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B. Ivimey

Moderator of

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    ITONF - International Thoracic Oncology Nursing Forum (ITONF) Workshop (ID 220)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Nurses
    • Presentations: 9
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      ITONF Members Meeting / Discussion (ID 4051)

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      Abstract not provided

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      Networking Break (ID 4050)

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      Abstract not provided

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      ITONF.01 - Opening of Workshop (ITONF Update and Workshop Intro) (ID 4049)

      B. Ivimey

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      Abstract not provided

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      ITONF.02 - Preparing Nurses for the Next Generation of MDT Lung Cancer Care (ID 4033)

      M. Krishnasamy

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      ITONF.03 - Out of the Shadows into the Clinic (ID 4034)

      J.K. Cataldo

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      ITONF.04 - Survivorship - How Do We Define in Lung Cancer (ID 4035)

      C. Broderick

      • Abstract
      • Presentation

      Abstract not provided

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      ITONF.05 - Positive Impact of Specialist Lung Cancer Nurses on Better Patient Outcomes (ID 4036)

      A.M. Tod

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      ITONF.06 - Non-Pharmacological Management of Breathlessness and Cough in Lung Cancer Patients (ID 4037)

      A. Molassiosis

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      ITONF.07 - Workshop Close / Questions (ID 4038)

      B. Ivimey

      • Abstract

      Abstract not provided

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    MS14 - Interface Between Disease Modifying Treatment and Palliation (ID 31)

    • Event: WCLC 2013
    • Type: Mini Symposia
    • Track: Supportive Care
    • Presentations: 5
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      MS14.0 - N/A - Chair Intro (ID 520)

      • Abstract

      Abstract not provided

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      MS14.1 - Sliding Slope Between Cure and Palliation: Local Cure in Disseminated Disease (ID 521)

      B. Slotman

      • Abstract
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      Abstract
      For a long time, radiotherapy for lung cancer were considered in terms of being either curative, palliative or radical. Conventional radiotherapy for early stage NSCLC was general considered ‘ curative’, but the more modest expectation in patients with locally advanced NSCLC led to it being referred to as ‘radical’, as disease recurrences was considered very likely. In metastatic NSCLC, the role of radiotherapy was considered only in a palliative context, since it was generally accepted that in disseminated disease, local therapies could never be curative. These classifications have been reappraised in the light of recent data. In small cell lung cancer (SCLC), which has a very high risk of distant spread, recent studies have established that local treatments can extent survival and contribute to cure. This is not only the case for thoracic radiotherapy, but also for prophylactic radiotherapy to the brain (PCI; prophylactic cranial irradiation). Studies in patients with limited disease SCLC have shown a survival benefit of about 5% at 3 years,a benefit of similar magnitude to that for thoracic radiotherapy in this patient group. Even in patients with proven disseminated SCLC (extensive stage), the use of PCI has improved survival. In a randomized trial, patients who received PCI had a 1 year survival of 27% compared to 13% for patients who did not receive PCI [1]. A study on the use of thoracic radiotherapy after the completion of chemotherapy in patients with ES-SCLC has recently been closed and the results are awaited next year. With the advancements in radiotherapy techniques, we can now ablate tumors with very high doses, and with great precision using stereotactic techniques. Local control rates in excess of 90% are obtained and in fit, potentially operable patients, 5-year survival rates above 60 % are achieved [2,3]. These ablative radiation doses may also exert a benefical immunological effect both locally and systemically. The same principles of high-dose high-precision radiotherapy are being applied in patients with a limited number of metastases (oligometastases). This patient group is increasingly being identified due to improved imaging techniques, and interest is growing due to the availability of more effectivity of systemic therapy in subgroups of lung cancer. Aggressive treatment of metastases by surgery or ablative therapy, such as SBRT, might offer a real chance of cure for these patients. We have initiated a clinical study to evaluate the benefit of this approach [4]. References 1. Slotman BJ et al., New Engl J Med 357, 664-72, 2007. 2. Onishi H et al., Int J Radiat Oncol Biol Phys 75, 243-247, 2011. 3. Lagerwaard FJ et al., Int J Radiat Oncol Biol Phys 83, 348-53, 2012 [updated]. 4. Palma D et al., BMC Cancer 12, 305, 2012.

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      MS14.2 - Decision Making; When to Stop Disease Modifying Treatment (ID 522)

