Therapy response assessment of non-small cell lung cancer using dual-energy computed tomography iodine map

2021 ◽  
pp. 1-12
Author(s):  
Lei Zhao ◽  
Lijuan Liu ◽  
Haiyan Zhao ◽  
Jiaqi Bao ◽  
Yana Dou ◽  
...  
Keyword(s):  
Advanced Nsclc ◽  
Therapy Response ◽  
Roc Curves ◽  
Iodine Concentration ◽  
Dual Energy ◽  
Small Cell ◽  
Small Cell Lung ◽  
Quantitative Parameters ◽  
Iodine Map ◽  
Post Therapy

OBJECTIVE: To investigate feasibility of the quantitative parameters of dual-energy computed tomography (DECT) to assess therapy response in advanced non-small cell lung cancer (NSCLC) compared with the traditional enhanced CT parameters based on the Response Evaluation Criteria in Solid Tumors (RECIST) guidelines. METHODS: Forty-five patients with unresectable locally advanced NSCLC who underwent DECT before and after chemotherapy or concurrent chemoradiotherapy (cCRT) were prospectively enrolled. By comparing baseline studies with follow-up, patients were divided into two groups according to RECIST guidelines as follows: disease control (DC, including partial response and stable disease) and progressive disease (PD). The diameter (D), attenuation, iodine concentration and normalized iodine concentration of arterial and venous phases (ICA, ICv, NICA, NICv) and the percentage of these changes pre- and post-therapy were measured and calculated. The Pearson correlation was used to analyze correlation between various quantitative parameters. The receiver operating characteristic (ROC) curves were used to evaluate accuracy of therapy response prediction. RESULTS: The change percentages of Attenuation (Δ-Attenuation-A and Δ-Attenuation-V), IC (ΔICA and ΔICV) and NIC (ΔNICA and ΔNICV) pre- and post-therapy correlate with the change percentage of D (ΔD). Among these, ΔICA strongly correlates with Δ D (r = 0.793, P <  0.001). The areas under ROC curves generated using Δ-Attenuation-A, ΔICA, and ΔNICA are 0.796, 0.900, and 0.880 with the corresponding cutoff value of 9.096, −15.692, and −4.7569, respectively, which are significantly different (P <  0.001). CONCLUSIONS: The quantitative parameters of DECT iodine map, especially iodine concentration, in arterial phase provides a new quantitative image marker to predict therapy response of patients diagnosed with advanced NSCLC.

scholarly journals Dual-energy Spectral CT Quantitative Parameters for the Differentiation of Glioma Recurrence from Treatment-Related Changes: A Preliminary Study

2019 ◽  
Author(s):  
Yanchun Lv ◽  
Jian Zhou ◽  
Xiaofei Lv ◽  
Li Tian ◽  
Haoqiang He ◽  
...  
Keyword(s):  
Atomic Number ◽  
Predictive Value ◽  
Effective Atomic Number ◽  
Roc Curves ◽  
Iodine Concentration ◽  
Dual Energy ◽  
Spectral Ct ◽  
Quantitative Parameters ◽  
Glioma Recurrence ◽  
Venous Phase

Abstract Background: Differentiating glioma recurrence from treatment-related changes can be challenging on conventional imaging. We evaluated the use of dual-energy spectral computed tomographic (CT) quantitative parameters for this differentiation. Methods: Twenty-eight patients were examined by dual-energy spectral imaging CT. The slope of the spectral Hounsfield unit curve (λ HU ), effective atomic number (Z eff ), normalized effective atomic number (Z eff-N ), iodine concentration (IC), and normalized iodine concentration (IC N ) in the post-treatment enhanced areas were calculated. Pathological results or clinicoradiologic follow-up of ≥2 months were used for final diagnosis. Nonparametric and t -tests were used to compare quantitative parameters between glioma recurrence and treatment-related changes. Positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated; sensitivity and specificity were calculated using receiver operating characteristic (ROC) curves. ROC curves were generated using predictive probabilities to evaluate the diagnostic value. Results: There were no significant differences in quantitative parameters based on examination of pre-contrast λ HU , Z eff , Z eff-N , IC, IC N and venous phase IC N ( P >0.05). Venous phase λ HU , Z eff , Z eff-N , and IC in glioma recurrence were higher than in treatment-related changes ( P <0.001). The optimal venous phase threshold was 1.03, 7.75, 1.04, and 2.85 mg/cm 3 , achieving 66.7%, 91.7%, 83.3%, and 91.7% sensitivity; 100.0%, 77.8%, 88.9%, and 77.8% specificity; 100.0%, 73.3%, 83.3%, and 73.3% PPV; 81.8%, 93.3%, 88.9%, and 93.3% NPV; and 86.7%, 83.3%, 86.7%, and 83.3% accuracy, respectively. The areas under the curve (AUC) were 0.912, 0.912, 0.931, and 0.910 in glioma recurrence and treatment-related changes, respectively. Conclusions: Dual-energy spectral CT imaging may provide quantitative values to aid in differentiation of glioma recurrence from treatment-related changes.

