Virtual Library

Background:
Patients with lung cancer are at increased risk of venous thromboembolism (VTE). Patient-related factors may help estimate an individual’s risk for VTE. Cardiovascular disease (CVD) risk factors increase the risk of arterial embolism, but it is less clear whether these factors increase the risk of VTE associated with lung cancer.We evaluated associations between major CVD risk factors and the occurrence of VTE in lung cancer patients using data from the Lung Cancer and Thrombosis Study conducted by the China VTE Study Group.

Methods:
A total of 632 hospitalized patients with newly diagnosed lung cancer were screened for VTE, and their major CVD risk factors were assessed at the baseline examination. Additionally, VTE diagnoses within the three months prior to recruitment were reviewed.

Results:
Eighty-six of the 632 (13.6%) experienced a VTE event, and 7.8%, 3.3%, and 16.6% of the patients also experienced diabetes, dyslipidemia and hypertension, respectively. Hypertension was more frequent in patients with VTE than in those without VTE (24.4% vs. 15.4%, P=0.04). Multivariate logistic regression analysis, including age, sex, smoking, body mass index, diabetes, dyslipidemia, hypertension and white blood cell count, found that hypertension (odds ratio [OR] 1.8; 95% CI 1.0-3.3; P=0.041) and leukocytosis (OR 2.7; 95% CI 1.5-4.8; P=0.001) were significantly associated with VTE in different tumor histology models and that hypertension (OR 1.9; 95% CI 1.1-3.4; P=0.029) and leukocytosis (OR 2.7; 95% CI 1.5-4.7; P=0.001) were also significantly associated with VTE in different tumor stage models. Leukocytosis was linearly associated with hypertension and VTE (P for trend = 0.006), and the ORs for VTE increased with leukocytosis (all P for trend < 0.05).

Conclusion:
Hypertension was associated with the risk of VTE in patients with newly diagnosed lung cancer, which may be mediated by the presence of inflammation.

Background:
Neoplastic obstruction of the airways occurs in about 30% of lung neoplasms, and is often associated woth end-stage, or advanced disease. Nonetheless, endoscopic treatment of the obstruction may improve quality of life and survival in selected patients. The primary objective is to evaluate the median survival and the predictors of mortality in patients undergoing endoscopic treatment of neoplastic airway obstruction. The secondary objective is to evaluate the morbidity of the procedure.

Methods:
Retrospective study, from January 2010 to December 2014. All data was collected until February 2015. We included patients with neoplastic obstruction of the trachea and bronchi, that underwent endoscopic treatment. Procedures were performed in the operating room under general anesthesia, through rigid bronchoscopy or suspension laryngoscopy.Age, sex, neoadjuant chemo-radiotherapy, adjuvant chemo-radiotherapy, ECOG status, ASA status, urgent procedures, need for mechanical ventilation, reintervention procedures, site of obstruction, type of stent and tumor histology were considered predictors for mortality.The median survival was analyzed by Kaplan-Meier curve. Prognostic factors of mortality were analyzed by Cox regression.

Results:
We included 42 patients (25M / 17F) with a mean age of 54 + 11 years, that underwent 68 endoscopic procedures. The most common histologic types were lung cancer (n = 15; 36%), esophagus (n = 11; 26%) and cystic adenoid carcinoma (n = 8; 19%). Twenty-five stents were placed. The silicone Y stent was the most common (n=14;56%). Eleven percent of patients required a tracheostomy. Complications occurred in 37.5% of cases; pneumonia (n = 10; 15%) and stent obstruction (n = 6; 9%) were the most frequent.The median survival was 221 days. The 30-day mortality was 14%, and overall mortality 40%. The predictors of mortality by Cox regression were re-intervention procedures (HR 5.9; p <0.001; 95% CI 2:25 to 15:45), mechanical ventilation before the procedure (HR 7:38; p = 0.015; 95% CI: 1.46- 37) and tumor hystology (HR: .23; p <0.001; 95% CI: .11 - .47). Individuals with esophageal cancer had a significant lower median survival, when compared with lung cancer and cystic adenoid carcinoma (94 vs 166 vs 346 days; p=0.002).

Conclusion:
The morbidity and mortality of patients submitted to endoscopic treatment of neoplastic airway obstruction is not negligible. Reintervention procedures, mechanical ventilation prior to treatment and tumor histology were significant predictors of mortality.