      C. Manegold

      • Abstract
      • Presentation
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      Abstract
      Decision making in advanced NSCLC undoubtedly should primarily consider evidence based treatment standards recommended by international guidelines (1, 2) According to international guidelines, decision making in 2013 is characterized by customizing therapy in advanced non-small cell lung cancer, by selecting a specific therapeutic regimen based on tumor histology and molecular biology. This refers to first-line therapy in patients with good performance status, but also to subsequent lines of therapy since antineoplastic drugs and regimens used in induction therapy directly influence the selection of agents/regimens considered for second/third-line treatment. The availability of antineoplastic monoclonal antibodies, small molecules and newer cytotoxic such as pemetrexed, the antiangiogenic bevacizumab as well as the tyrosine kinase inhibitors erlotinib, gefitinib and crizotinib has recently changed the treatment algorithm of advanced NSCLC. Therapy optimization by modern medical therapy is characterized by treatment individualization based on predictive factors. This process seems to continue since other products holding considerable promise for the near future such as tumor vaccines and other immunotherapeutic approaches, anti-angeniogenic agents, and newer EGFR-targeting monoclonal antibodies have already reached the level of phase III-testing or the registration process. Today’s recommendation can be summarized as follows: First-line therapy: In patients with good performance status with non-squamous tumors haboring an activating EGFR-mutation, an EGFR tyrosine kinase inhibitor may be the leading option, not only because of being active but also because of its feasibility and improved toxicity profile (3-5). In patients with non-squamous cell tumors not expressing EGFR-mutations, combination therapy remains standard with pemetrexed as the preferred partner of cisplatin (6). Furthermore, it has been demonstrated that in non-squamous NSCLC the addition of bevacizumab to standard doublet therapy improves survival (7, 8). With regard to patients with squamous cell tumors gemcitabine, vinorelbine or taxanes in combination with platinum-based agents remain the chemotherapeutic standards. Bevacizumab and pemetrexed are not recommended in squamous cell tumors either because of the agents toxicity profile (bevacizumab) or because of being less effective in this particular histological subtype (pemetrexed). For elderly patients not being fit for standard doublet chemotherapy medical treatment requires modification. Here single agent therapy is widely considered to be the preferred option for maintaining quality of life, reducing tumor association symptoms and improving survival (9). Fit elderly patients benefit from combination chemotherapy as much as younger patients and platinum-based chemotherapy is recommended as well (10, 11). Combination therapy remains investigational in patients with poor performance status (≥ PS 2), and single agent chemotherapy is the preferred option (12). Second-line therapy: In patients with disease progression during or after completion of induction (first-line) chemotherapy second-line therapy is indicated if the patient remains in good clinical condition. Selection of drugs for second-line therapy is based on whether the drug has been used earlier, the toxicity profile or the patients wish. The approved options for second-line therapy are docetaxel and pemetrexed (in case of non-squamous histology), erlotinib and gefitinib (in tumors expressing activating EGFR-mutations) (13-16). Crizotinib has recently been registered for second-line therapy in ALK-positive tumors (17). Maintenance therapy: The prolongation of induction therapy represents an evidence based new option to improve outcome in advanced NSCLC, in general and with strong implications for second line therapy, in particular. Three randomized studies investigated pemetrexed and erlotinib as maintenance therapy following 4 cycles of chemotherapy (18-21). In these trials switch-early second-line- (pemetrexed, erlotinib) or continuation-true- (pemetrexed) maintenance therapy has significantly increased PFS and OS. Based on this given evidence these two compounds have been registered for maintenance therapy in patients with advanced NSCLC, not progressing following 4 cycles of first-line standard platinum-based therapy. According to the European Medicines Agency (EMA) pemetrexed is indicated as monotherapy for maintenance treatment of locally advanced or metastatic NSCLC other than predominantly squamous cell histology in patients who’s disease has not progressed immediately following platinum-based chemotherapy, including platinum-pemetrexed combinations, and erlotinib is indicated as monotherapy for maintenance treatment in patients with locally advanced or metastatic NSCLC with stable disease after 4 cycles of standard platinum-based first-line therapy. When prescribing erlotinib, clinical factors associate with prolonged survival should be taken into account. There is clearly more which must be considered and which would lead to stop or even not to initiate a modern medical therapy. Even if national and international treatment recommendations undoubtedly represent the backbone of the decision making process, the management of patients with advanced non-small cell lung cancer often clinically requires modification for a number of reasons not necessarily considered by guidelines.This refers to first and subsequent-line treatment as well. The majority of lung cancer patients are older patients and often express specific age related treatment expectations. Other relevant factors for decision making in a non-curative setting are patient social environment and patient psychological status, regulations of national health care providers and reimbursement systems, drug availability, diagnostic and health care infrastructure. These circumstances modify decision making and lead to the use of older agents and regimens, to changes in dosing and scheduling of newer agents and regimens, to single agent therapy, to a reduction of treatment cycles and to a more free indication of best supportive care measures. Our increased understanding of the molecular biology of lung cancer and the change of its epidemiology has opened up venues for more rational treatment strategies and at the same time has challenged the additional diagnostic algorithms, the established health care financing and the complex process of drug development. Customized therapy and therapeutic targeting were made possible through the identification of new treatment predictors and the development of a number of antineoplastic agents which have shown clinical evidence for being more beneficial then the treatment standard in selected patients. Consequently, therapy individualization by histology and molecular markers has significantly influence the work of pathologists around the globe and the process of obtaining a therapeutically relevant tumor diagnosis. Not only histological sub-typing becomes clinical relevant but molecular information is also of increasing importance for treatment selection. Routine molecular testing in certified laboratories must be established, and this diagnostic process should ideally performed under the guidance of evidence based recommendation such as the recently published guidelines from the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology for the molecular testing to select patients for EGFR-ALK-thyrosine kinase inhibitors (22). This process requires advanced diagnostic techniques and expertise. Investigating and implementing medical targeting in lung cancer because of its large dimension is costly and characterize by the limitation of financial and clinical resources, and currently not every where available. Since the majority of large randomized phase III trials during the last decade turned out negative in their primary endpoints, the time of conducting trials on large unselected patient population seems definitely over and the classical investigational strategy must probably be replaced by smaller trials in selected patients, and trials using study endpoints which can function as substitutes for the traditional overall survival endpoints (23). This inevitable change in the altitude of conducting clinical trials will increase the need for patients treated in clinical trials and, therefore, has a significant impact in decision making in advanced NSCLC. Another hurdle for making promising therapies difficult to be generally prescribed are that clinical evidence of being beneficial and the scientific rational do not necessarily equal clinical practicability and reimbursement in a given cultural and economic system. For Europe and specifically Germany it is important that an agent has reached a positive vote by the registration agency EMA and that it find acceptance by the national health care providers responsible for reimbursement. For this reasons the clinical evidence of being beneficial must be well documented and strong. Information about treatment selection by predictive factors and treatment restriction to patients who benefit the most is very welcome. In addition, if the treatment selection requires advanced diagnostic testing generally accepted and validated methods should easy to be reached and should provide reliable and reproducible results by at the same time being cost effective. References: 1. Azzoli et al, J Clin Oncol 29, 3825-3831, 2011 2. Peters et al, Ann Oncol 23 (suppl. 7), 56-64, 2012 3. Mok et al et al, N Engl J Med 361, 947-957, 2009 4. Zhou et al, Lancet Oncol 12, 735-742, 2011 5. Rosell et al, Lancet Oncol 13, 329-346, 2012 6. Scagliotti et al, J Clin Oncol 26, 3543-3551, 2008 7. Sandler et al, N Engl J Med 355, 2542-2550, 2006 8. Reck et al, J Clin Oncol 27, 1227-1235, 2009 9. Gridell et al, J Natl Cancer Inst 95, 362-372, 2003 10. Langer et al, J Clin Oncol 22 (suppl), 639 (abstr. 2571), 2003 11. Quoix et al, Lancet 378, 1079-1088, 2011 12. Gridelli et al, Ann Oncol 15, 419-426, 2004 13. Shepherd et al, J Clin Oncol 18, 2095-2103, 2000 14. Hanna et al, J Clin Oncol 22, 1589-1597, 2004 15. Thatcher et al, Lancet 366, 1527-1537, 2005 16. Douillard et al, J Clin Oncol 28, 744-752, 2010 17. Shaw et al, N Engl J Med 368, 2385-2394, 2013 18. Capuzzo et al, Lancet Oncol 11, 521-529, 2010 19. Ciuleanu et al, Lancet 374, 1432-1400, 2009 20. Paz-Ares et al, Lancet Oncol 13, 247-255, 2012 21. Paz-Ares et al, J Clin Oncol 31, 2895-2902, 2013 22. Lindeman et al, J Thoracic Oncol 8, 823-859, 2013 23. Pilz and Manegold, Memo 6, 92-97, 2013

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      MS14.3 - End of Life Discussions - Evidence-Based Communication (ID 523)

