NEW YORK—Lung cancer generally is diagnosed in older adults, mean age of 70, who also have multiple comorbidities. That is especially the case for veterans, who have especially high rates of smoking-related diseases.
In fact, according to a recent report, 30% of VHA patients qualified for lung cancer screening and reported at least two significant comorbidities. Not only are veterans at increased risk of lung cancer, many have comorbidities such as chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). Past research has demonstrated that that Stage I lung cancer patients with comorbidities receive less treatment and suffer, higher rates of treatment-related complications and reduced survival.
In light of that, researchers from the Icahn School of Medicine at Mount Sinai and the James J. Peters VAMC and colleagues used simulation modeling to assess projected outcomes associated with different management strategies of Veterans with Stage I non-small cell lung cancer (NSCLC) with COPD and/or CAD.
The study published by PLoS One used data from a 2000-2015 cohort of 14,029 veterans with NSCLC in a well-validated mathematical model of lung cancer to compare treatment with lobectomy, limited resection or stereotactic body radiation therapy (SBRT).1
Results indicated that, for veterans younger than 70, lobectomy was associated with greater projected quality-adjusted life expectancy, regardless of comorbidity status. On the other hand, for most combinations of tumors and comorbidity profiles, no dominant treatment was identified for patients 80 and older, although less invasive treatments appeared superior to lobectomy.
The authors advised that “dominant treatment choices differed by CAD status for older patients in a third of scenarios, but not for patients <70 years old.”
Researchers suggested that COPD severity and diagnosis of CAD affected the harm/benefit ratio of treatments for Stage I NSCLC among veterans. “Surgery is the recommended treatment for stage I NSCLC, although there is uncertainty regarding the extent of lung resection (lobectomy or sublobar resection), particularly for patients with comorbidities,” they explained. “Lobectomy is generally the standard of care, especially for tumors greater than 2 cm while limited resection (i.e., wedge resection or segmentectomy) is frequently used for patients with borderline lung function or those at high operative risk. Stereotactic body radiotherapy (SBRT) has emerged as a non-surgical alternative for stage I patients deemed high surgical risk.”
The problem is that clinical trials of cancer therapies have largely focused on younger lung cancer patients without major comorbid illness, according to the report. “The results of these trials are unlikely to be directly applicable to the subset of veterans with serious comorbidities due to increased risks of treatment complications and a greater impact of competing risks (non-lung cancer deaths), as well as lower quality of life, all of which are associated with decreased long-term benefits of aggressive treatments.”
The result is that which lung cancer treatment pathways are optimal for Stage I NSCLC in veterans with major comorbid illnesses are not clear. That makes clinical decision-making much more difficult.
“In summary, using a simulation model of treatment of early-stage lung cancer in Veterans with comorbid illnesses we found that lobectomy was associated with higher projected quality-adjusted life year gains in many patients; however, certain patient groups had very limited added benefit from more invasive approaches,” researcher concluded. “These results can be used to inform future research in the treatment of lung cancer in veterans with COPD and/or CAD, two common comorbidities in these patients.”
- Sigel K, Kong CY, Rehmani S, Bates S, et. al. Optimal treatment strategies for stage I non-small cell lung cancer in veterans with pulmonary and cardiac comorbidities. PLoS One. 2021 Mar 18;16(3):e0248067. doi: 10.1371/journal.pone.0248067. PMID: 33735217; PMCID: PMC7971489.