Background:
Lung cancer is getting more common and important especially in 6th-7th decade. Several recently published studies showed that eveluating the elderly patients with only Eastern Cooperative Oncology Group (ECOG) to manage the treatment is not eough. It is needed to consider this elderly group of patients precisely. In our study we aim to search the the clinical value of the comprehensive geriatric assessment of the elderly patients as a a parameter that can be used to guide the treatment decision.

Methods:
In our study 65 years old and over newly diagnosed 74 lung cancer patients in our hospital from April 2013 to April 2014 were included. In order to evaluate the comprehensive geriatric assessment, we applied the activities of daily living (ADL’s), instrumental activities of daily living ( IADLs), mini-mental test, mini-nutritional test, Yesavage depression scale and Charlson comorbidity index . Receiving treatment and the survival were assessed with 6 other tests and ECOG in single and multi variable analysis.

Results:
Men were 94.6 % of all patients. In this group 6.8% in small cell carsinoma, 90.5% in non-small cell carsinoma, 2.7 % in malignant epithelial tumour were diagnosed. According to ADL’s 86.5 % was independent and 13.5 % was semi-dependent as well as to IADLs 60.8 % was independent, 20.3 % semi-dependent and 18.9 % was dependent. %12.2 of the patients had malnutrition, %56.7 had malnutrition risk. The data provided that 54 % of all patients had severe dementia and 17.6 % has mild dementia. According to Yesavade depression scale 13.5% of patients were developed depression. Charlson comorbidity index provided the data that 2 % of patients had very high risk probability, 5% high risk, 42.5 % moderate, 25% low risk probability. It is found significant the relationship between the receiving treatment and results of ADL’s, IADLs, mini-mental test, Yesavage depression scale, and ECOG as well as ADL’s, IADLs, mini-mental test, Yesavage depression scale, ECOG and mini-nutritional test and the survival in single variable analysis (p<0,05). In order to consider which test will have more prominent role to receive the treatment ,multivariable analysis was performed and only IADLs was found significant as a determining factor for receiving or not receiving treatment (p=0,003). Yesavage depression scale was found more efficient to find out the factors affecting the survival in multivariable comparison analysis (p=0,011).

Conclusion:
The study published by Maione and collegues evaluating the relationship between functional status, comorbidity, life quality and the survival in 566 advanced stage non-small cell cancer patients showed that patients with beter IADLs ( p= 0.04) have better survival as similarly obtained from our study. Buccheri and his group reported the data from 133 heterogeneous bronchogenic cancer patients developed depression,have a worse survival comparing with the patients having no depression. The results of our study indicates that assessing with ECOG is not enough for considering the treatment,but how CGA is important to consider it as well. Improving the life quality and the survival of the advanced stage elderly patients with cancer, future research requires a more wide population

Background:
Chemotherapy-induced nausea and vomiting (CINV) is still a major adverse effect especially for patients treated with highly emetogenic chemotherapy (HEC). In clinical practice, 5-HT3 receptor antagonist, NK-1 receptor antagonist, and corticosteroids are widely used to alleviate emetic episodes during chemotherapy. With those drugs, acute-nausea and vomiting is successfully manageable. However, late-onset nausea and vomiting is sometimes difficult to be controlled and therefore, the promising drugs is needed. Olanzapine is an antipsychotic agent which is approved for schizophrenia and bipolar disorder in Japan. Recently, the combination therapy with olanzapine and the conventional anti-emetic drugs has been reported highly effective to prevent late-onset CIMV after HEC. However, it remains unclear whether olanzapine is really effective for patients who develop acute- or late-onset CIMV after HEC.

Methods:
All consecutive patients, who were treated with HEC and olanzapine at Jichi Medical University Hospital from January 2014 to December 2014, were included. “Antimetic Response” was defined as the absence of nausea and vomitting, no use of breakthrough antiemetic medications, or increased dietary intake (≧50%). The details of clinical information were reviewed from the medical records .

Results:
Among 18 patients treated with HEC and olanzapine as antimetic medication, 11 were males and 7 were females, with a median age of 60.5 years (42-74 years). Primary tumors were non-small cell lung cancer in 11 cases, small cell lung cancer in 5, malignant mesothelioma in one case, and embryonal carcinoma in one case. Olanzapine was used for preventing CINV in 8 patients with the previous experience of late-onset CINV and in 2 patients without, for treating late-onset CINV in 6 patients and acute onset CINV in 2 patients. "Antiemetic response" has been observed in 15 patients (83.3%). Among 8 patients previously experiencing late-onset CINV, "Antimetic response" was obtained in 7 patients(87.5%).