      J. Clayton

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      Abstract
      Advance care planning refers to a “process of discussion, reflection, understanding and communication between a patient, their family and health providers for the purpose of clarifying values, treatment preferences and goals of end of life care” (1). Advance care planning provides a formal means of ensuring health professionals and family members are aware of the patient’s wishes for care if they were to become too unwell to speak for themselves in the future. This process may include the patient completing an Advance Care Directive, which documents their wishes and/or the appointment of a substitute decision maker. Advance care planning is a patient-centred initiative that promotes shared-decision making and supports substitute decision-making, where appropriate, and aims to achieve good end of life care. The potential benefits of advance care planning for patients with advanced lung cancer have been highlighted in recent literature and clinical practice guidelines (2-4). However, there are many barriers to implementing advance care planning in this setting including patient, family, health professional and system related factors. In particular doctors and nurses caring for patients with lung cancer may be reluctant to raise the topic of advance care planning for fear of upsetting patients or they may lack confidence in knowing how to discuss it. This talk will focus on evidence-based strategies and practical tips for health professionals when having advance care planning discussions with patients with advanced lung cancer and their families. Recommendations from Australian “Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers” will be described (5). The key recommendations are for health professionals to: Prepare for the discussion, where possible; Relate to the person; Elicit patient/caregiver understanding and information preferences; Provide information, tailored to the individual needs of both patients and their families; Acknowledge emotions and concerns; (foster) Realistic hope; Encourage questions and further discussions; and Document what had been discussed. (PREPARED). Sample phrases and useful questions for facilitating advance care planning discussions will be presented. Further resources regarding advance care planning will be provided (6-9). References: (1) Royal Australasian College of General Practitioners Advance Care Planning Definition http://www.racgp.org.au/your-practice/business/tools/support/acp/ (2) Mack JW, Cronin A, Keating NL et al. Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. Journal of Clinical Oncology 2012; 35: 4387-4395 (3) (USA) National Comprehensive Cancer Network: Practice guidelines in oncology: Palliative care. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (4) Smith, T, Clayton, J, Michael, N. What is the role of advance care planning and timing of referral for patients with lung cancer? [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=47787, cited 2013 Aug 26]. Available from http://wiki.cancer.org.au/australia/Clinical_question:What_is_the_role_of_advance_care_planning_and_timing_of_referral_for_patients_with_lung_cancer%3F. In: Cancer Council Australia Lung Cancer Guidelines Working Party. Clinical practice guidelines for the treatment of lung cancer. Sydney: Cancer Council Australia. Available from: http://wiki.cancer.org.au/australia/Guidelines:Lung_cancer (5) Clayton JM, Hancock KM, Butow PN, Tattersall MHN, Currow DC. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Medical Journal of Australia 2007; 186: S77- 108 https://www.mja.com.au/journal/2007/186/12/clinical-practice-guidelines-communicating-prognosis-and-end-life-issues-adults (6) The conversation project http://theconversationproject.org (7) Respecting Patient Choices http://www.respectingpatientchoices.org.au (8) Oncotalk http://www.oncotalk.info (9) Vital talk http://vitaltalk.blogspot.com.au

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      MS14.4 - Transition to End of Life Care (ID 524)

      C.S. Karapetis

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      Abstract
      Metastatic lung cancer remains an incurable condition despite recent advances in medical therapy. New treatments can prolong survival and enhance quality of life for patients. Lung cancers can shrink and impressive responses may divert attention from the inevitable reality that the cancer will eventually acquire resistance to therapy. In the current era, patients are guided through multiple lines of therapy; first line, maintenance, second-line and so on. Such ‘lines of therapy’ extend the time on active therapeutic measures designed to alter the biological behavior of advanced lung cancer. Cancer centres that conduct clinical trials may offer potential active intervention beyond the proven ‘lines of therapy’, thereby extending time on active therapy. This may delay the transition to end-of-life care, but the likelihood of benefit with therapies beyond 2[nd] line is low. Whilst oncologists have a greater armamentarium in the fight against lung cancer, there comes a time for every patient when the medical advice will be to stop ‘active therapy’ as there is no prospect of benefit. The focus of care will be on symptom control with acceptance of palliative care. This is the time when patients accept that medical intervention will not prolong survival time, cannot alter the growth and spread of the cancer and will not influence the harmful effect of the cancer on the body. The body will fail, and in the process a functional decline will become obvious. This transition to ‘end-of-life’ care is not a clearly defined time point. Complex decision-making and emotional discussions are usually required. Several issues should be taken into account in determining when anti-cancer therapies should continue to be utilised or when such measures should be abandoned. These issues include: The likelihood of a beneficial response to a proposed therapy The safety and toxicity of the proposed intervention The patient’s ‘performance status’ – an overall measure of functional capacity Comorbidity and organ dysfunction Patient preference There are validated measures of prognosis that may assist in determining when this transition to palliative care should commence, including extent of cancer, weight loss, serum albumin, white cell count, neutrophil to lymphocyte ratio, lactate dehydrogenase and measures of critical organ function (cerebral, pulmonary, liver and renal). The synthesis of all of this information, a global assessment of the patient and knowledge of all the available treatment options is required to determine the timing of transition to ‘end-of-life’ care. The transition is usually handled through a multidisciplinary approach, with potential involvement of multiple health care professionals including the general practitioner, palliative care physician, medical oncologist, radiation oncologist and surgeon. Additional input from health care professionals in the fields of psychology, psychiatry, dietetics, social work and physiotherapy can enhance the quality of care in this transition period, depending on the degrees of distress and disability. Expert counseling is required. Involvement of the primary carers and family in discussions and decision-making is also important. Optimising care for patients during the late stages of cancer should focus on alleviating symptoms, allow planning for death, facilitate arrangements and enable personal commitments before death, dealing with grief and supporting the caregivers. These measures can improve quality of life, reduce anxiety and permit a more peaceful death. Ongoing active cancer therapies may introduce adverse events, require additional hospital visits and expose patients to invasive procedures. This can delay the introduction and implementation of optimal palliative care in the ‘end-of life’ period. The transition to end of life care should also be an opportunity to consider advanced directives. This issue needs to be discussed in a sensitive manner. Decisions around intensive medical intervention and confirmation of ‘not-for-resuscitation’ status will allow for patient wishes to be respected and permit patient autonomy at this difficult stage. An appreciation and acceptance of ‘end’-of-life’ care, when the prognosis is clearly very poor and death from an advancing lung cancer inevitable, will improve the prospect of allowing a comfortable death, a ‘good death’. This should be a goal that every cancer specialist seeks for patients with incurable cancer.

