Virtual Library
Start Your Search
iain Phillips
Author of
-
+
MA10 - Assessing and Managing Supportive Care Needs (ID 215)
- Event: WCLC 2020
- Type: Mini Oral
- Track: Palliative and Supportive Care
- Presentations: 1
- Moderators:
- Coordinates: 1/31/2021, 11:45 - 12:45, Scientific Program Auditorium
-
+
MA10.10 - Lung Cancer Admission Rates During the COVID-19 Pandemic to a Tertiary Cancer Centre in South East Scotland. (ID 3554)
11:45 - 12:45 | Author(s): iain Phillips
- Abstract
Introduction
Lung cancer is associated with a lower socio-economic status, major co-morbidities and a poorer performance status. These factors, and the negative association often affiliated with lung cancer, can create barriers to healthcare engagement. Anecdotally patients admitted during the lockdown phase of the COVID-19 pandemic were more unwell and required more intervention than normal. We examined acute admissions during the pandemic to establish the impact of the COVID-19 pandemic on patients with lung cancer.
Methods
We identified all patients admitted with suspected or previously diagnosed lung cancer admitted acutely to Edinburgh Cancer Centre between 29th of March and 29th June 2020. In Scotland, lockdown was eased from 29th of May, so we divided our analysis into early lockdown (29th March-April), late lockdown (May) and recovery (June). We gathered patient demographics (age, gender), duration of admission (days), admission route (referral from routine contact with oncology specialist for emergency care, self-presentation to oncology patient helpline, self-presentation to GP or A&E, and planned admission for specialist oncology treatment) and outcomes from the admission, including mortality and palliative care involvement. We compared this with admissions in April 2019.
Results
During the three months evaluated, 77 patients were admitted, of whom 46 were male and 31 were female. The mean age of patients was 65.8 (range 42 to 87), with no significant difference between each month assessed. The number of admissions in the 3 assessment periods were 29 (early lockdown), 21 (late lockdown) and 27 (recovery), compared with 10 admissions in April 2019.
Patients were admitted for a longer period of time in early lockdown (mean 7.4 days) and late lockdown (mean 7.0 days), but less in the recovery period (mean 2.7 days). There were 3 inpatient deaths in early lockdown, 2 in late lockdown and none during the recovery period, suggesting patients may have been presenting with more advanced acute illness during lockdown.
Admission route shifted from being prompted by a routine remote consultation to patient-driven self-presentation as the pandemic progressed. During early and late lockdown, around half of patients were admitted after a scheduled remote consultation (48% (14/29) in early lockdown, 57% (12/21) in late lockdown). In contrast, 19% (5/27) patients were admitted via this route during the recovery period, with 41% (11/27) being admitted via patients self-presenting to the patient helpline and 37% (10/27) self-presenting to A+E/GP.
Conclusion
Our data suggests that there were more patients with lung cancer admitted acutely with cancer, non-COVID-19-related illness during the COVID-19 pandemic. The early and late lockdown phase was particularly characterised by a reduction in self-presentation and longer resulting admissions, suggesting patients were admitted with more complex pathology and consequently longer admission from acute illness.
Overall, our experience highlights the need to make acute cancer services accessible to patients as the COVID-19 pandemic continues, and that patients with lung cancer may be a particularly vulnerable group.
-
+
P09 - Health Services Research/Health Economics - Real World Outcomes (ID 121)
- Event: WCLC 2020
- Type: Posters
- Track: Health Services Research/Health Economics
- Presentations: 1
- Moderators:
- Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
-
+
P09.32 - Is the New Patient Respiratory Appointment an Appropriate Time to Refer Patients With Likely Lung Cancer for Prehabilitation? (ID 2953)
00:00 - 00:00 | Author(s): iain Phillips
- Abstract
Introduction
Patients with lung cancer are often co-morbid1 with high symptom burden.2 Lung cancer treatments are increasing in intensity and duration. Prehabilitation provides an opportunity to improve outcomes for patients.3
We completed a feasibility study to ask the following:
1. Would possible cancer on a CT scan in a patient fit for further investigation be appropriate screening criteria for prehabilitation referral?