Conclusion:
Our results strongly suggest the olanzapine provides an additional effect on CINV uncontrolled with conventional antiemetic therapy, regardless of whether CINV is acute or chronic.

Background:
The aim of this study was to investigate the symptom distress, anxiety and depression in patients with NSCLC undergoing adjuvant chemotherapy after VATS lobectomy.

Methods:
A total of 62 patients undergoing adjuvant chemotherapy from January 2013 to December 2014 after VATS lobectomy were enrolled. The M.D. Anderson Symptom Inventory (MDASI) and the Hospital Anxiety and Depression Scale (HADS) were used to assess the patients, symptom distress, anxiety and depression condition.

Results:
The patients averagely scored 3.02 points in symptom items, and 2.58 points in interference items, with the scores being positively correlated with anxiety and depression respectively (P<0.01 for both). The patients mainly reported symptoms of alopecia, lack of appetite, dyspnea, etc.

Conclusion:
Symptom distress is commonly seen in patients with NSCLC undergoing adjuvant chemotherapy after VATS lobectomy. And symptom distress, anxiety and depression react upon each another. Therefore physicians should pay more attention to these patients, mental state and guide them to rationally release their emotions.

Background:
Febrile neutropenia is considered a severe complication of cancer chemotherapy, and one for which lung cancer is frequently associated with higher mortality rates than other solid tumors. The focus of this analysis was to identify risk factors most associated with in-hospital mortality and to describe their impact on mortality in patients with lung cancer.

Methods:
Hospitalization data from the University Health Consortium database inclusive of the years 2004-2012 from 239 US medical centers were analyzed. The study population included all adult patients with solid tumors who had neutropenia. Cancer type, presence of neutropenia, comorbidities, and further subgroups were based on ICD-9-CM codes. The primary study outcome was in-hospital mortality in lung cancer patients vs. other solid tumors. Further analysis concentrated on comparisons of the two groups with respect to number and type of comorbidities, occurrence of sepsis, pneumonia, or any infection, and ICU stay and influence of these factors on mortality. Differences between the groups were compared using chi-square test.

Results:
The analysis was based on 61,086 adult patients, including 11,111 lung cancer patients and 49,975 patients with other solid tumors. Overall 4290 (7.0%) patients died. Lung cancer was the tumor type associated with highest mortality (11.2%, compared with other solid tumors, 6.1%; p <0.0001) Lung cancer patients were older: 50% of lung cancer patients were over age 65, compared to 31.6% of patients with other solid tumors (p<0.0001). Lung cancer patients were more likely to have multiple (≥2) comorbidities than patients with other solid tumors (57.3% vs. 37.3% p<0.0001). The risk of mortality was directly related to the number of comorbidities (ranging from mortality risk of 0.9% for patients with 0 comorbidities to 35.2% for patients with 5 or more). The comorbidity-mortality relationship was observed in lung cancer patients as well as patients with other solid tumors, and the association persisted after adjusting for multiple covariates, including age. Even independent of number of comorbidities and age, lung cancer patients had higher mortality (Odds Ratio (OR)=1.38, 95%CI: 1.28-1.48). Four risk factors for mortality in addition to number of comorbidities were identified: pneumonia, sepsis, any documented infection, and ICU stay. Pneumonia occurred more commonly in the lung cancer patients (26.4% vs. 10.3%; p<0.0001). Comorbid pulmonary disease was strongly associated with development of pneumonia (OR=4.52, 95%CI: 4.30-4.74) and occurred more often in the lung cancer patients (52.1% vs. 24.0%; p<0.0001). With or without pulmonary disease as a comorbidity, lung cancer patients were more likely to have pneumonia than other solid tumor types (with – 36.0% vs. 22.8%, p<0.0001) (without – 16.1% vs. 6.4%, p<0.0001).

Conclusion:
Lung cancer patients presenting with febrile neutropenia are older, have more comorbidities, have a higher incidence of comorbid pulmonary disease, and are more likely to have pneumonia. These factors may help explain their higher mortality. In order to reduce the mortality of chemotherapy in lung cancer patients, careful pretreatment assessment and optimal supportive care during therapy are critical.

Background:
Co-morbidity is a key factor in determining prognosis and defining treatment in lung cancer. In the face of an ageing population and increasing prevalence of chronic medical conditions, lung cancer physicians will need to develop robust systems and services to ensure appropriate optimisation of co-morbidities during the diagnosis and staging pathway. The aim of this study was to provide a detailed description of co-morbidities and physiology in a UK lung cancer population.