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    MTE17 - Nursing Goes Global - Meeting the Challenges Posed by Mesothelioma (ID 61)

    • Event: WCLC 2013
    • Type: Meet the Expert (ticketed session)
    • Track: Mesothelioma
    • Presentations: 5
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      MTE17.0 - N/A - Chair Intro (ID 610)

      • Abstract

      Abstract not provided

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      MTE17.1 - The Driving Force of Social Networking (ID 611)

      M. Hesdorffer

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      Abstract
      The Driving Force of Social Networking According to Facebook executives, the social network reports 1.06 billion monthly active users. This number has been steadily increasing with a 25% increase in monthly users from last year and a rise of 28% in daily users. Now that we know the numbers what is happening in the world of patients. Though the premise exists that Facebook is strictly for social media networking, I wouldn’t hesitate to guess that patients, especially those who are home bound, spend an enormous amount of time on the web. Patients with rare diseases, in particular, have found Facebook to be a useful tool in finding others facing similar circumstances. PatientsLikeMe.com, launched in 2004, uses a number of tools to collect data and derives a hefty profit from selling this data to pharmaceutical companies as well as research institutions. It reports over 200K users on the site covering 1800 diseases. It uses sophisticated questionnaires to gather data about its users. Another active social media network, 23andme.com promotes the selling of an at-home saliva kit to map out genetic codes. They provide users with interactive tools meant “to shed new light on your distant ancestors, your close family and most of all, yourself.” In 2013, this company spent up to $5 million in advertising, further demonstrating that healthcare on the web is a lucrative field. Law firms representing mesothelioma patients spent over $50 million in goggle keyword advertising in 2012, making mesothelioma the most expensive word in Google advertising. Many of the larger firms representing victims of asbestos have now also launched Facebook pages and groups. These are usually marketed as patient support and advocacy sites providing patients with support and referrals to both medical and legal professionals. To the unsuspecting patient, these sites appear to be either VA sponsored or true advocacy sites which could not be further from the truth. Do you really want your patients to receive medical advice and referrals from representatives of legal entities or other for-profit operations with secondary motives? Nurses are the most trusted professionals valued by the public according to numerous surveys. Who is better equipped to engage with patients in social media and help them to understand the “rules of engagement”? The median age for the diagnosis of lung cancer is 72 and for mesothelioma 70. People in their 70s are less likely to be knowledgeable about the risks vs. the benefits of engaging in social media networking. We are all too familiar with the patient or family members who present to the office armed with paperwork obtained during web searches. Some of the information is valuable, but much is not applicable to their current situation and some is entirely misleading. An inordinate amount of time is consumed by those affected by the disease and the practitioner sorting through and commenting on relevancy of such information. I would suggest that if a nurse could guide their navigation of the web and provide accurate medical information and accurate interpretation of this information, the patient and their representatives as well as the provider could have a more focused discussion. Social media provides a unique opportunity to capture large numbers of patients and their advocates which can be used as a tool for both education and support. It would be the role of the nurse to explain the workings of the platform and to set guidelines to assist in protecting privacy to the degree possible when engaging on these sites. Patients need to understand the potential consequences of engaging in online health-related discussions and must be willing to accept the risks associated with membership in a group. It is fairly common for potential employers to peruse Facebook pages to gather additional background information on future employees. It could certainly be feasible that health insurance companies, especially if a dispute arises, might also turn to social media for information. Patients should be encouraged to read the privacy policy on these sites and an open dialogue about privacy within the group should be an ongoing. Patients themselves are the driving force in this healthcare-related online movement. As a result, hundreds of groups run by patients are available for others to join and this is where this trend can become problematic. Patients with the loudest voice on Facebook, or perhaps the miracle responders, can sway a captive patient group into potential risky decisions with the best of intentions. Groups starting off as support groups can quickly and unexpectedly have their conversations shift toward sharing of medical information and practice. As nurses, we know that patients need to be fully informed without bias to be able to practice good decision-making. Nurse-led groups can promote support and can help to guide the conversation to avoid misinformation or “cyber opinion bullying” by the strongest patient leader. Nurses can designate a peer group leader but promote their role within the group as the medical monitor. This provides an opportunity to gently correct misinformation and present new medical information to the group thus maintaining professionalism and the integrity of the group. Patients with rare diseases are often isolated and local support groups may not be applicable to their particular situation. Patients in these groups often express relief that they are able to connect with others in similar circumstances. However, connecting with others in this manner can be bittersweet. The group can celebrate the victories but will also mourn setbacks and death of group members. Having a nursing professional in the group provides access to a trained individual who can assist in emotional healing as well as recognize and refer if group members need one on one counseling. In cancer, less than 10% of all patients enroll in clinical trials. As nurses we can educate patients about clinical trials and promote participation in such trials. Cancer patients are seeking knowledge on the web, and as educators, it is our role to see that this need is met. T

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      MTE17.2 - Preparing to Meet the Growing Need (ID 612)

      L. Darlison

      • Abstract
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      Abstract not provided

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      MTE17.3 - Surgical Options and Global Differences (ID 613)