scholarly journals Dual-energy Spectral CT Quantitative Parameters for the Differentiation of Glioma Recurrence from Treatment-Related Changes: A Preliminary Study

2019 ◽  
Author(s):  
Yanchun Lv ◽  
Jian Zhou ◽  
Xiaofei Lv ◽  
Li Tian ◽  
Haoqiang He ◽  
...  
Keyword(s):  
Atomic Number ◽  
Predictive Value ◽  
Effective Atomic Number ◽  
Roc Curves ◽  
Iodine Concentration ◽  
Dual Energy ◽  
Spectral Ct ◽  
Quantitative Parameters ◽  
Glioma Recurrence ◽  
Venous Phase

Abstract Background: Differentiating glioma recurrence from treatment-related changes can be challenging on conventional imaging. We evaluated the use of dual-energy spectral computed tomographic (CT) quantitative parameters for this differentiation. Methods: Twenty-eight patients were examined by dual-energy spectral imaging CT. The slope of the spectral Hounsfield unit curve (λHU), effective atomic number (Zeff), normalized effective atomic number (Zeff-N), iodine concentration (IC), and normalized iodine concentration (ICN) in the post-treatment enhanced areas were calculated. Pathological results or clinicoradiologic follow-up of ≥2 months were used for final diagnosis. Nonparametric and t-tests were used to compare quantitative parameters between glioma recurrence and treatment-related changes. Positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated; sensitivity and specificity were calculated using receiver operating characteristic (ROC) curves. ROC curves were generated using predictive probabilities to evaluate the diagnostic value. Results: There were no significant differences in quantitative parameters based on examination of pre-contrast λHU, Zeff, Zeff-N, IC, ICN and venous phase ICN (P>0.05). Venous phase λHU, Zeff, Zeff-N, and IC in glioma recurrence were higher than in treatment-related changes (P<0.001). The optimal venous phase threshold was 1.03, 7.75, 1.04, and 2.85 mg/cm3, achieving 66.7%, 91.7%, 83.3%, and 91.7% sensitivity; 100.0%, 77.8%, 88.9%, and 77.8% specificity; 100.0%, 73.3%, 83.3%, and 73.3% PPV; 81.8%, 93.3%, 88.9%, and 93.3% NPV; and 86.7%, 83.3%, 86.7%, and 83.3% accuracy, respectively. The areas under the curve (AUC) were 0.912, 0.912, 0.931, and 0.910 in glioma recurrence and treatment-related changes, respectively. Conclusions: Dual-energy spectral CT imaging may provide quantitative values to aid in differentiation of glioma recurrence from treatment-related changes.

scholarly journals Dual-energy Spectral CT Quantitative Parameters for the Differentiation of Glioma Recurrence from Treatment-Related Changes: A Preliminary Study

2019 ◽  
Author(s):  
Yanchun Lv ◽  
Jian Zhou ◽  
Xiaofei Lv ◽  
Li Tian ◽  
Haoqiang He ◽  
...  
Keyword(s):  
Hounsfield Unit ◽  
Roc Curves ◽  
Iodine Concentration ◽  
Final Diagnosis ◽  
Dual Energy ◽  
Spectral Ct ◽  
Predictive Values ◽  
Quantitative Parameters ◽  
Glioma Recurrence ◽  
Venous Phase

Abstract Background: Differentiating glioma recurrence from treatment-related changes can be challenging on conventional imaging. We evaluated the efficacy of quantitative parameters measured by dual-energy spectral computed tomographic (CT) for this differentiation. Methods: Twenty-eight patients were examined by dual-energy spectral CT. The effective and normalized atomic number (Zeff and Zeff-N, respectively); spectral Hounsfield unit curve (λHU) slope; and iodine and normalized iodine concentration (IC and ICN, respectively) in the post-treatment enhanced areas were calculated. Pathological results or clinicoradiologic follow-up of ≥2 months were used for final diagnosis. Nonparametric and t-tests were used to compare quantitative parameters between glioma recurrence and treatment-related changes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and accuracy were calculated using receiver operating characteristic (ROC) curves. Predictive probabilities were used to generate ROC curves to determine the diagnostic value. Results: Examination of pre-contrast λHU, Zeff, Zeff-N, IC, ICN, and venous phase ICN showed no significant differences in quantitative parameters (P>0.05). Venous phase λHU, Zeff, Zeff-N, and IC in glioma recurrence were higher than in treatment-related changes (P<0.001). The optimal venous phase threshold was 1.03, 7.75, 1.04, and 2.85 mg/cm3, achieving 66.7%, 91.7%, 83.3%, and 91.7% sensitivity; 100.0%, 77.8%, 88.9%, and 77.8% specificity; 100.0%, 73.3%, 83.3%, and 73.3% PPV; 81.8%, 93.3%, 88.9%, and 93.3% NPV; and 86.7%, 83.3%, 86.7%, and 83.3% accuracy, respectively. The respective areas under the curve (AUCs) were 0.912, 0.912, 0.931, and 0.910 in glioma recurrence and treatment-related changes. Conclusions: Glioma recurrence could be potentially differentiated from treatment-related changes based on quantitative values measured by dual-energy spectral CT imaging.

