoma of the right kidney s/p nephrectomy presented with persistent hypercalcemia. Serum calcium of 10.2-11.0 mg/dL and PTH of 160-186 pg/mL. Thyroid US showed a 1.1cm hyperechoic, cystic nodule in the left inferior thyroid lobe. Sestamibi was consistent with ITPA. FNA of left thyroid mass with PTH washout of 2602 pg/mL. Parathyroidectomy with left thyroid lobectomy was completed with resolution of hypercalcemia. Discussion: PHPT is a common endocrinopathy with 85% of cases due to PAs, 15% due to parathyroid hyperplasia, and &amp;lt;1% due to carcinoma. ITPAs have an incidence of 1.3% to 6.7% and are due to improper embryologic migration. Sestamibi parathyroid scan allows for localization of PA and for minimally invasive procedures. Other imaging modalities include SPECT, US, SPECT-CT, and MRI. PTH washout with more than 101 pg/mL confirms the presence of parathyroid tissue or adenoma. Conclusion: This is a rare presentation of a common endocrinopathy. These patients were noted to have PHTP. Initial exploratory neck dissections did not localize. FNA and US were able to confirm IPTAs and hemi-thyroidectomy was needed for definitive management with resolution of PHTP. Presentation: Saturday, June 17, 2023

Deep learning-based characterization of the drug tolerant persister cell state in lung cancer.

141 Background: Lung cancer is the leading cause of cancer-related lethality globally. Targeted therapies improve the clinical outcome of cancer treatment; however, a subpopulation of cancer cells survive during initial therapy and evolve into drug tolerant persister cells (DTPs) that maintain a residual disease reservoir. Residual disease preludes acquired resistance and tumor progression; therefore, identifying and eliminating DTPs could benefit future treatment paradigms. We have shown that Hippo pathway effector YAP1 (Yes Associated Protein-1) is activated in oncogene-driven lung cancers when cancer cells are exposed to various targeted therapies, such as EGFR, ALK, and RAS inhibitors. YAP1 transcriptional activation during targeted therapy is characterized by its increased nuclear localization and interaction with transcription factors. This activation promotes the expression of genes involved in cell survival, cellular plasticity, and metabolic reprogramming at the residual disease state. We hypothesized that detection of intrinsic or acquired persister cells may aid the development of optimized treatment regimens. In this study, we are building image-based deep learning models to identify YAP1 activation-mediated DTPs from histologically stained slides. Methods: H&amp;E or YAP-stained immunohistochemistry (IHC) images from clinical lung cancer and patient-derived tumor xenograft samples were collected throughout targeted therapy and were annotated with semi-automation using high performance computing clusters. A deep learning model (U-Net algorithm) was used for image segmentation, training, validation, and testing. Results: 1638 images were annotated and over 80,000 patches from these images for YAP positive cells (or regions of interest) comprised the training dataset with semi-supervised automation. Subsequently, we built a customized deep-learning model to detect YAP-mediated DTP cell states from whole histopathological image slides. The deep learning-based model achieved excellent accuracy of 0.8238 and 0.9091 in training, and 0.8040 and 0.8949 in validation datasets for two different annotations, respectively. For a test dataset, the model obtained 0.81 and 0.902 accuracy for the two annotations, respectively. Conclusions: We have constructed a deep learning convolutional neural network model to infer the presence of the YAP1 activation-mediated drug tolerant persister cell state prior to or during targeted treatment of lung cancer. Implementing our AI-based model into routine lung cancer care in the future could identify patient subpopulations with YAP1 activated tumors who would most benefit from receiving YAP1-targeted small molecule inhibitors.

Rates of colorectal cancer screening versus lung cancer screening: Where does the problem lie?