      J. McLean

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      Abstract
      Malignant Pleural Mesothelioma is a global challenge for heath professionals, and the role of surgery is key to that challenge. Surgery has a palliative function and a curative function. The palliative function is to drain the fluid, take a biopsy, optimise lung re-expansion, and prevent fluid recurrence by pleurodesis. Video assisted thoracoscopy (VAT) is the palliative operation of choice because it is less painful, has a reduced hospital stay, and the surgeon can assess the chest cavity for suitability for more aggressive treatment. An important predictor for a successful VAT pleurodesis is lung re-expansion after initial pleural drainage assessed by radiology and a patient response of “I can breath now.” If pleurodesis is ineffective and the fluid recurs, or if lung entrapment prevents lung re-expansion, then open surgery via thoracotomy with partial or subtotal pleurectomy / decortication should be considered, providing the patient is medically fit and has a reasonable life expectancy. Partial pleurectomy /decortication is more invasive, has an increased potential for prolonged air-leak, is more painful and has a longer recovery period, however the patient may benefit from an improved quality of life, living without symptoms related to lung entrapment. Brancatisano (1991) reported our experience of 50 patients having partial pleurectomy / decortication. The median survival was 16 months with a range of 3 to 54 months and 21% of patients survived more than two years. The curative role is less defined. Surgical resection is the curative treatment option for most solid malignant tumours and this ideal underpins the practice of surgeons treating MPM. Cytoreductive surgery, to reduce the burden of disease and prolong disease free living by complete macroscopic surgical resection is offered to patients with early disease in some centers. Here lies the key challenge. There are differing operative techniques aiming for the same outcome: extrapleural pneumonectomy, EPP, and lung sparing pleurectomy/decortication, EPD EPP, offered since the 1970s, involves complete resection en bloc of the lung, parietal pleura, ipsilateral pericardium, and ipsilateral hemi-diaphragm, along with complete excision of thoracic lymph nodes. Defects of the pericardium and hemi-diaphragm are repaired with Gortex mesh to prevent cardiac and visceral herniation. An early publication reported an unacceptable morbidity and mortality of 45% and 31%respecively (Butchart, 1976). David Sugarbaker, determined to improve patient survival, continued offering EPP but high recurrence rates proved surgery alone provided little benefit to survival. With persistence, his team offered EPP in combination with chemotherapy (prior to pemetrexed) and radiotherapy. In 1991 Sugarbaker reported survival rates of 70% at one year and 48% at two years. Morbidity and mortality rates were 19% and 6% respectively. This multimodality treatment required surgery to reduce tumour bulk, while chemotherapy and radiotherapy treated micro-metastatic disease. In 1996, Sugarbaker again reported similar results but added that epithelial cell types had better survival rates compared to sarcomatoid or mixed histology tumours. Other centres around the world reported individual surgical series each contributing to a collection of experiences. Weder (2007) reported on 45 EPP trimodality patients and found epithelial cell type had better survival. Cao (2010), attempted to evaluate the safety and efficacy of EPP found an overall survival of 13 – 23.9 months and concluded/confirmed that selected patients might benefit from EPP especially when combined with neoadjuvant chemo and adjuvant radiotherapy. Controversy about the ability of EPP to affect a cure or contribute to improved survival was to be sorted by the UK Mesothelioma and Radical Surgery feasibility study known as the MARS trial. This randomised control trial concluded that EPP offers no benefit and possibly harms patients. Surgeons, skilled at performing EPP and who had reported their results vehemently opposed this conclusion. The only centre in Australia offering trimodality therapy reported 70 patients having EPP between 1994 and 2008, having a median survival of 20 months, and morbidity and mortality of 37% and 5.7% respectively (Yan, 2009). Pleurectomy / decortication or P/D was the other preferred operation as some surgeons questioned the morbidity and mortality of EPP. Valarie Rusch (1993) pioneered P/D in order remove all visible and palpable tumours and achieve macroscopic complete resection. Other surgeons varied this procedure making comparing results difficult so specific terminology was used to describe 3 approaches. 1) Extended or radical pleurectomy/decortication (EPD); parietal and visceral pleura is resected along WITH diaphragm and pericardium. 2) Pleurectomy/decortication (PD); parietal and visceral pleura is resected WITHOUT diaphragm and pericardium. 3) Partial pleurectomy/visceral decortication as a palliative procedure. Individual cancer centers have reported case series. Flores (2008) compared EPP to pleurectomy / decortication. Nerangi-Miandoab (2008) reported epithelial cell type was a predictor of survival in patients having pleurectomy / decortication compared to no surgery. Nakas (2008) concluded patients not suitable for EPP should be offered radical P/D. Zahid (2011) found P/D may improve survival but at the expense of increased morbidity and is best offered to patients enrolled in prospective trials. Global differences related to the role of surgery in cytoreductive therapy relate to what radical surgical procedure provides the best chance of extended disease free survival. Is it EPP, lung sparing EPD, or P/D? What is certain is that EPP and EPD should be offered as part of trimodality therapy. Furthermore, the procedure must be performed by an experienced surgeon, and supported by a team with proven expertise and experience to care for these patients. Rusch (2012) reminds us that the role of surgery in the management of MPM remains controversial but it also remains a treatment option because of the limited benefits of radiotherapy and chemotherapy. Surgery is offered either as a palliative procedure or with curative intent. There is little need for debate about the palliative option but debate about curative intent continues. Finally, while global differences are important, what is learnt from collective experiences is more important. There is an urgent need to identify patients with favourable prognostic factors, suitable for cytoreductive therapy. We need to provide support, hopeful encouragement, and equitable access to multi modality treatment because there is a growing number of well living long-term survivors.

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      MTE17.4 - Discussion (ID 614)

      N. n/a

      • Abstract

      Abstract not provided

  • +

    O11 - Symptom Management (ID 137)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Supportive Care
    • Presentations: 10
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      O11.01 - Wiki-based treatment guidelines for lung cancer (ID 1274)

      I.N. Olver, J. Von Dincklage, L. Holliday, C. Vuletich

      • Abstract
      • Presentation
      • Slides

      Background
      The updating of written clincial practice guidelines regularly is difficult and expensive. New evidence in cancer treatment is published frequently. Guideline booklets are difficult to disseminate widely and stakeholder feedback is mainly pre-publication. To enable lung cancer guidelines to be rapidly updated and widely disseminated and therefore more likely to be utilised, Cancer Council Australia developed a web-based wiki platform for guidelines and is evaluating its impact.

      Methods
      The initial methodology paralled the steps in published written guideline development but these were integrated with the wiki capability. An expert group, whose competing interests were documented, were identified, the key clinical questions and search strategies were developed for each question and literature searches recorded on the wiki. An online literature screening and critical appraisal process was developed. This provides data on which papers were used to form the guidelines and why papers were either selected or rejected depending on their quality. Evidence-based recommendations were formulated and evidence tables automatically generated. The wiki was closed in that only the invited experts could write or change a guideline but any stakeholder could comment on the guidelines at any time and the writing group would review and respond to comments. The initial vesion of the guidelines were distributed for targetted review by expert groups. We used web analytics to monitor usage. The writers remain engaged to appraise new papers and update the guideline rapidly as necessary. All previous versions could be accessed.

      Results
      Evaluation of the lung caner treatment guidelines developed on the wiki, showed that 22 authors had identified 67 clinical questions covering treatment of all stages of lung cancer. The literature search and screening process resulted in 2035 potentially relevant articles being forwarded for detailed methodological evaluation with another 571 added through snowballing and other methods. To fine-tune the initial draft content, the working party used the wiki to exchange 156 internal comments in 9 weeks. When the guidelines were released for the initial 30-day public consultation period, 1055 users visited lung cancer content pages. The majority of users (487) accessed the guidelines directly as a result of targeted emails, while 387 found the site by Google searches. Most respondents were from Australia (799) and New Zealand (60) with the United States (47) having the largest user group of respondents from the other countries who visited the site. A survey of the usability of the site indicated widespread acceptance. The average time on a content page was 1:27minutes. The landing page was the most popular content page with 3426 page views and an exit rate of 18.85%, which indicates that the landing page served as an important tool for visitors to navigate the guidelines. To date there were 38 external comments which occasioned 31 edits by the working party.

      Conclusion
      Adopting a platform built on MediaWiki, and moving to electronic guidelines has allowed rapid updates as new evidence becomes available and wider dissemination than print formats. The next strategy to boost uptake is to write Qstream education modules to accompany the guidelines.

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      O11.02 - The "CLiC" Cough in Lung Cancer Study: The Characterisation of Cough in Lung Cancer (ID 2986)

      A.S.M. Harle, A. Molassiotis, J. Smith, F. Blackhall

      • Abstract
      • Presentation
      • Slides

      Background
      The “CLiC” Study seeks to characterise cough and identify its predictors using subjective and objective cough assessment tools, including the recently validated Manchester Cough in Lung Cancer Scale (MCLCS). Results will enable the identification of robust endpoints and therapeutic targets for novel antitussive interventional trials.

