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M. Janssen-Heijnen

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    MS07 - Epidemiology and Prevention (ID 24)

    • Event: WCLC 2013
    • Type: Mini Symposia
    • Track: Prevention & Epidemiology
    • Presentations: 1
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      MS07.2 - Comorbidity & Competing Causes of Death in Lung Cancer Patients (ID 487)

      14:00 - 15:30  |  Author(s): M. Janssen-Heijnen

      • Abstract
      • Presentation
      • Slides

      Background Over fifty percent of all newly diagnosed lung cancer patients are aged over 65 years at the time of lung cancer diagnosis, and about 30% are aged over 70. Since lung cancer is a disease that mainly occurs in elderly, and smoking is the most important risk factor [1], many patients have (smoking-related) comorbidity at the time of lung cancer diagnosis. This may complicate the management of lung cancer and may also serve as a competing cause of death. Methods An overview of literature concerning the prevalence and prognostic influence of comorbidity in lung cancer patients as well as competing causes of death. ResultsPrevalence of comorbidity Previous studies have shown that over 70% of patients suffered from at least one serious comorbid condition at the time of lung cancer diagnosis [2, 3]. The prevalence of (especially tobacco-related) comorbidity was higher among lung cancer patients as compared to patients with other major tumour types or the general population [2, 4]. The most frequent concomitant diseases among lung cancer patients were tobacco-related, such as cardiovascular diseases (25-30%), chronic obstructive pulmonary diseases (COPD, 25-30%) and previous malignancies (about 20%) [2, 3]. Prognostic influence of comorbidity Since in most cancer trials significant comorbidity is an exclusion criteria, limited information is available on the prognostic influence of comorbidity (which is important information for everyday clinical practice). Previous studies have shown that comorbidity only had a significant influence on survival in case of a localized lung tumour or in case of severe comorbidity [2, 3, 5-7]. A poorer overall survival in patients with comorbidity might be explained by death due to complications of treatment, death from cancer due to less aggressive treatment, or an increased risk of mortality due to comorbid conditions (competing causes of death). Comorbidity may increase the risk of peroperative and postoperative complications, especially those of the cardiorespiratory system [8]. A previous population-based publication has also shown that up to 75% of elderly SCLC patients receiving chemotherapy developed grade 3-5 toxicity, and two thirds of these patients receiving chemotherapy were unable to complete the treatment [9]. Elderly patients with localized non-small cell lung cancer (NSCLC) underwent less surgery than younger patients, older patients with non-localized NSCLC received less chemotherapy or chemoradiation, and elderly with small cell lung cancer (SCLC) received less chemotherapy and chemoradiation [5, 9, 10]. Competing causes of death Increased mortality due to comorbidity is probably of less importance in case of a lethal disease as non-localized NSCLC or SCLC [2, 10, 11]. Most patients probably die of lung cancer before they become at risk of dying of the comorbid condition. Previous studies have shown that 80-90% of all lung cancer patients died of lung cancer. The most common other causes of death were other tobacco-related conditions as cancers and cardiovascular causes [12-14]. Respiratory failure is the most common immediate cause of death for patients with lung cancer, probably because most of them have lung disease besides cancer and therapy for lung cancer may also add to impairment of lung function [15]. The finding that over 90% of lung cancer patients have contributing causes of death, suggests the possibility that saving a patient from one cause may only allow another disease process to become the immediate cause of death [15]. Conclusions The majority of patients with lung cancer also have serious comorbidity, especially other smoking-related diseases as cardiovascular diseases and COPD. Besides making treatment complex, comorbid conditions may also serve as competing causes of death. References 1. Doll R, Peto R, Wheatley K et al. Mortality in relation to smoking: 40 years' observations on male British doctors. Bmj 1994; 309: 901-911. 2. Piccirillo JF, Tierney RM, Costas I et al. Prognostic importance of comorbidity in a hospital-based cancer registry. Jama 2004; 291: 2441-2447. 3. Janssen-Heijnen ML, Schipper RM, Razenberg PP et al. Prevalence of co-morbidity in lung cancer patients and its relationship with treatment: a population-based study. Lung Cancer 1998; 21: 105-113. 4. Janssen-Heijnen ML, Houterman S, Lemmens VE et al. Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approach. Crit Rev Oncol Hematol 2005; 55: 231-240. 5. Luchtenborg M, Jakobsen E, Krasnik M et al. The effect of comorbidity on stage-specific survival in resected non-small cell lung cancer patients. Eur J Cancer 2012; 48: 3386-3395. 6. Jorgensen TL, Hallas J, Friis S, Herrstedt J. Comorbidity in elderly cancer patients in relation to overall and cancer-specific mortality. Br J Cancer 2012; 106: 1353-1360. 7. Birim O, Kappetein AP, Bogers AJ. Charlson comorbidity index as a predictor of long-term outcome after surgery for nonsmall cell lung cancer. Eur J Cardiothorac Surg 2005; 28: 759-762. 8. Wang S, Wong ML, Hamilton N et al. Impact of age and comorbidity on non-small-cell lung cancer treatment in older veterans. J Clin Oncol 2012; 30: 1447-1455. 9. Janssen-Heijnen ML, Maas HA, van de Schans SA et al. Chemotherapy in elderly small-cell lung cancer patients: yes we can, but should we do it? Ann Oncol 2011; 22: 821-826. 10. Janssen-Heijnen ML, Smulders S, Lemmens VE et al. Effect of comorbidity on the treatment and prognosis of elderly patients with non-small cell lung cancer. Thorax 2004; 59: 602-607. 11. Phernambucq EC, Spoelstra FO, Verbakel WF et al. Outcomes of concurrent chemoradiotherapy in patients with stage III non-small-cell lung cancer and significant comorbidity. Ann Oncol 2011; 22: 132-138. 12. Janssen-Heijnen ML, Maas HA, Siesling S et al. Treatment and survival of patients with small-cell lung cancer: small steps forward, but not for patients >80. Ann Oncol 2012; 23: 954–960. 13. Pirie K, Peto R, Reeves GK et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. Lancet 2013; 381: 133-141. 14. Thun MJ, Carter BD, Feskanich D et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med 2013; 368: 351-364. 15. Nichols L, Saunders R, Knollmann FD. Causes of death of patients with lung cancer. Arch Pathol Lab Med 2012; 136: 1552-1557.

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