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S. McLachlan



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    O07 - Supportive and Surgical Care (ID 136)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O07.02 - The preferred and actual levels of involvement in decision-making among patients considering adjuvant chemotherapy (ACT) for non-small-cell lung cancer (NSCLC). (ID 2038)

      10:40 - 10:50  |  Author(s): S. McLachlan

      • Abstract
      • Presentation
      • Slides

      Background
      Patients with cancer have varying preferences for involvement in decision-making between active, collaborative and passive roles. Previous studies suggest that many patients prefer a more active role than they experienced, and a more active role over time[MSA(1] . We sought the preferred and actual level of involvement in decision-making among patients considering ACT after resection of early NSCLC.

      Methods
      98 patients completed a self-administered questionnaire at baseline (before ACT, if they were having it) and at 6 months (after ACT, if they had it). Preferred and actual level of involvement in decision-making were assessed by the Control Preferences Scale (CPS) and trichotomised into active, collaborative, and passive roles. Health-related quality of life (HRQL) data were assessed by the Patient DATA Form. Differences on the original CPS scale between preferred and actual roles and between preferred roles over time were assessed with the Wilcoxon signed-rank test. Determinants of preference for an active role were assessed with chi-square tests of association in 2x2 tables, summarising by odds ratios (ORs). Wilcoxon rank-sum (WRS) tests were used to assess differences in survival benefits required to make ACT worthwhile between patients preferring active and less active roles.

      Results
      Most patients were male (55%) with a median age of 64 years (range, 43-79 years), married (74%) and previous smokers (82%). The majority had had a lobectomy (85%), adenocarcinoma histology (63%), and half (46%) had stage II disease. 83 patients decided to have ACT (85%), 15 declined ACT (15%). ACT was most commonly 4 cycles (71%) of cisplatin/ vinorelbine (73%). Preferred role in decision-making at baseline (n=98) was active in 26 (27%), collaborative in 46 (47%), and passive in 26 (27%); and at 6 months (n=73) was active in 15 (21%), collaborative in 37 (51%) and passive in 21 (29%). Preferred decision-making roles were stable over time (p=0.5). Actual decision-making roles at baseline (n=98) were active in 24 (24%), collaborative in 47 (48%), and passive in 27 (28%). There was concordance between preferred and actual decision-making roles at baseline (p=0.4). Preferring a more active role was associated with university education (p=0.02, OR 2.9) and worse HRQL during ACT: physical well-being (p=0.05, OR 4.4), overall well-being (p=0.02, OR 5.5), sleep (p=0.03, OR 8.4) and shortness of breath (p=0.01, OR 7.6). Patients who preferred an active decision-making role judged larger survival benefits to make ACT worthwhile than patients who preferred a passive role (eg extra survival time of 1 year v 6 months, WRS p=0.03; extra survival rate of 17.5% v 2.5%, WRS p <0.01).

      Conclusion
      Patients with recently resected NSCLC varied in their preferred roles in decision-making about ACT with most patients preferring a collaborative role. Their preferences were stable over time, and were concordant with their perceived actual role in decision-making at baseline. Preferences for an active role in decision-making were associated with judging larger survival benefits necessary to make ACT worthwhile. Clinicians should elicit and consider patients’ preferences for involvement in decision-making when discussing ACT for NSCLC.

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    P1.12 - Poster Session 1 - NSCLC Early Stage (ID 203)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Medical Oncology
    • Presentations: 2
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      P1.12-010 - Lung cancer clinicians' preferences for adjuvant chemotherapy (ACT) in non-small-cell lung cancer (NSCLC): what makes it worthwhile? (ID 1498)

      09:30 - 09:30  |  Author(s): S. McLachlan

      • Abstract

      Background
      Clinicians play an important role helping patients make decisions about ACT, but their views about trade-offs between the benefits and harms of ACT may differ from those of their patients. We sought to determine the minimum survival benefits that lung cancer clinicians judged sufficient to make ACT in NSCLC worthwhile, the factors associated with these judgements, and comparisons with the preferences of their patients.