      Methods
      Patients with lung cancer (LC) and complaining of cough were recruited irrespective of stage and treatment, from two cancer centres. Demographic and clinical data were collected. Patients completed the MCLCS, Cough Severity Diary (CSD), cough severity Visual Analogue Scale (VAS) and the Brief Reflux Inventory (BRI, a validated 5-item questionnaire assessing gastro-oesophageal reflux disease (GORD)). The oncology specific European Organization for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire (EORTC QLQ) C30 with the module (LC13), (including item 31: "In the past week, how often did you cough?") was also completed. Cough was graded according to Common Toxicity Criteria for Adverse Events (CTCAEv4.0). A sample size of 178 patients was required for analysis of 160 (based on Peduzzi J Clin Epidem 1996) for 10 participants per correlate per outcome in binary logistic regression, assuming a 10% attrition rate, the prevalence of severe cough to be 50% and 8 cough predictors.

      Results
      We recruited 179 patients (Oct'11-Nov'12). The median age was 65 yrs (range 25-83 years), with 53% patients male. The majority (79%) had non small cell lung cancer (NSCLC) and advanced stage disease (>IIIA 60%). In total, 36% were receiving cancer therapy at entry. Overall, 60% felt their cough warranted treatment. Having ensured validity of the cough assessment tools, the mean cough severity score (VAS) (n=171) was 43.4mm (SD 29.6). The mean cough-specific QoL score (MCLCS) was 25.3 (SD 8.8, with a range 1-50, high scores representing worse QoL).

      Table showing association between cough predictors and cough severity (VAS) and cough specific QoL (MCLCS) scores on univariate analysis[*]
      Cough Severity (VAS) Cough Specific QoL (MCLCS) Comment
      Age (≤70yrs vs >70yrs) p=0.365# p=0.834#
      Gender p=0.048# p=0.171# women worse cough severity
      Smoking Status (current, ex, never) p=0.191## p=0.356##
      Performance Status (WHO PS 0-3) p<0.0001## p<0.0001## poorer PS worse cough severity poorer PS worse cough related QoL
      Histology (NSCLC vs SCLC) p=0.348# p=0.274#
      Stage (early vs advanced) p=0.358# p=0.301#
      Tumour Location (central vs peripheral) p=0.486# p=0.040# central tumours poorer cough related QoL
      COPD (Chronic Obstructive Pulmonary Disease) (self-reported) p=0.578# p=0.128#
      LRTI (Lower Respiratory Tract Infection) (self-reported) p=0.022# p=0.044# LRTI worse cough severity LRTI worse cough related QoL
      Asthma (self-reported) p=0.021# p=0.054# asthma worse cough severity
      GORD (BRI questionnaire) p<0.0001# p<0.0001# GORD worse cough severity GORD worse cough related QoL
      Nausea (EORTC QLQ C30) p=0.004## p=0.017## Increased nausea worse cough severity. Increased nausea worse cough related QoL
      Oral Steroids p=0.434# p=0.017# On steroids worse cough related QoL
      Over the Counter Antitussives p=0.011# p=0.067# On antitussives worse cough severity
      Opiates p=0.497# p=0.018# On opiates worse cough related QoL
      *Not all analysed cough predictors shown # Mann-Whitney-U Test ## Kruskal-Wallis Test

      Conclusion
      This is the largest single study to use validated cough-specific assessment tools in LC to characterise and assess potential influences on cough. LC patients have a severe cough, with comparable VAS scores to those of patients presenting to specialist chronic cough clinics. New antitussive therapies are needed. Key predictors of cough severity and reduced cough-specific QoL are performance status (PS), nausea and GORD. Preclinical research suggests that the neurokinin-1 pathway may mediate the vagal cough reflex pathway. Our results further support this hypothesis and imply that the neurokinin-1 pathway may be a relevant therapeutic target. The association with GORD may be explained by the shared vagal innervation of the airway and upper gastrointestinal tract.

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      O11.03 - The "CLiC" Cough in Lung Cancer Study: The Validation of Objective and Subjective Cough Assessment Tools in Lung Cancer Patients (ID 3006)

      A.S.M. Harle, A. Molassiotis, J. Smith, F. Blackhall

      • Abstract

      Background
      Cough is a common lung cancer (LC) symptom, yet effective therapies are lacking. The development and testing of novel therapies relies upon appropriate tools for the assessment of cough. CLiC is the first study to evaluate two new tools 1) objective ambulatory cough monitoring (ACM) from acoustic recordings (VitaloJAK™) and 2) the Manchester Cough in Lung Cancer Scale (MCLCS) quality of life (QoL) questionnaire. These provide complementary assessments of cough frequency and its impact upon the patient.

      Methods
      Patients with LC and complaining of cough were recruited, irrespective of stage or treatment, from two cancer centres. Demographic and clinical data were collected. All patients completed the MCLCS, Cough Severity Diary (CSD) and cough severity Visual Analogue Scale (VAS). The European Organization for Research and Treatment of Cancer QoL Questionnaire (EORTC QLQ) C30 with the module (LC13), (including item 31: "In the past week, how often did you cough?") was also completed. The Common Toxicity Criteria for Adverse Events (CTCAEv4.0) was used to grade cough. A subgroup underwent ACM and MCLCS on Days 0&60.

      Results
      We recruited 179 patients (Oct'11-Nov'12): median age 65yrs (range 25-83 years), 53% male. Majority (79%) had non small cell lung cancer, 60% advanced stage (>IIIA), 36% were on cancer therapy.

      Table showing correlations between subjective cough assessment tools
      EORTC QLQ C30 cough item 31 CTCAE Cough Grading MCLCS Manchester Cough LC Scale CSD Cough Severity Diary
      VAS Cough Severity 0.54**§ n=171 0.50**§ n=170 0.67**§ n=163 0.70**¥ n=84
      EORTC QLQC-30 cough item Q31 0.45**§ n=173 0.57**§ n=165 0.52**§ n=85)
      CTCAE Cough Grading 0.56**§ n=164 0.59**§ n=85
      MCLCS Manchester Cough LC Scale 0.76**¥ n=82
      ** p<0.0001 ¥high correlation §moderate correlation
      Table showing correlations between objective ACM and subjective cough tools
      VAS Cough Severity MCLCS Manchester Cough LC Scale Log Cough/hr Asleep Log Cough/hr Awake Log Cough/hr 24-hour
      VAS Cough Severity 0.73** n=37 0.33* n=37 0.61** n=37 0.57** n=37
      MCLCS Manchester Cough LC Scale 0.24 n=35 0.51* n=35 0.44* n=35
      Log Cough/hr Asleep 0.52** n=35 0.62** n=35
      Log Cough/hr Awake 0.97** n=37
      ** p<0.0001 * p<0.05
      Intra-class correlations demonstrated good repeatability over time between Days 0&60 for cough frequency (24hour: r=0.77, p<0.0001, awake: r=0.79, p<0.0001, sleep: r=0.66, p=0.004) and MCLCS: r=067,p<0.001 .The median cough scores/hour were 14.1(24hour: range 0.7-156), 18.5 (awake: range 1-233) and 6.0 (asleep: range 0-110).

