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BACKGROUND: Cancer therapy is associated with severe financial burden. However, the magnitude and longitudinal patient relationship with financial toxicity (FT) in the initial course of therapy is unclear. METHODS: Patients with stage II-IV lung cancer were recruited in a prospective longitudinal study between July 2018 and March 2020. FT was measured via the validated COmprehensive Score for financial Toxicity (COST) at the time of cancer diagnosis and at 6-month follow-up (6MFU). 6MFU data were compared with corresponding baseline data. A lower COST score indicates increased financial hardship. RESULTS: At the time of analysis, 215 agreed to participate. Subsequently, 112 patients completed 6MFU. On average, slightly more FT was observed at diagnosis compared with 6MFU (median COSTbase 25 v COST6M 27; P < .001); however, individual patients experienced large changes in FT. At 6MFU, 27.7% of patients had made financial sacrifices to pay for treatment but only 4.5% refused medical care based on cost. Median reported out-of-pocket (OOP) costs for the initial 6 months of cancer treatment was $2,496 (range, $0-25,900). Risk factors for FT at diagnosis were unique from risk factors at 6MFU. Actual OOP expenses were not correlated with FT; however, inability to predict upcoming treatment expenses resulted in higher FT at 6MFU. DISCUSSION: FT is a pervasive challenge during the initiation of lung cancer treatment. Few patients are willing to sacrifice medical care regardless of the cost. Risk factors for FT evolve, resulting in unique interventional targets throughout therapy.

BACKGROUND Patients with stage IV oligometastatic (≤ 3 sites) non-small-cell lung cancer have a progression-free survival (PFS) and overall survival benefit when all sites of metastatic disease and the primary tumor are treated radically with consolidative radiotherapy (cRT). However, the optimal selection of patients most likely from cRT is yet to be defined. PATIENTS AND METHODS Patients with metastatic non-small-cell lung cancer treated with definitive radiotherapy to all metastatic sites and primary tumor (2008-2019) were retrospectively identified. Univariable Cox proportional-hazards model was used to compare outcomes with demographic and clinical characteristics. A predictive nomogram model for selection of patients most likely to benefit from cRT was constructed. RESULTS There were 91 patients identified with a total of 114 metastases treated. Median PFS from the start of cRT was 10.9 months (95% confidence interval [CI], 8.1-16.6), while the median survival time was 37.0 months (95% CI, 31.3-NR). On univariable modeling, patients with squamous histology (hazard ratio, 4.16; 95% CI, 1.99-8.71; P < .001) and those treated with non-stereotactic body radiotherapy hypofractionated therapy (hazard ratio, 5.43; 95% CI, 2.10-14.01; P < .001) had worse overall survival, while patients with targetable mutations (hazard ratio, 0.49; 95% CI, 0.25-0.98; P = .04) had a longer survival. Using a predictive nomogram model, patients with a solitary site of metastasis, targetable mutations, intracranial disease, and metachronous timing of oligometastases had a larger PFS benefit from cRT. CONCLUSION cRT is associated with favorable outcomes in PFS and overall survival. These results may aid in patient counseling, selection for aggressive local therapy, and stratification in future prospective clinical trials.

Genetic and environmental interactions predispose certain groups to lung cancer, including families. Families or caregiving units experience the disease interdependently. We have previously evaluated the concerns and preferences of patients in addressing the lung cancer experience and cancer risks in their families. This qualitative study evaluates the concerns and preferences of family members and caregivers of patients with lung cancer in the lung cancer experience and familial cancer risks. We held focus groups to discuss the format and timing of addressing these preferences and concerns. Qualitative data generated was analyzed using a grounded theory approach. Five focus groups totaling 19 participants were conducted. Seven themes were identified: (1) journey to lung cancer diagnosis has core dimensions for patient and family, (2) importance of communication between patients, families, and providers, (3) challenges for caregivers and family, (4) mixed perceptions of lung cancer causation among relatives, (5) discussion of cancer risk with relatives has complex dynamics, (6) impact of diagnosis on family health behaviors and screening, (7) role of genetic counseling. Family members of patients with lung cancer are interested in discussing risk factors, prevention, and diagnoses and also would like access to other supportive services do learn about and cope with some of the stresses and barriers they experience in the family lung cancer journey. The diagnosis represents a potential teachable moment with the opportunity to reduce the risk of LC development or improve early detection in LC patient’s family members.