e22504 Background: In 2021, the U.S. Preventive Services Task Force recommended expanding the population who should undergo routine lung or colorectal cancer screening to include those between 50 and 80, with a 20-pack or more smoking history, and those who are currently smoking or have quit within the last 15 years. According to the Centers for Disease Control, 74.3% of the at-risk population undergo colorectal cancer screening. In contrast, according to the American Lung Association, only 5.8% of the eligible population undergoes lung cancer screening. Methods: This is a retrospective analysis of 158 patients who underwent colorectal cancer screening by colonoscopy between July 2022 and October 2022 at a high-volume hospital in Indiana. Patients were followed up in their primary care office between November 2022 and January 2023 to assess if they had also met the screening criteria for lung cancer with a low dose computed tomography (LDCT) scan. Patients who met the lung screening criteria were interviewed at their subsequent primary care appointment to evaluate their knowledge, attitudes, and compliance with lung cancer screening. Results: Of the 158 participants, 86 (54.4%) met the criteria for lung cancer screening with a LDCT. Only 5 (5.8%) of the eligible subjects underwent LDCT screening. 72 of the 81 patients who were not screened for lung cancer had scheduled follow-ups with their primary care provider during the study time frame. Of these 72 patients, 45 (62.5%) lacked knowledge about LDCT and lung cancer screening, despite meeting the criteria for it. 22 (30.5%) did not think they needed a LDCT, and 5 (6.9%) had no interest in screening despite previous awareness. All 72 patients who had colorectal cancer screening but not lung cancer screening were asked why they underwent the former but not the latter. 68 (94.4%) indicated that colonoscopy was recommended to them and that they knew someone in their families who had it done. Conclusions: Colon cancer screening rates remain high compared to lung cancer screening rates in an at-risk population. A lack of knowledge from patients is the primary reason for not receiving LDCT, despite receiving colon cancer screening.

ERBB2 exon 20 insertions are rare in Brazilian non-small cell lung cancer.

ERBB2 exon 20 insertions may impact the clinical management of lung cancer patients. However, the frequency of ERBB2 exon 20 insertions in lung cancer patients in Brazil is scarce. Here, we analyzed 722 Brazilian non-small cell lung cancer (NSCLC) patients from Barretos Cancer Hospital that were indicated to require routine lung cancer molecular testing. ERBB2 exon 20 insertions were evaluated by a targeted panel using next-generation sequencing (NGS). Clinicopathological and molecular data were collected from patient medical records. Among the 722 NSCLC patients, 85.2% had lung adenocarcinomas, 53.9% were male, 66.8% were quitter or current smokers, and 63.2% were diagnosed at an advanced stage of the disease. We identified 0.8% (6/722) of patients who harbored the insertion p.(Tyr772_Ala775dup) at exon 20 of the ERBB2 gene. All ERBB2 mutated patients were diagnosed with lung adenocarcinoma, were never smokers, and wild-type for EGFR, KRAS, and ALK hotspot alterations. Less than 1% of Brazilian NSCLC patients harbor ERBB2 exon 20 insertions, yet they could benefit in future from the new drugs in development.

EVALUATION OF LUNG CANCER SCREENING ELIGIBILITY IN A SMOKING CESSATION CLINIC LOCATED IN AN URBAN COMMUNITY: A QUALITY-IMPROVEMENT PROJECT

EVALUATION OF LUNG CANCER SCREENING ELIGIBILITY IN A SMOKING CESSATION CLINIC LOCATED IN AN URBAN COMMUNITY: A QUALITY-IMPROVEMENT PROJECT

PULMONARY CRYPTOCOCCUS: THE GREAT IMPERSONATOR

PULMONARY CRYPTOCOCCUS: THE GREAT IMPERSONATOR

ASSESSING THE DIAGNOSTIC YIELD AND SAFETY PROFILE OF A NEW ROBOTIC-ASSISTED BRONCHOSCOPY PROGRAM IN A HIGH-RISK PATIENT POPULATION

ASSESSING THE DIAGNOSTIC YIELD AND SAFETY PROFILE OF A NEW ROBOTIC-ASSISTED BRONCHOSCOPY PROGRAM IN A HIGH-RISK PATIENT POPULATION

EP08.01-060 Long term Survival Outcomes in NSCLC Patients with Targeted Therapy and Immunotherapy: An IASLC Analysis of ASCO CancerLinQ Discovery Data

Both immunotherapy and targeted therapies have become part of routine lung cancer therapy; we analyzed the ASCO CancerLinQ database to study long-term outcomes for patients treated with targeted therapy and immunotherapy for advanced NSCLC.

Stepping into the real world: a mixed-methods evaluation of the implementation of electronic patient reported outcomes in routine lung cancer care