Phase II study of docetaxel and cisplatin in advanced non-small-cell lung cancer.

1998 ◽  
Vol 16 (5) ◽  
pp. 1948-1953 ◽  
Author(s):  
J Zalcberg ◽  
M Millward ◽  
J Bishop ◽  
M McKeage ◽  
A Zimet ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Phase Ii ◽  
Advanced Nsclc ◽  
Response Rate ◽  
Phase Ii Study ◽  
Performance Status ◽  
Objective Response ◽  
Small Cell ◽  
Small Cell Lung ◽  
Grade 3

PURPOSE Docetaxel (Taxotere, Rhone-Poulenc Rorer, Antony, France) and cisplatin are two of the most active single agents used in the treatment of non-small-cell lung cancer (NSCLC). A recently reported phase I study of the combination of docetaxel and cisplatin recommended a dose of 75 mg/m2 of both drugs every 3 weeks for subsequent phase II study. PATIENTS AND METHODS Eligible patients were aged 18 to 75 years with a World Health Organization (WHO) performance status < or = 2 and life expectancy > or = 12 weeks, with metastatic and/or locally advanced NSCLC proven histologically or cytologically. Patients were not permitted to have received prior chemotherapy, extensive radiotherapy, or any radiotherapy to the target lesion and must have had measurable disease. Concurrent treatment with colony-stimulating factors (CSFs) or prophylactic antibiotics was not permitted. Docetaxel (75 mg/m2) in 250 mL 5% dextrose was given intravenously (i.v.) over 1 hour immediately before cisplatin (75 mg/m2) in 500 mL normal saline given i.v. over 1 hour in 3-week cycles. Premedication included ondansetron, dexamethasone, promethazine, and standard hyperhydration with magnesium supplementation. RESULTS A total of 47 patients, two thirds of whom had metastatic disease, were entered onto this phase II study. The majority of patients were male (72%) and of good (WHO 0 to 1) performance status (85%). All 47 patients were assessable for toxicity and 36 were for response. Three patients were ineligible and eight (17%) discontinued treatment because of significant toxicity. In assessable patients, the overall objective response rate was 38.9% (95% confidence limits [CL], 23.1% to 56.5%), 36.1% had stable disease, and 25% progressive disease. On an intention-to-treat analysis, the objective response rate was 29.8%. Median survival was 9.6 months and estimated 1-year survival was 33%. Significant (grade 3/4) toxicities included nausea (26%), hypotension (15%), diarrhea (13%), and dyspnea mainly related to chest infection (13%). One patient experienced National Cancer Institute (NCI) grade 3 neurosensory toxicity after eight cycles. Grade 3/4 neutropenia was common and occurred in 87% of patients, but thrombocytopenia > or = grade 3 was rare (one patient). Significant (grade 3/4) abnormalities of magnesium levels were common (24%). Febrile neutropenia occurred in 13% of patients and neutropenic infection in 11%, contributing to two treatment-related deaths. No neutropenic enterocolitis or severe fluid retention was reported. CONCLUSION Compared with other active regimens used in this setting, the combination of docetaxel and cisplatin in advanced NSCLC is an active regimen with a similar toxicity profile to other combination regimens.