2. Was the time between CT scan and starting anti-cancer treatment sufficient to commence prehabilitation?
Methods
24 consecutive patients attending urgent respiratory clinics with possible lung cancer were recruited between October and November 2019. Patients’ general fitness was assessed by: PG-SGA (Patient Generated Subjective Global Assessment), G8 frailty assessment and patient reported performance status. Following the clinic CT scan reports were reviewed, we included as high risk all scans that implied or explicitly stated likely lung cancer (eg suspicious, concerning, favour).
Results
24 patients (13:M, 11:F) were recruited; median age 72 years (range 47-89). All patients approached consented to involvement.
15/24 had high suspicion of cancer on CT. Of the 8 patients suitable for further investigation, 7 had confirmed histological diagnosis of lung cancer. 4 patients were not fit enough for further investigation, 2 remain under follow up and 1 had an alternative diagnosis confirmed.
6 were referred to oncology. Time between first respiratory and first oncology clinic appointments varied from 13 to 62 days. At initial respiratory appointment 5 of these patients PG-SGA score was >4 (need for intervention). 5 patients self rated performance status 0-2, 1 patient reported as 3. All had a G8 frailty score <14 (abnormal).
Conclusion
1. A CT scan suspicious for cancer in patients fit for further investigation identified 87.5% (7/8) of those with subsequently confirmed lung cancer. These are appropriate criteria for prehabilitation referral.
2. Referring patients when likely lung cancer is indentified on CT allows adequate time for intervention, including in the shortest time to oncology (13 days).
3. 83% (5/6) required dietetic input, 100% (6/6) scored low on the G8 assessment and 83% (5/6) self assessed PS 0-2.
References:
1. Gould MK et al. Comorbidity profiles and their effect on treatment selection and survival among patients with lung cancer. Ann Am Thorac Soc 2017;14(10):1571-15802. Phillips I et al. Symptom burden strongly correlates with the need for a dietician in advanced NSCLC. 18th annual BTOG/ Lung Cancer 2020:139(1):S79-S80
3. Giles C, Cummins S. Prehabilitation before cancer treatment. BMJ 2019;366:l5120
-
+
P20 - Locoregional and Oligometastatic Disease - Radiation (ID 130)
- Event: WCLC 2020
- Type: Posters
- Track: Locoregional and Oligometastatic Disease
- Presentations: 1
- Moderators:
- Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
-
+
P20.05 - Oesophageal Dose Predicts on Treatment Toxicity in Patients Receiving Concurrent Chemo-Radiotherapy for Non-Small Cell Lung Cancer (ID 2976)
00:00 - 00:00 | Author(s): iain Phillips
- Abstract
Introduction
Previous studies suggest that there is a relationship between radiotherapy dose and organ toxicity in patients receiving radical radiotherapy for lung cancer.
We aimed to establish the incidence of toxicity from 3D conformal radiotherapy and describe the associations between radiotherapy dose and gastrointestinal toxicities.
Methods
We conducted a retrospective analysis of radiation doses and toxicities in 72 patients with stage 3 NSCLC who received concurrent chemoradiotherapy at the Edinburgh Cancer Centre between 2016 and 2017. Patients received 60Gy in 30 fractions of external beam radiotherapy, with concurrent cisplatin and vinorelbine. Patients underwent a weekly nurse led toxicity assessment and CTCAE gradings were recorded. 64 patients had both accessible radiotherapy treatment data and toxicity tables, and were included in the statistical analysis of toxicities. For the purpose of this study GI toxicities entailed: dysphagia, oesophagitis, nausea, vomiting, anorexia and weight loss. 5 patients were excluded as they had no radiotherapy data available and 3 patients were excluded as they had no toxicity data. We then conducted a single-tail t-test of the mean difference in OesV100 dose between patients with GI toxicities of 2 or above, and those with GI toxicities of 1 or less.
Results
The median age of patients was 64 years old (range 42-78) and 56% were male and 44% were female. 67 patients (93%) had radiotherapy plans available. Lung V20 & MLD (Mean Lung Dose), OesV100, Heart V30, and Heart V5 were all recorded. 69 (96% of patients) had toxicity tables from the 6 weeks of treatment, and 55 (75%) had follow-up toxicities noted at week 10. 13 patients did not have follow-up toxicities readily available as they had returned to a different health board.