Methods:
Prospective data was collected on all newly diagnosed lung cancer patients at the University Hospital South Manchester from November 2014 and February 2015. UHSM is a regional lung cancer centre and diagnoses over 200 lung cancers per year. Co-morbidities were assessed using the Charlson co-morbidity index. Performance status, MRC Dyspnoea Scale, BMI and physiological parameters for the cardiorespiratory and renal systems were also measured.

Results:
73 patients were diagnosed with lung cancer in the study period. Mean age was 70 years and 35 (48%) were male. 37 (51%) had radiological evidence of emphysema on staging CT of the thorax. Co-morbidities and physiological parameters for the patient cohort are presented in tables 1 & 2. Table 1: Charlson Co-morbidity Index

	n = 73 n (%)
0	9 (12%)
1-2	26 (37%)
3-4	16 (22%)
5-6	12 (16%)
≥7	10 (14%)
Chronic pulmonary disease	27 (37%)
Myocardial Infarction	14 (19%)
Cerebrovascular disease	13 (18%)
Diabetes without end-organ damage	10 (14%)
Congestive cardiac failure	7 (10%)
Peripheral vascular disease	7 (10%)
Moderate-severe CKD	5 (7%)
Dementia	3 (4%)
Diabetes with end-organ damage	3 (4%)
Connective tissue disease	3 (4%)
Chronic liver disease	2 (3%)
Lymphoma	1 (1%)

Table 2: Fitness and physiological parameters

PS 0-1	45 (62%)
PS 2-4	28 (38%)
MRC Dyspnoea Scale 1-2	38 (52%)
MRC Dyspnoea Scale 3-5	35 (48%)
BMI <20	17 (23%)
BMI 20-30	34 (47%)
BMI >30	22 (30%)
FEV1 % predicted, mean	77.1 ±26.7
FEV1:FVC	62.1 ±14.6
DLCO % predicted, mean	72.0 ±21.2
Shuttle walk distance, metres, mean	366 ±154
Lowest O2 sats during shuttle, %, mean	92 ±4.1
Peak VO2 % predicted, mean	71.7 ±17.8
Estimated glomerular filtration rate	75.4 ±18.9
Revised cardiac index ≥3	9 (12%)

Conclusion:
Chronic respiratory disease and disability is a major component of co-morbidity and physiological impairment in lung cancer patients. Cardiovascular disease and abnormalities in BMI are also highly prevalent. These results inform the need for rapid and reliable access to prehabilitation and dietetic services, robust cardiorespiratory physiological testing and specialist cardiovascular teams for all lung cancer physicians.

Background:
Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum.

Methods:
A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a five year period at a single institution was performed. Procedures considered palliative were reviewed for demographics, diagnoses, palliative prognosis score, treatment, morbidity, operative mortality and survival. Excluded were referrals from thoracic surgery to other specialties for palliative procedures.

Results:
During the study period, 3842 procedures were performed of which 884 (23%) were palliative. Indications included pleural and/or pericardial effusion, dysphagia, hemoptysis, tracheobronchial obstruction, bronchopleural fistula and tracheoesophageal fistula. The majority was related to a malignancy. Only 127 patients (14%) had a palliative care assessment prior to thoracic surgery consultation. Mean survival following thoracic surgery intervention was 110 days for patients with malignancy.

Conclusion:
This investigation found that thoracic surgeons commonly care for patients when the intention is palliation. The majority of these patients have an associated malignancy, a poor performance status and a significantly decreased survival compared to the general population. Thoracic surgeons should be familiar with the concepts of palliative care and consideration should be given to expanding exposure to the principles of palliative care in the cardiothoracic residency training curriculum.

Background:
Lung cancer is the leading cause of cancer related morbidity and mortality in both the sexes in Nepal. It accounts for 15.4 % of total cancer as per hospital based Cancer Registry in Nepal. The purpose of this study was to review the patient characteristics and sociocultural factors and their influences in lung cancer cases presenting to the National Hospital and Cancer Research Center of Nepal.

Methods:
A retrospective cross-sectional study was done for the lung cancer cases from January 2009 to May 2014. 72 cases were identified by searching through inpatient records at the National Cancer Hospital but only 43 cases were selected for the analysis purpose due to lack of complete data in other remaining cases. Mean age, gender, ethnicity, locality, smoking habits, histological cell types and staging of the lung cancer patients at the initial presentation time were evaluated. Data were analyzed using SPSS statistical software.