      Conclusion
      We have demonstrated moderate to strong correlations between established measures of cough and two novel assessment tools, suggesting the validity of MCLCS and ACM. Their good repeatability suggests they have excellent potential for the assessment of novel treatments in future intervention studies for LC-related cough. In contrast, standard oncology tools are blunt and poorly discriminate cough.

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      O11.04 - Patterns of Quality of Life, Their Characteristics and Relationship to Symptoms -- 12 Months Follow-up in Newly Diagnosed Advanced Lung Cancer Patients (ID 3359)

      Y. Lai, Y. Liao, Y. Lee, W. Liao, C. Yu, P. Yang

      • Abstract
      • Presentation
      • Slides

      Background
      Patients with newly diagnosed advanced lung cancer may experience severe impacts on their quality of life (QOL). However, relatively few studies have examined the longitudinal patterns of QOL and their relationship to patients’ symptoms during the first 12 months of cancer diagnosis. Thus, the purposes of this study were to (1) examine the overall pattern and the potential sub-patterns (if any) of QOL in these patients during the first 12 months of cancer diagnosis; and (2) identify those important characteristics of each QOL sub-pattern and their relationship to patients’ symptoms.

      Methods
      This is a 12-month prospective longitudinal study. Newly diagnosed advanced lung cancer patients (Stage IIIB & IV) were eligible to be recruited and followed for 12 months on 5 time points (Pre-treatment, 1, 3, 6 and 12 months since treatments). The overall QOL was measured by the overall QOL item in the EORTC QLQ-C30 (0-100 scoring, higher is better). The QOL patterns and factors related to the patterns were analyzed by Latent Class Growth Analysis (LCGA). Potential factors (independent variables) used to predict the overall QOL change and each QOL sub-pattern (dependent variables) included: physical function, selected symptoms, emotion distress, self-efficacy (on coping with cancer) and important demographic and treatment related variables.

      Results
      A total of 200 subjects completed the 5 follow-up assessments. Generally, patients had moderate level of QOL across the 12 months. There were three QOL sub-patterns were identified. In the pattern I (around 50% of subjects), patients reported moderate to relatively good levels of QOL (scoring around 70-80) across the 12 months. In the pattern II (around 45% of subjects), patients reported moderate levels of QOL (scoring around 50-70 QOL). In the pattern III (<10% subjects), patients reported poor level of QOL (scoring around 40 or less). Overall, symptoms including fatigue, pain, lack of appetite and dyspnea were significantly related to the changes of QOL. Other factors also included psychological distress, uncertainty and self-efficacy (level of confidence) in coping well with lung cancer.

      Conclusion
      The results provide a relatively comprehensive picture about the overall QOL and the sub-patterns of QOL for those newly diagnosed advanced lung cancer patients. The results further support the giving timing and tailoring interventions are needed to better improve lung cancer patients’ QOL. (Acknowledgement: National Health Research Institute,NHRI,Taiwan).

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      O11.05 - DISCUSSANT (ID 4006)

      L. Morgan

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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      O11.06 - The effects of inspiratory muscle training in the management of breathlessness in patients with lung cancer: a pilot feasibility randomized trial (ID 3179)

      A. Molassiotis, A. Charalambous, P. Taylor, Z. Stamataki, Y.J. Summers

      • Abstract
      • Presentation
      • Slides

      Background
      Breathlessness in patients with lung cancer is common symptom affecting 50-70% of patients, rising to 90% for those with advanced lung cancer. Managing breathlessness is complex, treatment options are limited and treatments are sometimes unsuccessful. Inspiratory muscle training (IMT) is a non-pharmacological method that has shown positive results in Chronic Obstructive Pulmonary Disease and mixed results in other respiratory illnesses. As this treatment method has never been tested in patients with lung cancer, the aim of the current study was to assess how feasible this treatment is in the lung cancer population and explore changes in outcome variables, before launching a larger randomized trial.

      Methods
      Pilot feasibility randomized trial in patients with lung cancer having stable disease. The experimental group received training using a pressure threshold device (commercially available from Phillips Respironics). Patients were instructed to do 5 sessions weekly for 12 weeks for a total of 30mins per day, divided over 2 sessions. Patients in the control group received standard care and received the treatment at the end of their trial participation. Outcome measures were completed at baseline and monthly for 3 months, and included: physiological parameters (FEV1,FVC); perceived severity of breathlessness in six 10-point VAS assessing average breathlessness over past 24 hours, worst breathlessness over past 24hrs, breathlessness now, distress from breathlessness, ability to cope with breathlessness and satisfaction with breathlessness management; modified Borg scale; quality of life using the short form-Chronic Respiratory Disease Questionnaire (with subscales on dyspnea, fatigue; emotional function and mastery of breathlessness); Hospital Anxiety & Depression Scale, and safety.

      Results
      46 patients (M=37, F=9) at a mean age of 69.5 years old and a mean of 16 months post-diagnosis who were not currently receiving chemotherapy/radiotherapy were recruited from 3 centres in the UK and Cyprus. Seventy-percent had NSCLC and advanced disease. There were no changes in FEV1 and FVC levels between groups. There were time by intervention interaction effects in average breathlessness and worst breathlessness in past 24hrs (p<0.01) with the intervention arm showing stable breathlessness and the control group deteriorating, but no between-group differences. Statistical and clinically important differences were seen with regards to ability to cope with breathlessness (p=0.02), satisfaction with breathlessness management (p=0.024), fatigue (p=0.007), emotional function (p=0.006), breathlessness mastery (p=0.031), anxiety (p=0.027) and depression (p=0.048). The m-Borg difference between the 2 groups at 3 months was 0.80, which is borderline clinically significant but not statistically significant. Changes were more evident in the 3-month assessment. IMT was safe with only a small number of patients complaining of muscle fatigue and dizziness.

      Conclusion
      This trial shows the IMT is feasible and safe in patients with lung cancer with significant benefits particularly in their ability to cope with breathlessness and emotional distress. The details of this trial allow us to refine the treatment protocol and findings guarantee a fully-powered larger trial (N should be around 196 with m-Borg as primary outcome).

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      O11.07 - Tracheobronchial Stent Insertion in the Management of Primary Lung Cancer: 5 Year Experience (ID 818)

      H. Wilson, V. Anikin, E. Beddow

      • Abstract
      • Presentation
      • Slides

      Background
      Central airway obstruction is seen in around 30% of patients with primary lung cancer. This is often a life-threatening presentation of the disease due to imminent airway loss and therefore requires urgent intervention. Direct bronchoscopic techniques including airway stenting can offer an immediate improvement in symptoms and quality of life, in addition to providing time for further treatment modalities. Here we report outcomes from a large single centre five year experience of tracheobronchial stent insertion for palliation of advanced primary lung cancer.