Of the 64 patients included in the statistical analysis, 33 had a toxicity of grade 2 or above at any point during treatment or follow-up. This group had a statistically significant mean difference (MD) in Oesophageal V100%, compared to those without any grade 2 toxicity (V100% of 6.9% vs 2.5%, 95% confidence interval of MD, 0.45 to 8.2; P value of 0.0146). When only GI toxicities were considered (n=43) the mean Oesophagus V100% of this group was 7.6% vs 2.63% (95% CI of MD, 1.2% to 8.9%; P-value 0.0134). Lung V20, MLD, Heart V30 and Heart V5 did not show any relationship with Grade 2 or higher toxicity.
Conclusion
1. Toxicity grades were well documented during patients’ 6-week period of radiotherapy.
2. We found an association between OesV100 dose, and any grade 2 or above toxicity, as well as with GI toxicities.
-
+
P30 - Palliative and Supportive Care (ID 163)
- Event: WCLC 2020
- Type: Posters
- Track: Palliative and Supportive Care
- Presentations: 2
- Moderators:
- Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
-
+
P30.01 - Machine Learning can be used to Predict need to see a Dietitian in Patients with Advanced Lung Cancer. (ID 3141)
00:00 - 00:00 | Presenting Author(s): iain Phillips
- Abstract
Introduction
The DAIL (Dietetic Assessment and Intervention in Lung Cancer) study investigated the need for dietetic input in patients with Non-Small Cell Lung Cancer (NSCLC). It based need to see a dietician on the PG-SGA (Patient Generated Subjective Global Assessment), as the gold standard test. This abstract reports on a sub-study aimed at identifying if machine learning could be used to predict the need to see a dietitian using alternative data points collected during the study, when compared to the PG-SGA.
Methods
96 patients with stage 3b and 4 lung cancer were recruited between April 2017 and June 2019. Of these 20 had incomplete data, leaving 76 patients; 56 from Royal Surrey County Hospital (RSH) and 20 from Frimley Park Hospital (FPH).
The PG-SGA was completed in all cases. This was compared to data points collected from the study, which included: the G8 frailty assessment, EORTC QLQ C30 and LC13 quality of life assessments, hand grip strength, psoas muscle surface area, spirometry, routine blood tests, Body Mass Index (BMI) and weight change, leading to 137 data points for each patient.
Univariate analysis was used to find the strongest single correlates with “need to see a dietitian” (NTSD) and “critical need to see a dietitian” (CNTSD). The correlates with a Spearman correlation above +/-0.4 were selected to train a Support Vector Machine (SVM) to predict NTSD and CNTSD (SVM1) and the misclassification error calculated.
Results
The number of measures with Spearman correlation coefficients above +/-0.4 was 18 and 13 out of a total of 137 for NTSD and CNTSD respectively. SVMs trained with these measures produced 3% and 7% misclassification error. For the SVM trained on the RSH data and tested on the FPH data the results were weaker with errors of 20% or more. This is likely to be due to the fact that only 20 patients were included in the FPH data set.
Conclusion
This work suggests that machine learning can be used to predict the need to see a dietician for lung cancer patients. The results are promising, producing low misclassification rates. It could potentially automate screening for need to see a dietitian. However the results for FPH data using a model trained on RSH data suggest more work is needed to transfer the model between datasets from different hospitals.
-
+
P30.03 - A Simple Solution to Screening for Dietetic Need in Patients with Advanced Non-Small Cell Lung Cancer (ID 2399)
00:00 - 00:00 | Presenting Author(s): iain Phillips
- Abstract
Introduction
European Society for Clinical Nutrition and Metabolism (ESPEN) and National Institute for Clinical Excellence (NICE) guidelines recommend that cancer patients should be screened for malnutrition at diagnosis. In t he UK, anecdotally access for lung cancer patients to specialist dietetic services is limited. The DAIL (Dietetic Assessment and Intervention in Lung Cancer) study investigated the need for dietetic input in patients with Non-Small Cell Lung Cancer (NSCLC).