BackgroundTo realize the broader benefits of electronic patient-reported outcome measures (ePROMs) in routine care, we used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to inform the translation of a clinically effective ePROM system (hereafter referred to as the PRM system) into practice. The study aimed to evaluate the processes and success of implementing the PRM system in the routine care of patients diagnosed with lung cancer.MethodA controlled before-and-after mixed-methods study was undertaken. Data sources included a self-report questionnaire and interviews with healthcare providers, electronic health record data for PRMs patients and historical controls, and field notes. Descriptive statistics, logistic regression modelling, negative binomial models, generalized estimating equations and repeated measures ANOVA were used to analyze quantitative data. Qualitative data was thematically analyzed.ResultsA total of 48/79 eligible people diagnosed with lung cancer completed 90 assessments during the 5-month implementation period (RE-AIM reach). Every assessment breached the pre-defined threshold and care coordinators reviewed and actioned 95.6% of breaches, resulting in 146 referrals to allied health services, most frequently for social work (25.3%), dietetics (18.5%), physiotherapy (18.5%) and occupational therapy (17.1%). PRMs patients had significantly fewer visits to the cancer assessment unit for problematic symptoms (M = 0.23 vs. M = 0.43; p = 0.035), and were significantly more likely to be offered referrals (71% vs. 29%, p < 0.0001) than historical controls (RE-AIM effect). The levels of ‘organizational readiness for implementing change’ (ORIC) did not show much differences between baseline and follow-up, though this was already high at baseline; but significantly more staff reported improved confidence when asking patients to complete assessments (64.7% at baseline vs. 88.2% at follow-up, p = 0.0046), and when describing the assessment tool to patients (64.7% at baseline vs. 76.47% at follow-up, p = 0.0018) (RE-AIM adoption). A total of 78 staff received PRM system training, and 95.6% of the PRM system alerts were actioned (RE-AIM implementation); and all lung cancer care coordinators were engaged with the PRM system beyond the end of the study period (RE-AIM maintenance).ConclusionThis study demonstrates the potential of the PRM system in enhancing the routine care of lung cancer patients, through leveraging the capabilities of automated web-based care options.Plain English summaryResearch has shown the clear benefits of using electronically collected patient-reported outcome measures (ePROMs) for cancer patients and health services. However, we need to better understand how to implement ePROMs as part of routine care. This study evaluated the processes and outcomes of implementing an ePROMs system in the routine care of patients diagnosed with lung cancer. Key findings included: (a) a majority of eligible patients completed the scheduled assessments; (b) patient concerns were identified in every assessment, and care coordinators reviewed and actioned almost all of these, including making significantly more referrals to allied health services; (c) patients completing assessments regularly were less likely to present to the cancer assessment unit with problematic symptoms, suggesting that ePROMs identified patient concerns early and this led to a timely response to concerns; (d) staff training and engagement was high, and staff reporting increased confidence when asking patients to complete assessments and when describing the assessment tool to patients at the end of the implementation period. This study shows that implementing ePROMs in routine care is feasible and can lead to improvements in patient care.

Clinical value of CT-guided biopsy of small (≤1.5 cm) suspicious lung nodules: Diagnostic accuracy, molecular characterization and long-term clinical outcomes

Small pulmonary nodules (≤1.5 cm) are frequently detected on routine chest imaging and lung cancer screening studies. Our goal was to determine the clinical value of CT-guided core needle biopsy (CNB) in the evaluation of such nodules. In this single-center study, we retrospectively analyzed patient data (n = 44) for CNBs on lung nodules (≤1.5 cm) performed at our biopsy center between May 2017 and March 2020. We analyzed for the rate of pathology diagnosis, molecular/biomarker analysis, complications, and change in clinical management and outcome over a period ranging up to 60 months after biopsy. A pathology diagnosis of malignancy or benign lesion was obtained in 97.9% of biopsies in this cohort. The rate of complications was low with only 6.8% of patients requiring the insertion of a temporary small profile interventional radiology (IR) pigtail chest tube for pneumothorax. Out of the subset of biopsy specimens that were sent for tissue molecular analysis, 90% had enough tissue preserved after initial pathological analysis to obtain at least one molecular marker. Our data show that CT-guided CNB is safe and reliable, and should be considered for the evaluation of small, suspicious lung nodules found on routine screenings for the early detection and evaluation of malignant lesions.

Impacts of lung cancer multidisciplinary meeting presentation: Drivers and outcomes from a population registry retrospective cohort study

IntroductionMultidisciplinary Meetings (MDM) are recommended in routine lung cancer care, however its broader impacts demand further evaluation. We assessed the drivers and impacts of MDM presentation in the Victorian Lung Cancer Registry (VLCR). MethodsWe examined the effect of MDM presentation on receipt of treatment and survival in VLCR patients diagnosed between 2011 and 2020. We compared patient characteristics, drivers of MDM discussion and survival between the two groups. ResultsOf 9,628 patients, 5,900 (61.3%) were discussed at MDM, 3,728 (38.7%) were not. In the non-MDM group, a lower proportion received surgery (22.1% vs. 31.2%), radiotherapy (34.2% vs. 44.4%) and chemotherapy (44.7% vs. 49.0%). Patients were less likely to be discussed if ≥80 years (OR 0.73, p < 0.001), of ECOG performance status (PS) 4 (OR 0.23, p < 0.001), clinical stage IV (OR 0.34, p < 0.001) or referred from regional (OR 0.52, p < 0.001) or private hospital (OR 0.18, p < 0.001). MDM-presented patients had better median survival (1.70 vs 0.75 years, p < 0.001) and lower adjusted mortality risk (HR 0.75; 0.71–0.80, p < 0.001), a protective effect consistent across all hospital types. Undocumented PS, histopathology and clinical stage were associated with lower likelihood of MDM discussion and worse mortality. ConclusionsIn the VLCR, being male, ≥80 years, of poorer PS, advanced clinical stage and poor clinical characterisation significantly disadvantaged patients in relation to MDM discussion. MDM-discussed patients were more likely to undergo treatment and had a 25% lower risk of mortality. This study supports the use of MDMs in lung cancer and identifies areas of inequity to be addressed.