Results:
The highest incidence of lung cancer is seen between 61-80 years of age (62.7%). There was no significant difference between the number of cases among male (51.16%) and female (48.83%). Majority of cases were from central part of the country near capital city (76.7%) whereas eastern and the entire western regions contributed to 7.1% and 16.2% cases respectively which clearly shows the lack of easy accessibility among patient for treatment at tertiary cancer center. People from Newar (39.5%) and Chettri (30.2%) ethnic origin were among the group with highest incidence of lung cancer in our study. 79.06% were smoker than compared to 20.93% who were non-smokers. 76.47% of patient started smoking at age between 10-20 years. 85.29% of the patients consumed local brand cigarettes which has either poor filter or no filter at all. 88.37% of the patients were diagnosed with Non Squamous lung Cancer (NSCLC) and 11.62% were diagnosed with Small Cell lung Cancer(SCLC). In NSCLC majority had squamous cell carcinoma (68.42%) and adenocarcinoma (31.57%). 86.84% of the patients were diagnosed with advanced stage III/IV lung cancer at the time of presentation to the hospital which shows significant delay in getting early diagnosis and treatment in majority of patient with the lung cancer.

Conclusion:
Because of the negligence for the simple cough patient tend to come to see the doctors late. The other reason for late presentation (stage III and IV) being the terrain and lack of diagnostic facilities in many parts of the country. Other important aspect of late presentation is treating the lung lesions as Pulmonary TB by the general physicians because of TB being one of the most common pulmonary diseases in the country. Such a study in larger scale would be beneficial for the implementation of awareness campaign, early detection, and treatment of the disease at the possible early stage.

Background:
Typically, resection of non-small cell lung cancer (NSCLC) is done solely for curative intent. Rarely, a patient may benefit from aggressive palliative resection when non-oncologic conditions pose a greater threat to health and quality of life. A 59 year old man with cT3N1M1 NSCLC suffered from fevers, and relentless cough productive of copious foul sputum secondary to tumor necrosis and abscess (Fig. 1). Infectious symptoms worsened despite intravenous antibiotics. Clinical staging also suggested adrenal metastasis. Figure 1



Methods:
Cytology of pleural fluid was positive and right upper lobectomy revealed pT3N1 poorly differentiated squamous cell carcinoma. The specimen opened ex vivo was consistent with necrosis and abscess (Fig. 2). Figure 1



Results:
The patient tolerated resection very well, and was home without complication in 8 days. Infectious symptoms promptly cleared. He underwent six cycles of carboplatin and paclitaxel, without significant toxicity. CT and bone scan revealed no evidence of disease 18 months post-resection.

Conclusion:
In some NSCLC patients whose greatest threat to health and quality of life is related to complications such as lung abscess, focusing on clearing the infection rather than strictly adhering to oncologic curative intent criteria may improve quality of life, alleviate symptoms and improve survival. In this particular case, the patient had a relentless cough of putrid sputum and fevers. He was not a candidate for curative resection due to adrenal metastasis and positive pleural cytology. A palliative resection could be justified, as his symptoms were severe, potentially able to be resolved with surgery, and no other treatment options were available. Following resection, the infection cleared, and symptoms resolved. He then tolerated chemotherapy with a favorable response and over 18 month survival.

Background:
In the screening of the possible etiology of pulmonary embolism rule out the presence of an occult neoplasia. Tumors more often associated with thrombotic phenomena are lung, pancreas and colon. The pulmonary artery sarcoma is a rare entity and its clinical diagnosis is complex.

Methods:
We report a case of a non-smoker 71 years old woman. In 1999 suffers first episode of thrombophlebitis. Since then presents several episodes of DVT in the lower limbs so it was anticoagulated with acenocumarol. In October 2014 she was admitted due to costalgia and fever and suspected diagnosis of pneumonia. She told a 3 months history of asthenia and progressive edema of the lower limbs. It is performed thoracic CT, with a massive pulmonary thromboembolism. The doppler sonography of lower limb show a chronic thrombosis. After clinical stabilization she was put under rivaroxaban. At 15th admission day, she starts with dyspnea with chest discomfort, and respiratory failure was found. In an urgent CT was shown a progression of the known embolism. Being a massive thrombosis refractory to treatment and progressive elevation of pulmonary pressure, surgeon was consulted, and is was performed a thromboendarterectomy and a pulmonary artery homograft replacement. In the pathology report, is reported a intermediate-grade sarcoma, suggestive of intramural primary origin and intimal type intimal grade. In January 2015 CT shows progression of local disease, and is discussed in the tumor board, considering unresectability of disesase, and it is proposed to start palliative chemotherapy