      Methods
      A retrospective review of all patients undergoing tracheobronchial stent insertion between January 2007 and January 2012 was performed. Patients undergoing stent insertion for benign or secondary malignant disease were excluded. A total of 70 patients underwent 80 stenting procedures with an average age of 66 years. Patient notes were used to collect patient demographic, disease and stenting data. Outcomes included post-procedure length of stay, complications, need for further intervention and overall survival.

      Results
      Disease was identified within the trachea in 18 cases, bilaterally within the bronchi in 10 cases and in the left or right bronchus in 23 and 28 cases respectively. Expandable, nitinol stents were used for all patients with either a proximal or distal release system. Uncovered stents (57), covered stents (20) or a mixture of the two (3) were placed. The average length of stay was 2.5 days (range 0-17); however, 69% of patients were discharged on the same day or on day one following the procedure. There were no cases of stent migration identified. The most common complication was retained secretions requiring repeat bronchoscopy which occurred in 5 cases. One patient required telescopic insertion of a second stent due to malposition of the first. Median survival was 2.6 months with a 20% one-year survival. There were 4 in hospital deaths.

      Conclusion
      Central airway obstruction secondary to primary lung cancer can cause disabling dyspnoea and impending suffocation. Interventional bronchoscopic techniques, in particular airway stenting, can provide immediate relief of these symptoms. The survival data here reflects the advanced stage of disease in this patient group and, although unlikely to improve survival, airway stenting can offer the opportunity for further adjuvant treatment in some cases. More importantly perhaps, 91% of patients were discharged home following the procedure allowing an improved in quality of life. In our experience, tracheobronchial stent insertion can be used effectively to achieve these outcomes with minimal complications and a short hospital admission. Figure 1

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      O11.08 - A Comparison of Tracheobronchial Stent Insertion With and Without Radiological Guidance in Patients with Advanced Primary Lung Carcinoma (ID 819)

      H. Wilson, E. Beddow

      • Abstract
      • Slides

      Background
      Tracheobronchial stent insertion is safe and effective in managing central airway obstruction in advanced lung carcinoma. Airway stenting offers both immediate relief of severe dyspnoea and time for adjuvant therapy. It is commonly used in specialist thoracic centres with a variety of stent models employed. A large number of centres still use fluoroscopic guidance for stent positioning, leading to increased radiation exposure for both patients and staff. The aim of this study was to compare outcomes in patients undergoing stent insertion with or without radiological guidance.

      Methods
      70 patients were identified who underwent a total of 79 stent procedures. The cohort was divided into two groups based on whether stents were inserted under radiological guidance or direct vision at bronchoscopy. Retrospective analysis of notes was performed to collect data with regards to stenting strategy and post-operative course. The primary outcomes were length of stay, complications, repeat procedure and survival.

      Results
      Of the 79 stent procedures, 41 were with radiological guidance (group 1) and 38 were under direct vision only (group 2). There was an equal distribution with regards to the position of the stents (Table 1). Both techniques were well tolerated with minimal complications and no stent migration. Post-procedure length of stay was 2.73 days in group 1 and 2.26 days in group 2, with no significant statistical difference seen (p=0.93). There was also no difference in need for further stent intervention. A comparison of survival is shown in Figure 1. Figure 1 Figure 2

      Conclusion
      Airway stenting is a vital technique in the management of impending central airways obstruction. Although traditionally carried out under radiological guidance, we found no differences in complications, need for repeat procedure or survival when using direct vision. This not only saves radiation exposure to patients and staff, but also improves the cost-effectiveness and logistics of planning these urgent cases.

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      O11.09 - Ibandronic Acid vs. Zoledronic Acid In Lung Cancer Patients With Skeletal Metastases. How Do They Compare? (ID 90)

      I.A. Dimitroulis, A. Dervas, S. Vasileiou, M. Toumbis

      • Abstract
      • Slides

      Background
      Amino-biphosphonates are third-generation bisphosphonates which act by inhibition of osteoclasts. We have presented at two previous ATS conferences (Dimitroulis I.A. et al 2009, 2011), the role of each amino-biphosphonate separately. We set out to investigate the superiority or inferiority of Ibandronic acid (Ibandronate) over Zoledronic acid (Zoledronate), in terms of efficacy in reducing bone pain, and complications in patients with skeletal metastases due to Lung Cancer.

      Methods
      Ninety six patients with Skeletal Metastases due to Lung Cancer were enrolled, and were randomized on a 1:1 basis to receive infusions of Ibandronate (50 pts) or Zoledronate (46 pts) intravenously, every 21 days. Infusion time for Zoledronate (4mg) was 15 minutes, and for Ibandronate (6mg) one hour. Patients (pts) were analysed for pain relief, skeletal-related events (SREs) and adverse events. All pts underwent dental and cardiac examination before enrollment, and completed blood tests every 21 days. Bone scan was performed every 6 months. Blood tests (including close monitoring of calcium levels and renal function) were performed before each amino-biphosphonate administration.

      Results
      Patients in both arms were well matched for their diagnosis, stage of disease, burden of skeletal disease, and performance status. Median follow-up was 24 months. At 24 months, mean increases in British Pain Inventory pain scores were lower with Zoledronate compared to Ibandronate (0.43 vs 0.89 [p=0.03]). Analgesic effect as defined by the 4 point analgesic scale was less with Zoledronate as compared to Ibandronate. Incidence of SREs was not significantly different between two arms (35% for Zoledronate vs 38% for Ibandronate [p=0.2]). Median time to the first SRE was not reached in either arm. At 18 months of median follow up, percentages of patients with skeletal-related events were 41% in the Zoledronate arm vs 45% in the Ibandronate arm (p=0.05). Zoledronate caused fever in six (12%) patients and hypocalcemia in one patient. Ibandronate caused hypocalcemia in one patient (2.2%). No cases of jaw osteonecrosis, atrial fibrillation or renal failure (all of them possible side-effects of amino-biphosphonates) were observed.

      Conclusion
      Zoledronate is the preferred amino-bisphosphonate for its shorter infusion time, availability and relative benefits. It is slightly better than Ibandronate in reducing bone pain and preventing skeletal-related events. The only possible drawback is that, locally, Zoledronate is 1.3 times more expensive than Ibandronate (according to the mean European Economic Community price).

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      O11.10 - DISCUSSANT (ID 4007)

      A.B. Oton

      • Abstract
      • Presentation
      • Slides

      Abstract not provided

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Author of

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    ITONF - International Thoracic Oncology Nursing Forum (ITONF) Workshop (ID 220)

    • Event: WCLC 2013
    • Type: Other Sessions
    • Track: Nurses
    • Presentations: 2
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      ITONF.01 - Opening of Workshop (ITONF Update and Workshop Intro) (ID 4049)

      B. Ivimey

      • Abstract

      Abstract not provided

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      ITONF.07 - Workshop Close / Questions (ID 4038)

      B. Ivimey

      • Abstract

      Abstract not provided