The immune microenvironment in EGFR- and ERBB2-mutated lung adenocarcinoma

BackgroundTargeted therapies have improved survival and quality of life for patients with non-small-cell lung cancer with actionable driver mutations. However, epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 gene (HER2, also known as ERBB2) exon 20 insertions (Ex20mut) are characterized by a poor response to currently approved tyrosine kinase inhibitors and immunotherapies. The underlying immune biology is not well understood.Materials and methodsWe carried out messenger RNA expression profiling of lung adenocarcinomas (ADCs) with ERBB2 (n = 19) and EGFR exon 20-insertion mutations (n = 13) and compared these to tumors with classical EGFR mutations (n = 40, affecting EGFR exons 18, 19 or 21) and EGFR/ERBB2 mutation-negative lung ADC (EGFR/ERBB2wt, n = 26) focusing on immunologically relevant transcripts. Tumor-infiltrating immune cells were estimated from gene expression profiles.ResultsCytotoxic cells were significantly lower in EGFR-mutated tumors regardless of the affected exon, while Th1 cells were significantly lower in EGFR-Ex20mut compared to EGFR/ERBB2wt tumors. We assessed the differentially expressed genes of ERBB2-Ex20mut and EGFR-Ex20mut tumors compared to EGFR-Ex18/19/21mut and EGFR/ERBB2wt tumors. Of these, the genes GUSB, HDAC11, IFNGR2, PUM1, RASGRF1 and RBL2 were up-regulated, while a lower expression of CBLC, GBP1, GBP2, GBP4 and MYC was observed in all three comparison groups. The omnibus test revealed 185 significantly (FDR = 5%) differentially expressed genes and we found these four most significant gene expression changes in the study cohort: VHL and JAK1 were overexpressed in ERBB2-Ex20mut and EGFR-Ex20mut tumors compared to both EGFR-Ex18/19/21mut and EGFR/ERBB2wt tumors. RIPK1 and STK11IP showed the highest expression in ERBB2-Ex20mut tumors.ConclusionsTargeted gene expression profiling is a promising tool to read out the characteristics of the tumor microenvironment from routine diagnostic lung cancer biopsies. Significant immune reactivity and specific immunosuppressive characteristics in ERBB2-Ex20mut and EGFR-Ex20mut lung ADC with at least some degree of immune infiltration support further clinical evaluation of immune-modulators as partners of immune checkpoint inhibitors in such tumors.

Enabling patients in effective self-management of breathlessness in lung cancer: the neglected pillar of personalized medicine.

Globally, engagement of patients in the self management of disease and symptom problems has become a health policy priority to improve health outcomes in cancer. Unfortunately, little attention has been focused on the provision of self-management support (SMS)in cancer and specifically for complex cancer symptoms such as breathlessness. Current management of breathlessness, which includes treatment of underlying disease, pharmacological agents to address comorbidities and opiates and anxiolytics to change perception and reduce the sense of breathing effort, is inadequate. In this perspective paper, we review the rationale and evidence for a structured, multicomponent SMS program in breathlessness including four components: breathing retraining, enhancing positive coping skills, optimizing exertional capacity and reducing symptom burden and health risks. The integration of SMS in routine lung cancer care is essential to improve breathlessness, reduce psychological distress, suffering and improve quality of life.

The Need for Brevity During Shared Decision Making (SDM) for Cancer Screening: Veterans' Perspectives on an "Everyday SDM" Compromise.