Methods
Patients with stage 3b and 4 NSCLC underwent a rang of assessments at a single time point, prior to starting first line systemic anti-cancer therapy. These included the PG-SGA (Patient Generated Subjective Global Assessment), EORTC quality of life survey, G8 and Charlson co-morbidity index. The PG-SGA was the assessment central to our study, a screening tool validated for oncology patients, which assesses malnutrition, symptoms, weight change and the need for dietetic review. The goal of the assessment was to establish if the DAIL tool, or a subset of the PG-SGA, could be used to identify patients in need of dietetic intervention.
Results
96 patients were consented between April 2017 and August 2019. The PG-SGA identified that 78% of patients required nutritional advice; with 52% patients having a critical need for dietetic input. Results were dominated by symptom scores. One or more nutrition impact symptoms or a self-reported history of weight loss strongly correlated with total PG-SGA score, which indicated a need for dietetic intervention. As a screening test, having one of these two aspects of the PG-SGA had a sensitivity of 88% (95% Confidence interval 78.44-94.36) and specificity of 95.24% (95% CI 76.18-99.88) for need for dietetic review.
Conclusion
The need for dietetic intervention is common in patients with advanced NSCLC. In a resource limited health setting the DAIL tool: a two question screening tool asking about symptomatology and self-reported weight loss could provide a readily implementable, inexpensive method to easily identify those in need of dietetic intervention.
-
+
P76 - Targeted Therapy - Clinically Focused - EGFR (ID 253)
- Event: WCLC 2020
- Type: Posters
- Track: Targeted Therapy - Clinically Focused
- Presentations: 1
- Moderators:
- Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
-
+
P76.89 - Is it Possible to Halt Cachexia in Poor Performance Patients with Metastatic EGFR Positive Lung Cancer? (ID 3649)
00:00 - 00:00 | Author(s): iain Phillips
- Abstract
Introduction
Cachexia is a pro-inflammatory syndrome associated with weight loss. It now has a formal definition defined by Fearon et al in their landmark paper. It is common in lung cancer.
It is a commonly held view that cachexia is irreversible in patients with advanced cancer. We wanted to understand whether 2 markers associated with cachexia (sarcopenia and the Glasgow Prognostic Score, GPS) are reversible on treatment, in patients with poor performance status at the time of diagnosis of metastatic EGFR positive lung cancer. Patients with significant weight loss and a poor GPS often have a poor prognosis.
Methods
We identified 5 patients who fitted the following criteria: metastatic EGFR positive lung cancer, performance status 3 or 4, responded to first line tyrosine kinase inhibitor treatment.
The surface area of the psoas muscles at the level of L3 were measured and recorded. A threshold for sarcopenia was defined as <390mm2. We tracked the surface area of psoas muscle during the first 6 months of treatment. GPS was used to assess inflammation. CRP ≤10 = 0 point, CRP >10 and albumin >35g/L = 1 point, CRP >10 and albumin ≤35g/L= 2 points.
Results
5 patients were identified, all were female, whose age ranged from 50-83. All were PS 3+ at start of treatment, all had an initial response to treatment. 4 patients are currently responding at 4, 11, 13 and 18 months respectively. The fifth patient progressed after 9 months.
All 5 patients had suitable images to assess the psoas muscle at L3. 4 patients were sarcopenic at baseline. 3 patients gained psoas muscle bulk in the first 2 months of treatment, with an increase of 8%, 11% and 17% in psoas surface area. 2 patients had broadly stable psoas muscle surface area during treatment. No patients had ongoing muscle loss within their first 4 months of treatment. The time between pre-treatment scan and initiation of therapy was on average 57 days (range 18-107), patients may have lost muscle surface area between their pre-treatment scan and initiation of treatment, which affects the interpretation of changes in muscle mass pre and post initiation of treatment.
2 patients had a GPS of 2, 1 of 1 and 1 of 0. 1 patient did not have a CRP measured. 1 patient’s albumin doubled from 20 to 40 within 2 months of treatment.
