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The International Agency for Research on Cancer (IARC) has classified outdoor air pollution and the particulate matter (PM) in outdoor air pollution as carcinogenic to humans, as based on sufficient evidence of carcinogenicity in humans and experimental animals and strong support by mechanistic studies. The data with important contributions to the evaluation are reviewed, highlighting the data with particular relevance to China, and implications of the evaluation with respect to China are discussed.

The air pollution levels in Chinese cities are among the highest observed in the world today and frequently exceed health-based national and international guidelines. Data from high-quality epidemiologic studies in Asia, Europe, and North America consistently show positive associations between lung cancer and PM exposure and other indicators of air pollution, which persist after adjustment for important lung cancer risk factors, such as tobacco smoking. Epidemiologic data from China are limited but nevertheless indicate an increased risk of lung cancer associated with several air pollutants. Excess cancer risk is also observed in experimental animals exposed to polluted outdoor air or extracted PM. The exposure of several species to outdoor air pollution is associated with markers of genetic damage that have been linked to increased cancer risk in humans. Numerous studies from China, especially genetic biomarker studies in exposed populations, support that the polluted air in China is genotoxic and carcinogenic to humans.

The evaluation by IARC indicates both the need for further research into the cancer risks associated with exposure to air pollution in China and the urgent need to act to reduce exposure to the population.

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The incidence of lung cancer in patients with interstitial lung disease (ILD) is higher than in the general population; however, the clinical benefit of chemotherapy and the appropriate regimen for non-small-cell lung cancer (NSCLC) patients with ILD remain unclear. This study was conducted to elucidate the safety and efficacy of palliative chemotherapy with gemcitabine or pemetrexed, both in combination with a platinum agent in NSCLC patients with ILD.

PATIENTS AND METHODS: Patients with advanced or recurrent NSCLC and ILD who received gemcitabine or pemetrexed in combination with a platinum agent as first-line chemotherapy were retrospectively analyzed. Clinical outcomes, including response rate, overall survival (OS), and progression-free survival (PFS), in addition to the acute exacerbation of ILD after chemotherapy were investigated.

RESULTS: Between January 2007 and December 2011, 52 patients were analyzed. The median age at chemotherapy was 67. Thirty-two patients (61.5 %) had adenocarcinoma histology. With respect to the types of ILD, idiopathic interstitial pneumonia (IIP) and non-IIP were observed in 42 (80.8 %) and 10 (19.2 %) patients, respectively. The FEV1 level was less than 80 % of the predicted value in 15 of the 41 patients in whom it was measured. The overall response rate was 42.3 % (95 % CI 28.8-55.9), and the median PFS was 5.4 months (95 % CI 4.6-6.2). The median OS was 7.9 months (95 % CI 5.5-10.3), and the 1-year survival rate was 31.7 % (95 % CI 19.0-44.4). Eight patients (15.4 %) died within 3 months of first-line chemotherapy. Multivariate analysis demonstrated that a heavy smoking history (40 or more pack-year smoking history) was an independent adverse prognostic factor for OS. An acute exacerbation of ILD (AE-ILD) caused by first-line chemotherapy was noted in 5.8 % of patients.

CONCLUSION: Our results suggest that gemcitabine or pemetrexed in combination with platinum agents could be a feasible option for advanced NSCLC with ILD with some risk of AE-ILD or early death. To establish the efficacy of palliative chemotherapy for patients with NSCLC and ILD, further well-controlled prospective studies are needed.

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BACKGROUND AND OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive mediastinal node sampling technique used for lung cancer staging and diagnosis of mediastinal lesions. The four published studies assessing sampling with 21-G or 22-G needles conflict. The study objective is to evaluate the diagnostic utility of 21-G versus 22-G EBUS-TBNA needles, and the ability to subcharacterize both benign and malignant lesions using histopathological assessment only.

METHODS: A retrospective analysis was performed from 303 patients referred for EBUS-TBNA between January 2011 and July 2013. Sampling needle gauge was selected at the discretion of the operator. Samples were assessed by histopathologists blinded to the needle gauge without rapid on-site evaluation for cytology. Contingency table analysis was performed to compare diagnostic utility and ability to subcharacterize malignant and benign lesions.

RESULTS: No difference in diagnostic ability was seen for malignancy (96.6% v 95.3% accuracy, 21-G vs 22-G). Subgroup analysis of benign 21-G tissue samples revealed superior characterization compared with 22-G samples (63/76, 83%, vs 31/52, 60%, P < 0.01). Characterization of non-small cell lung cancer (NSCLC) was also significantly better with samples obtained with 21-G needles versus 22-G needles (57/65, 88% vs 34/52, 65%, P < 0.01).

CONCLUSIONS: This large UK single-centre study suggests 21-G EBUS-TBNA needles are superior to 22-G in characterizing benign lesions (especially sarcoidosis) and NSCLC when using histopathological assessment. Making a positive benign diagnosis may avoid the need to perform mediastinoscopy. Obtaining sufficient histological material to subcharacterize NSCLC and particularly lung adenocarcinoma allows appropriate testing for genetic mutations facilitating targeted oncological therapy.

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Ideally, quality indicators are developed with the input of professional groups involved in the care of patients. This project, led by the Thoracic Oncology Network and Quality Improvement Committee of the American College of Chest Physicians, had the goal of developing quality indicators related to the evaluation and staging of lung cancer patients.

METHODS: Evidence based guidelines were used to generate a list of process of care quality indicators. Project members revised the content and wording of this list. A survey of the Steering Committee of the Thoracic Oncology Network was performed to rate the validity, feasibility, and relevance of the indicators. Predefined thresholds were used to select indicators from this list. This process was repeated for the selected indicators, through a survey available to all members of the Thoracic Oncology Network. Three academic medical centers determined if the surviving indicators were feasible and relevant within their practices.

RESULTS: 18 quality indicators were drafted. Eleven survived the first round of voting, and 7 survived the second round of voting. One was related to tissue acquisition for molecular testing, 4 were related to staging and stage documentation, 1 to smoking cessation counseling, and one to documentation of a performance status measure. The indicators were feasible and relevant within the practices assessed.

CONCLUSIONS: We have defined 7 process of care quality indicators related to the evaluation and staging of lung cancer patients, felt to be valid, feasible, and relevant, by lung cancer specialists.

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