Introduction. Detailed or “full” shared decision making (SDM) about cancer screening is difficult in the primary care setting. Time spent discussing cancer screening is time not spent on other important issues. Given time constraints, brief SDM that is incomplete but addresses key elements may be feasible and acceptable. However, little is known about how patients feel about abbreviated SDM. This study assessed patient perspectives on a compromise solution (“everyday SDM”): 1) primary care provided makes a tailored recommendation, 2) briefly presents qualitative information on key tradeoffs, and 3) conveys full support for decisional autonomy and desires for more information. Methods. We recruited a stratified random sample of Veterans from an academic Veterans Affairs medical center who were eligible for lung cancer screening, oversampling women and minority patients, to attend a 6-hour deliberative focus group. Experts informed participants about cancer screening, factors that influence screening benefits, and the role of patient preferences. Then, facilitator-led small groups elicited patient questions and informed opinions about the everyday SDM proposal, its acceptability, and their recommendations for improvement. Results. Thirty-six Veterans with a heavy smoking history participated (50% male, 83% white). There was a strong consensus that everyday SDM was acceptable if patients were the final deciders and could get more information on request. Participants broadly recommended that clinicians only mention downsides directly related to screening and avoid discussion of potential downstream harms (such as biopsies). Discussion. Although further testing in more diverse populations and different conditions is needed, these patients found the everyday SDM approach to be acceptable for routine lung cancer screening discussions, despite its use of an explicit recommendation and presentation of only qualitative information.

Deciphering the immunosuppressive tumor microenvironment in ALK- and EGFR-positive lung adenocarcinoma

IntroductionThe advent of immune checkpoint blockade (ICB) has led to significantly improved disease outcome in lung adenocarcinoma (ADC), but response of ALK/EGFR-positive tumors to immune therapy is limited. The underlying immune biology is incompletely understood.MethodsWe performed comparative mRNA expression profiling of 31 ALK-positive, 40 EGFR-positive and 43 ALK/EGFR-negative lung ADC focused on immune gene expression. The presence and levels of tumor infiltration lymphocytes (TILs) as well as fourteen specific immune cell populations were estimated from the gene expression profiles.ResultsWhile total TILs were not lower in ALK-positive and EGFR-positive tumors compared to ALK/EGFR-negative tumors, specific immunosuppressive characteristics were detected in both subgroups: In ALK-positive tumors, regulatory T cells were significantly higher compared to EGFR-positive (fold change: FC = 1.9, p = 0.0013) and ALK/EGFR-negative tumors (FC = 2.1, p = 0.00047). In EGFR-positive tumors, cytotoxic cells were significantly lower compared to ALK-positive (FC = − 1.7, p = 0.016) and to ALK/EGFR-negative tumors (FC = − 2.1, p = 2.0E-05). A total number of 289 genes, 40 part of cytokine–cytokine receptor signaling, were differentially expressed between the three subgroups. Among the latter, five genes were differently expressed in both ALK-positive and EGFR-positive tumors, while twelve genes showed differential expression solely in ALK-positive tumors and eleven genes solely in EGFR-positive tumors.ConclusionTargeted gene expression profiling is a promising tool to read out tumor microenvironment characteristics from routine diagnostic lung cancer biopsies. Significant immune reactivity including specific immunosuppressive characteristics in ALK- and EGFR-positive lung ADC, but not a total absence of immune infiltration supports further clinical evaluation of immune-modulators as partners of ICB in such tumors.

Malignancy Prediction Capacity and Possible Prediction Model of Circulating Tumor Cells for Suspicious Pulmonary Lesions.

More and more undetermined lung lesions are being identified in routine lung cancer screening. The aim of this study was to try to establish a malignancy prediction model according to the tumor presentations. From January 2017 to December 2018, 50 consecutive patients who were identified with suspicious lung lesions were enrolled into this study. Medical records were reviewed and tumor macroscopic and microscopic presentations were collected for analysis. Circulating tumor cells (CTC) were found to differ between benign and malignant lesions (p = 0.03) and also constituted the highest area under the receiver operation curve other than tumor presentations (p = 0.001). Since tumor size showed the highest sensitivity and CTC revealed the best specificity, a malignancy prediction model was proposed. Akaike information criterion (A.I.C.) of the combined malignancy prediction model was 26.73, which was lower than for tumor size or CTCs alone. Logistic regression revealed that the combined malignancy prediction model showed marginal statistical trends (p = 0.0518). In addition, the 95% confidence interval of combined malignancy prediction model showed less wide range than tumor size ≥ 0.7 cm alone. The calculated probability of malignancy in patients with tumor size ≥ 0.7 cm and CTC > 3 was 97.9%. By contrast, the probability of malignancy in patients whose tumor size was < 0.7 cm, and CTC ≤ 3 was 22.5%. A combined malignancy prediction model involving tumor size followed by the CTC count may provide additional information to assist decision making. For patients who present with tumor size ≥ 0.7 cm and CTC counts > 3, aggressive management should be considered, since the calculated probability of malignancy was 97.9%.