Conclusion
EGFR mutation positive tumours are oncogene addicted and driven by over-activity of a specific pathway. Although our sample size is very small, our analysis suggests, in patients with EGFR+ advanced lung cancer, switching off the activity of the EGFR pathway also reduces the burden of systemic inflammation, allowing patients to halt the loss of muscle bulk while responding to treatment. In some cases treatment allows patients to increase muscle bulk. It suggests that successful anti-cancer treatment can halt cachexia and in certain cirumstances, cachexia can be reversible.
-
+
P78 - Immunotherapy (Phase II/III Trials) - Immune Checkpoint Inhibitor Single Agent (ID 255)
- Event: WCLC 2020
- Type: Posters
- Track: Immunotherapy (Phase II/III Trials)
- Presentations: 1
- Moderators:
- Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
-
+
P78.11 - Immunotherapy-Induced Coeliac Disease in the Curative Lung Cancer Patient on Adjuvant Durvalumab (ID 3044)
00:00 - 00:00 | Author(s): iain Phillips
- Abstract
Introduction
The PACIFIC study led to the approval of durvalumab in the adjuvant setting for patients with unresectable, stage III non-small cell lung cancer (NSCLC) after chemo-radiotherapy (CRT)1, and whose tumours express programmed death-ligand-1 (PDL-1) in >1% of cells. PDL-1 is an immune regulating molecule which has been hypothesized to aid neoplastic lesions to evade the host’s immune system. Durvalumab is a human monoclonal IgG1 antibody which blocks PDL-1 on cytotoxic T-cells, leading to increased cytotoxic T-cell proliferation and activity, and cytokine production1. The activation of T-cells can lead to immune-related adverse events (IrAEs).
Methods
A 68-year-old female with stage III NSCLC received adjuvant durvalumab. Her PDL-1 was 90-100%. After four cycles of durvalumab, she presented with Grade 2 diarrhoea2. She was admitted to hospital and started on prednisone 50mg (1mg/kg). After three days, she had a sigmoidoscopy which appeared macroscopically normal. Biopsies showed a non-specific increase in intraepithelial lymphocytes. The diarrhoea resolved, and she was discharged on a weaning regime of prednisolone for presumed immune checkpoint inhibitor(ICPi)-induced colitis.
Two months later, she represented with Grade 3 diarrhea2. Examination and imaging was normal. Positive findings were an elevated serum anti-transglutaminase (anti-tTG) IgA level at 10.2unit/mL, low folic acid and low vitamin D. An oesophagogastroduodenoscopy (OGD) showed scalloping of the duodenum and biopsies showed marked villous blunting, chronic inflammation of the lamina propria and increased intraepithelial lymphocytes; all findings consistent with the diagnosis of CD. She was started on a lifelong gluten-free (GF) diet and given a weaning course of oral prednisone with the intention of improving her symptoms rapidly. Her diarrhoea immediately improved and a decision was made to restart immunotherapy once the steroids were complete. She did not report recurrence of her symptoms following an additional seven cycles of durvalumab therapy whilst on a GF diet. The anti-tTG IgA normalised after 3 months.
Results
This case highlights a rare IrAE of CD presenting during ICPi treatment. Durvalumab may have unmasked previously undiagnosed CD. Alternatively, the patient may have developed CD de-novo, as a direct consequence of ICPi treatment.
The detection of rare toxicities requires a large number of patients to be treated with ICPis, therefore rarer toxicities are often identified post licensing, when the number of patients receiving these drugs increases exponentially. There are three published cases of patients receiving immunotherapy developing CD after the commencement of the drug but the exact incidence of this IrAE and exact underlying mechanism for the development of CD secondary to immunotherapy is unknown.
Conclusion
This is the first reported case of CD arising following ICPis in both the adjuvant lung cancer setting, and with the drug durvalumab. A new diagnosis of CD will have long-term consequences for this patient who may have been cured with CRT alone. However, the majority of patients with stage III NSCLC have disease progression despite CRT and therefore the addition of immunotherapy in improving survival is significant. Although diarrhoea due to CD is an exceptional IrAE, symptoms can resolve quickly once a diagnosis is made and a GF diet commenced.