      Methods
      82 lung cancer clinicians (medical oncologists & thoracic surgeons) completed a self-administered questionnaire. The time trade-off method was used to determine the minimum survival benefits judged sufficient to make ACT worthwhile in 4 hypothetical scenarios. Baseline survival times were 3 years and 5 years and baseline survival rates (at 5 years) were 50% and 65%. Patients’ preferences were those of 122 patients considering ACT for NSCLC elicited in a related study using similar methods. Differences between groups were assessed by 2-sample non-parametric tests. Determinants of preferences were assessed by univariable comparison after normal score transformation. Variance was assessed with the Ansari-Bradley rank test.

      Results
      Most clinicians were male (75%) with a median age of 43 years (range 28-65), had 5 or more years of professional experience (69%), were married (92%), and had dependent children (72%). More were medical oncologists (63%) than thoracic surgeons (31%). The median benefit judged sufficient (by 50% of clinicians) was an extra 9 months (IQR 6-12 months) beyond survival times of both 3 years and 5 years, and an extra 5% (IQR 5-10%) beyond 5-year survival rates of both 50% and 65%. Medical oncologists, compared with thoracic surgeons, judged smaller benefits sufficient to make ACT worthwhile (median benefit 8 months v 12 months, p=0.03). Clinicians’ preferences, compared with patients’ preferences, had the same median benefit (9 months survival time, 5% survival rate) but varied over a smaller range (IQR, 6-12 months v 1-12 months, p<0.001; 5%-10% v 0.1-10% p<0.001).

      Conclusion
      Lung cancer clinicians judged moderate survival benefits sufficient to make ACT in NSCLC worthwhile, but preferences differed according to specialty. Clinicians’ preferences were similar to patients’ preferences, but varied less. Lung cancer clinicians should be mindful of their own preferences and how they may influence discussions and decisions about ACT in NSCLC.

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      P1.12-011 - Patients' preferences for adjuvant chemotherapy (ACT) in early non-small cell lung cancer (NSCLC): What makes it worthwhile? (ID 1773)

      09:30 - 09:30  |  Author(s): S. McLachlan

      • Abstract

      Background
      ACT for NSCLC improves overall survival, but the benefits are modest and must be weighed against the harms and inconvenience of the treatment. The aim of this study was to determine the survival benefits judged necessary to make ACT worthwhile for patients with resected early NSCLC, and the factors associated with their judgments.

      Methods
      122 patients considering ACT completed a self-administered questionnaire at baseline (before ACT, if they were having it) and 6 months later (after ACT, if they had it). The time trade-off method was used to determine the minimum survival benefits judged sufficient to make ACT worthwhile in 4 hypothetical scenarios. Baseline survival times were 3 and 5 years and baseline survival rates (at 5 years) were 50% and 65%. All tests were 2-sided and non-parametric. Determinants of preferences were assessed by (rank test) comparison of preferences in groups defined by each factor.

      Results
      Most patients were male (57%) with a median age of 63 years (range, 43-79 years), married (72%) and previous smokers (81%). The majority had had a lobectomy (84%), adenocarcinoma histology (60%), and half had stage II disease (50%). 106 patients decided to have ACT (87%), 16 declined ACT (13%); female sex and age over 65 years were associated with declining. ACT was most commonly 4 cycles (68%) of cisplatin/ vinorelbine (73%). At baseline, the median benefit judged sufficient (by 50% of patients) was 9 months (IQR 1-12 months) beyond life expectancies of 3 years and 5 years, and 5% (IQR 0.1-10%) beyond 5-year survival rates of 50% and 65%. Preferences varied across the entire range of possible benefits (from 0 days and 0% to an extra 15 years and 50%). At baseline, deciding to have ACT (p=0.01) was the only factor that predicted judging smaller benefits sufficient to make ACT worthwhile. At 6 months (n=91), the median benefits judged sufficient were the same as at baseline (9 months & 5%), but preferences varied over a greater range (IQR’s 0-18 months & 0-15%). At 6 months, deciding to have ACT (p=0.02) and better physical (p=0.02), emotional (p=0.004), and overall well-being (p=0.004) during adjuvant chemotherapy were associated with judging smaller benefits sufficient to make ACT worthwhile. Fatigue, nausea, sleeplessness and reduced appetite were the side effects of ACT that patients were most concerned about experiencing (at baseline) and were rated the most troublesome (at 6 months).

      Conclusion
      Most patients judged moderate survival benefits sufficient to make ACT worthwhile, but preferences varied widely and were not predicted by baseline characteristics. Preferences were stable over time. Patients with NSCLC judged larger benefits necessary for ACT than patients with breast and colon cancer in our previous studies. Clinicians should elicit the preferences of individual patients when discussing and making decisions about ACT.