Results:
The pulmonary artery sarcoma is a rare disease, since its first description in 1923, there have been documented 200 cases. It can be classified according to their location relative to the vessel wall, or by histologic subtype. Usually located in the main pulmonary artery, diagnosis and complications arise from its intraluminal extension. Up to 50% of cases have pulmonary and mediastinal metastases at diagnosis and distant metastases in 16-19% It is an entity with very similar clinical and radiological features a thromboembolism, a fact that probably contribute to underdiagnosis. The symptoms are dyspnea (72-100%), chest pain (35-45%) and hemoptysis (15-24%), weight loss (21%), asthenia (10%) and fever (8%). The prognosis is poor, with survival reported between 6 months and 2 years (median 17 months) The treatment of choice is surgical approach, by pulmonary endarterectomy, lobectomy or pneumonectomy, with or without reconstruction of the pulmonary artery. In most cases R0 resection is not achieved. The role of radiotherapy (RT) and chemotherapy (CT) is not yet well defined. Regarding chemotherapy schedules, it have been used traditionally active drugs for the treatment of sarcomas

Conclusion:
The pulmonary artery sarcoma is a rare disease that should be suspected in patients with progressive or refractory pulmonary thromboembolism.

Background:
Cancer clinical trial (CCT) participation is critical to improving the care of patients with Non-Small Cell Lung Cancer (NSCLC), yet low participation in CCTs persists. Little is known about the specific barriers to CCT participation among patients with NSCLC. The On Q Care Planning System (CPS) is an electronic tablet based platform adapted to address potential barriers to CCT participation through algorithm-driven identification of and education about patient specific CCTs at the point of care. The primary objectives of this study were to 1) characterize knowledge, attitudes and beliefs about CCTs among patients with NSCLC and their providers and 2) evaluate the impact of the CPS on CCT participation.

Methods:
We performed a multi-site pilot implementation project of CPS as a clinical decision support and patient education tool. Patients were eligible if they had recurrent/metastatic NSCLC. The CPS contained clinical trial eligibility criteria for many CCTs in NSCLC open at the primary research site, as well as selected CCTs from surrounding cancer centers. Study aims were evaluated using patient and provider self-report surveys. Knowledge, attitudes and beliefs about CCTs for both patient’s and provider’s was captured through self-assessment surveys, using a combination of true/false questions and 1-5 Likert scale measures where 5 indicated highest level of agreement. Effect of CPS on CCT enrollment was measured by rate of enrollment in CCTs following the intervention, compared to historical rates of NSCLC CCT participation at our institution.

Results:
From April 2015 through July 2015, 9 providers (medical oncologists and nurse practitioners) and 79 patients with recurrent/metastatic NSCLC have been enrolled from 2 participating cancer centers. While providers reported being aware of open CCTs (mean score (m)=4.6), they felt that lack of adequate information about CCTs (m=3.0) and having time to review eligibility (m=2.6) were key barriers to CCT enrollment. Patients agreed that there were both the personal (m=3.7) and societal (m=4.1) benefits of CCTs. Similar to providers, key barriers to CCT participation for patients centered around lack of knowledge (concern about not knowing what drug they would receive (m=3.5) and that CCT agents would be too toxic (m=3.2)). Of the patients enrolled, 22 were at a point of new treatment or change in treatment and thus evaluable for rate of CCT referral and enrollment. In this subgroup, 21 (95.5%) received care plans with CCT recommendations. Following the study intervention visit, 8 (36.4%) of evaluable patients enrolled in a clinical trial. This compares favorably both with historical rates at our institution, where 13.8% of treatment eligible patients with lung cancer have been enrolled in CCTs, and with national averages which are less than 5%.

Conclusion:
CCT enrollment is critical to advancing the treatment of NSCLC, yet CCT enrollment in NSCLC remains low. For both providers and patients, the lack of readily accessible information about clinical trial eligibility and protocol details is a major barrier to CCT enrollment. The CPS is specifically designed to address these barriers. Indeed, in this pilot study, we showed a promising rate of CCT accrual with the use of the CPS. These findings should be validated in larger, randomized studies.