Purpose/objective(s) Patient reported outcomes (PRO) show promise in predicting which patients are at risk for worst outcomes after chemoradiation (CRT) and may be used to improve symptom management. We investigate if patient-reported symptoms collected during thoracic radiation (TRT) may help identify patients at risk of developing radiation pneumonitis (RP) post-TRT. Materials/methods Between 2016 to 2020, patients with stage III NSCLC treated with definitive-intent TRT at our institution were identified. Patients completed a 10-item symptom-report questionnaire using the PRO Common Terminology Criteria for Adverse Events (PRO-CTCAE v.1.0) weekly during RT and at follow-up. Physicians graded lung-specific symptoms and side-effects using CTCAE v4.0 at the same time-points. RP was defined as radiographic inflammation of the lung within the radiation field attributable to TRT, and excluding other causes. Patient and treatment characteristics were recorded. Descriptive statistics and univariate competing risks analysis were performed to describe and identify variables associated with development of RP. Results Of 131 patients identified: median age was 66 years, 53% were male, and 45.8% patients had co-morbid lung disease. Patients received a median of 63 Gy (Interquartile range (IQR): 60-63 Gy) with chemotherapy (88%). The median mean-lung-dose (MLD) was 14.5 Gy (IQR: 12-17 Gy) and the median lung V20 was 20% (IQR: 20%-30%). After TRT, 61 patients received immunotherapy. In the entire cohort, twenty-four patients (18%) developed any grade RP, of which n = 21 were grade ≥2. The median time to diagnosis of RP after TRT was 3.0 months. Factors associated with the development of RP included: age (HR 1.06, P = 0.0004) and MLD (P = 0.0005). In terms of PROs associated with development of RP: patient reported severe pain was significantly associated (HR 3.4, P = 0.01), while moderate anxiety (HR 2.3, P = 0.06), and cough (HR 4.53, P = 0.06) were non-significantly associated with RP. Physician assessed grade 2 dyspnea where medical intervention was needed was associated with RP (HR 3.43, P = 0.02). Conclusion Patient symptom reports during treatment may be associated with the risk development of RP. Larger studies of prospectively collected PROs during TRT are needed to further explore these potential associations with RP.

Purpose/Objective(s) Palliative radiation may be beneficial for patients with metastatic or locally advanced disease causing malignant airway obstruction (MAO). However, the subset of patients most likely to benefit from palliative airway radiation is unknown. In this study, we seek to report local control and survival outcomes for patients treated with palliative radiation for MAO and provide prognostic factors for improved overall survival. Materials/Methods An IRB approved single institution retrospective review of patients treated with palliative thoracic radiation for MAO from 2008-2016 was undertaken. The primary study endpoint was overall survival (OS) and secondary endpoints included local response and airway specific progression free survival. Kaplan-Meier survival, and Cox proportional hazards regression analyses were performed to identify factors associated with OS. Variables with clinical and univariate significance were modelled using multivariate logistic regression analysis. Results Palliative radiation for MAO was identified for 237 patients (median age of 63.8 yrs). 88.6% of patients were treated for primary lung cancer and 41.6% of those patients had adenocarcinoma histology. At time of analysis, 78.5% patients had died. Median follow-up was 2 months. Out of 116 patients with imaging follow-up: 31.0% had airway specific progression, 68.9% had complete or partial response at last follow up. For those patients with palliative tumor response, median time to progression was 5.0 (Range 1.1-17.8) months. Kaplan-Meier estimate of median overall survival following start of radiation therapy was 5.0 (95% CI 3.8-5.8) months. In multivariable analyses, there was a marginally increased hazard ratio for patients who had dyspnea at rest HR 2.09 (95% CI 0.78-5.62), oxygen requirement at presentation HR 1.28 (95% CI 0.81-2.01), and higher ECOG level 2-4 HR 1.21 (95% CI 0.81-1.80). Conversely, squamous cell histology and treatment with BED10 greater than or equal to 39 (equivalent to the commonly used 30Gy in 10 fraction regimen) were significantly predictive of improved OS, HR 0.56 (95% CI 0.32-0.97) and HR 0.42 (95% CI 0.28-0.64) respectively. Conclusion To our knowledge, this analysis is the largest collection of patients receiving palliative thoracic radiotherapy for MAO. These data show that MAO is a poor prognostic feature for survival, but treatment responses are seen. Increased BED delivered and squamous cell carcinoma, a radiosensitive tumor histology, were associated with improved survival. These results may help to inform optimized patient selection for and outcomes of patients with MAO receiving palliative RT.