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    P3.18 - Poster Session 3 - Pathology (ID 177)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Pathology
    • Presentations: 1
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      P3.18-007 - Metastatic sites with a major component of solid pattern pulmonary adenocarcinoma are associated with shorter survival with systemic therapy and infrequent EGFR mutations (ID 1790)

      09:30 - 09:30  |  Author(s): S. McLachlan

      • Abstract

      Background
      The predominant histologic subtype according to the IASCL/ATS/ERS classification has been associated with prognosis in patients undergoing curative surgical resection. It is recommended in the IASLC/ATS/ERS classification that histologic patterns present in small specimens be recorded in the final histopathology report. We investigated the relationship between histologic patterns in metastatic sites, overall survival and EGFR and KRAS mutations.

      Methods
      We identified patients who underwent surgical resection of non-small cell lung carcinoma in metastatic sites from 2000 to 2011. One biopsy site was selected per patient. A pathologist reviewed all slides to confirm the diagnosis of metastatic lung adenocarcinoma, recording all adenocarcinoma histologic patterns present. EGFR and KRAS mutations were scanned by high resolution melting, and confirmed by Sanger sequencing. Clinical data were extracted from the medical records.

      Results
      The 100 patients comprised 66 males, with a median age of 64 years. 85% had stage IV disease, and 15% had unresected stage III disease with mediastinal lymph node sampling. Most were current or former smokers (79%) of ECOG 0/1 (67%). Just over half the patients received systemic therapy (56%). The overall median survival was 10.2 months (95% CI 8.1 – 12.2 months). Metastatic sites included brain (30%), pleura (25%), bone/skeletal muscle (20%), and lymph nodes (mediastinal 18%; chest wall/neck 7%). It was possible in each biopsy to identify a major histologic pattern (Table 1). For patients receiving systemic therapy, survival was significantly shorter for those with a major component of solid pattern tumour in metastases compared to those with major acinar or micropapillary patterns in metastases (Table 1). No survival difference was noted on the basis of ECOG, stage, EGFR or KRAS mutations. For patients who did not receive systemic therapy, the major histologic pattern showed no association with overall survival (Table 1). Worse ECOG was the only significant factor in determining outcome (ECOG 0/1 vs 2+ – hazard ratio 2.18 (1.14 – 4.16, p=0.018)). EGFR mutations were significantly associated with major non-solid pattern histology in metastases (Fisher’s exact = 0.006). No association was observed by KRAS mutation status (Table 1).

      The major histologic component in sites of metastatic adenocarcinoma – overall survival by the use of systemic therapy; presence of EGFR and KRAS mutations (*Comparison across 4 histological types; OS - overall survival, CI - confidence interval, HR - hazard ratio)
      Solid Micropapillary Acinar Papillary Comments
      Major Pattern 50% 20% 29% 1%
      Mutations present n = 50 n = 20 n = 29 n = 1 n=100
      EGFR mutation, n (column %) 2 (4%) 5 (25%) 4 (14%) 1 (100%) Fisher's exact = 0.006 *
      KRAS mutation, n (column %) 18 (36%) 5 (25%) 9 (31%) 0 Fisher's exact = 0.789*
      Systemic Therapy Given n = 29 n = 13 n = 13 n = 1 n=56
      Median OS, months (95% CI) 9.4 (8.3 - 12.2) 18.9 (11.6 - 24.4) 15.9 (10.7 - 24.7) Solid vs MPA HR 0.33 (0.16 - 0.67, p = 0.002) Solid vs Acinar HR 0.32 (0.15 - 0.67, p=0.003)
      No Systemic Therapy n = 21 n = 7 n = 16 n = 0 n=44
      Median OS, months (95% CI) 4.3 (3.3 - 7.4) 4.7 (1.5 - 11.5) 4.4 (1.9 - 16.9) No significant differences

      Conclusion
      Our results suggest that patients with a major component of solid pattern tumour in metastatic sites may be more resistant to systemic therapy as evidenced by shorter overall survival in comparison to those with major micropapillary and acinar pattern tumour in metastases. Furthermore, major solid pattern metastases are unlikely to harbour EGFR mutations. These findings require validation in larger patient cohorts.