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P. Flynn



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

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

      09:30 - 16:30  |  Author(s): P. Flynn

      • Abstract

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

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

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

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

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

      09:30 - 16:30  |  Author(s): P. Flynn

      • Abstract

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

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

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

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

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    P1.21 - Poster Session 1 - Diagnosis and Staging (ID 169)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Prevention & Epidemiology
    • Presentations: 1
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      P1.21-008 - Accuracy of nodal staging in early stage NSCLC in the modern era of PET-CT, EBUS-TBNA and multidisciplinary team approach (ID 2745)

      09:30 - 16:30  |  Author(s): P. Flynn

      • Abstract

      Background
      Accurate staging of NSCLC remains the most important step in predicting outcome. It has been proposed that PET-CT, as an addition to conventional work up, allows for more accurate pre operative detection of stage IIIa and IIIb disease. On the other hand, it appears to have limitations in reliably staging nodal involvement in early stage NSCLC. We aimed to compare pre-operative nodal staging (PET-CT and/or EBUS-TBNA findings) with post-operative histopathological results to determine the accuracy of PET- CT in a multi-disciplinary team setting.

      Methods
      This was a prospective, observational study of consecutive patients discussed through Nepean Lung Cancer MDT that underwent surgical resection for NSCLC from Jan 2010 until Feb 2013. PET-CT parameters of all patients, including FDG uptake in primary lesion(s) as well as hilar and mediastinal lymph nodes, were compared with post operative histopathology of the primary lesions and resected lymph nodes. Pre-operative nodal staging based on PET-CT +/- EBUS-TBNA was compared with post-operative histopathological staging. A PET-CT SUV (max) of equal or more than 2.5 was considered positive.

      Results
      74 patients (mean age 69 years, range 47-86, 45 M ) underwent surgical resection with lymph node dissection for NSCLC (65 lobectomies, 5 bi-lobectomies, 2 wedge resections and 2 pneumonectomies). The most common malignancy in this group was Adenocarcinoma (39 [52.7%]) followed by Squamous Cell Carcinoma (25 [33.7%]) and undifferentiated large cell carcinoma (10 [13.5%]). Most patients were post-operatively confirmed to be in early stages (32 stage I and 26 stage II) with other patients in stage III (12 IIIa and 1 IIIb) and stage IV (3). In 47% of cases, PET-CT nodal staging was concordant with final histopathological results. There was discordance in 39/74 cases with PET-CT being more likely to upstage (30/74) than to downstage (9/74) the mediastinum. Symmetrical FDG uptake in hilar lymph nodes was common amongst upstaged cases. Anthracosis/silicosis was reported in lymph node histopathology of 16/74 (%21.6) patients, with 8 upstaged by PET-CT. Overall, sensitivity of PET-CT mediastinal staging in our cohort was 31.25% with a specificity of 70.5%. This translates into accuracy of 70.2%. In 7 cases, EBUS-TBNA was performed to establish nodal staging. One case of micro-metastasis, confirmed on post-operative histopathology, was not detected on EBUS-TBNA.

      Conclusion
      Nodal staging by PET-CT in early stage NSCLC has reasonable specificity but poor sensitivity, tending to upstage rather than downstage. Benign inflammatory processes affecting intra-thoracic lymph nodes such as anthracosis/silicosis may cause false positive PET-CTs. Nodal staging based only on PET-CT is inadequate and discussion through a multidisciplinary panel as well as minimally invasive investigations such as EBUS-TBNA is recommended. This is consistent with current international guidelines.