Purpose/Objective(s) Pleurectomy/Decortication (P/D) has become a common lung-sparing surgical approach for MPM. Chemotherapy may be delivered in the neoadjuvant or adjuvant setting. Adjuvant hemithoracic IMPRINT was developed at Memorial Sloan Kettering Cancer Center and found safe in a multi-institutional phase II study, with promising survival outcomes. CTEP approved a phase III randomized cooperative group trial (NRG LU-006) to evaluate the efficacy of this lung-sparing trimodality treatment approach for resectable MPM. Materials/Methods Patients with newly diagnosed MPM amenable to P/D are enrolled and undergo upfront P/D followed by adjuvant platinum/pemetrexed chemotherapy (preferred approach) or neoadjuvant chemotherapy followed by P/D. Patients are stratified by epithelioid vs. biphasic histologic subtype, achievement of a macroscopic complete resection (R0/1 vs. R2), and center patient volume (≤10 vs. > 10 P/Ds per year). Within 8 weeks after completion of the second modality, patients are randomized 1:1 to undergo hemithoracic IMPRINT vs. no further therapy. All IMPRINT contours and treatment plans are centrally reviewed. A contouring atlas and treatment planning constraints for target structures and organs at risk, including acceptable and unacceptable variations and deviations, were developed. Photon and proton therapy are permitted. The primary endpoint of the study is overall survival. Secondary endpoints include local failure-free, distant-metastases free and progression-free survival, treatment-related toxicities (CTCAE v5.0) and change in quality-of-life (EORTC QLQ-C30 mean score changes at 9 months post randomization). Exploratory objectives include correlation of clinical/radiographic staging with pathologic stage, immunologic and pathologic biomarkers as predictors of response, the rate of R0/R1 vs. R2 resections, and EORTC QLQ-C30 and LC13 symptom scores changes over time. This study was activated on January 29, 2020. As of 02/2021,16 sites are approved and 46 sites are pending approval to open the study. Treatment planning guidelines and helpful hints for photon and proton therapy will be presented. Two patients have been accrued, and the target accrual is 150 patients. Results TBD Conclusion NRG LU-006 is now open to accrual. This is the first NRG Oncology randomized phase III trial on malignant pleural mesothelioma and evaluates the use of IMPRINT following lung-sparing P/D and chemotherapy. Treatment planning aspects and current status will be presented.

The capture of high-quality treatment data and outcomes is necessary in order to learn from our clinical experiences with big data analytics. In radiotherapy, there are several practical challenges to overcome. Practical aspects of data collection are discussed pointing to a need for a culture change in clinical practice to one that captures structured patient-related data in routine care in a prospective manner. Radiation dosimetry and the contoured anatomy must also be captured routinely to represent the best estimate of delivered radiation. The quality and integrity present in the data are critical which poses opportunities to introduce electronic validity checking to improve them. Similarly, data completeness and methods and technology to improve the efficiency and sufficiency of data capture can be introduced. In the manuscript, the types of clinical data are discussed including patient reports, images, biospecimens, treatments, and symptom management. With a data-driven culture, the realization of a learning health system is possible unlocking the potential of big data and its influence on clinical decision-making and hypothesis generation.

Pancreatic adenosquamous carcinoma (PASC) accounts for only 1-4% of all exocrine pancreatic cancers and carries a particularly poor prognosis. This retrospective study was performed to determine whether inclusion of a platinum agent as part of adjuvant therapy is associated with improved survival in patients with resected PASC.Records of all patients who underwent pancreatic resection at Johns Hopkins Hospital from 1986 to 2012 were reviewed to identify those with PASC. Multivariable Cox proportional hazards modeling was used to assess for significant associations between patient characteristics and survival.In total, 62 patients (1.1%) with resected PASC were identified among 5,627 cases. Median age was 68 [interquartile range (IQR), 57-77] and 44% were female. Multivariate analysis revealed that, among all patients (n=62), the following factors were independently predictive of poor survival: lack of adjuvant therapy [hazard ratio (HR) =3.6; 95% confidence interval (CI), 1.8-7.0; P0.001], margin-positive resection (HR =3.5; 95% CI, 1.8-6.8; P0.001), lymph node involvement (HR =3.5; 95% CI, 1.5-8.2; P=0.004), and age (HR =1.0; 95% CI, 1.0-1.1; P=0.035). There were no significant differences between patients who did and did not receive adjuvant therapy following resection (all P0.05). A second multivariable model included only those patients who received adjuvant therapy (n=39). Lack of inclusion of a platinum agent in the adjuvant regimen (HR =2.4; 95% CI, 1.0-5.8; P=0.040) and larger tumor diameter (HR =1.3; 95% CI, 1.0-1.6; P=0.047) were independent predictors of inferior survival.Addition of a platinum agent to adjuvant regimens for resected PASC may improve survival among these high-risk patients, though collaborative prospective investigation is needed.