196 Checkpoint blockade therapy for brain-metastatic non-small cell lung cancer: a comparative effectiveness analysis of national data

2020 ◽  
Vol 8 (Suppl 3) ◽  
pp. A211-A211
Author(s):  
Nayan Lamba ◽  
Bryan Iorgulescu
Keyword(s):  
Brain Metastasis ◽  
Brain Metastases ◽  
Advanced Nsclc ◽  
Small Cell ◽  
Second Line ◽  
Newly Diagnosed ◽  
Small Cell Lung ◽  
Survival Analyses ◽  
Stage 4 ◽  
Insured Patients

BackgroundManagement of advanced non-small cell lung carcinoma (NSCLC) has been transformed by PD-1/PD-L1 immune checkpoint inhibitors (ICI), with FDA approvals in 2015 (second-line) and 2016 (first-line). Despite ~40% of NSCLC patients developing brain metastases, these patients were disproportionately excluded from the pioneering ICI trials. Thus herein we evaluate the overall survival (OS) associated with ICI in NSCLC brain metastases nationally.MethodsPatients newly-diagnosed with stage 4 NSCLC, including brain metastases, from 2010–2016 were identified from the National Cancer Database (comprising >70% of all newly-diagnosed cancers in the U.S.) Landmark survival analysis was used to address immortal time bias. Post-approval, median time from diagnosis to ICI was 58 days, and this timepoint was selected for all landmark survival analyses (OS estimated by Kaplan-Meier technique, and compared by logrank test and multivariable Cox regression) and for multivariable logistic regression to identify predictors of ICI utilization.Results50,858 patients presented with advanced NSCLC that involved the brain: representing 27.6% of all newly-diagnosed stage 4 cases. Following initial FDA approvals in 2015, ICI use in brain metastasis patients rose from 7.2% in 2015 to 12.7% in 2016. OS for NSCLC brain metastasis patients diagnosed post-approval (i.e. 2015, median 6.3 months, 95% [confidence interval] CI: 6.0–6.6) was substantially better than those diagnosed pre-approval (median 5.5 months, 95%CI: 5.4–5.7, p<0.001) and, in fact, than those diagnosed in 2014 (median 5.9 months, 95%CI: 5.6–6.1, p=0.002). Among patients diagnosed post-approval (in 2015, n=7,431), ICI receipt demonstrated substantially improved OS in landmark survival analyses (median 13.8 months, 95%CI: 12.2–15.1; vs. 8.5 months, 95%CI: 8.3–8.9, p<0.001) – benefits which persisted in multivariable landmark survival analyses (hazard ratio [HR] 0.83, 95%CI: 0.71–0.96, p=0.02), independent of patient characteristics, other therapies, and extracranial disease. For patients diagnosed post-approval, who reached the landmark timepoint, ICI receipt was independent of patient demographics, socioeconomic status, and hospital type—with the exception of Medicaid-insured patients, who were less likely than privately insured patients to receive ICI (OR 0.77, 95%CI: 0.60–0.97, p=0.03).ConclusionsNationally, the use of ICI for NSCLC brain metastasis patients is increasing, generally without significant socioeconomic barriers. Brain metastasis patients diagnosed in the post-approval second-line ICI era (2015) demonstrated significantly better OS than patients diagnosed pre-approval and even than patients diagnosed only in 2014. ICI was associated with a >60% relative increase in median OS. Together our findings from a real-world population demonstrate that the dramatic OS benefits of ICIs for advanced NSCLC also extended to brain metastasis patients.

440 Activity and safety of camrelizumab, an anti-PD-1 immune checkpoint inhibitor, for patients with advanced non-small-cell lung cancer

2020 ◽  
Vol 8 (Suppl 3) ◽  
pp. A466-A466
Author(s):  
Guo Gui Sun ◽  
Jing Hao Jia ◽  
Peng Gao ◽  
Xue Min Yao ◽  
Ming Da Chen ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Adverse Events ◽  
Small Cell Lung Cancer ◽  
Cell Lung Cancer ◽  
Advanced Nsclc ◽  
Small Cell ◽  
Large Sample Size ◽  
Small Cell Lung ◽  
Previously Treated ◽  
Line Chemotherapy

BackgroundEffective options are limited for patients with non–small-cell lung cancer (NSCLC) whose disease progresses after first-line chemotherapy. Camrelizumab is a potent anti-PD-1 monoclonal antibody and has shown promising activity in NSCLC. We assessed the activity and safety of camrelizumab for patients with previously treated, advanced NSCLC patients with negative oncogenic drivers.MethodsPatients who progressed during or following platinum-based doublet chemotherapy were enrolled. All patients received camrelizumab(200 mg)every 3 weeks or in combination with chemotherapy until loss of clinical benefit. The primary endpoint was objective response rate (ORR), other endpoints included disease control rate (DCR), progression-free survival (PFS) and safety.ResultsBetween Aug 5, 2019, and Jun 19, 2020, we enrolled 29 patients, 25 patients were available evaluated, ORR and DCR was 36% (9/25) and 92% (23/25), respectively. 25 of 29 patients were still receiving the treatment, the median PFS was not yet achieved. Compared with those without reactive cutaneous capillary endothelial proliferation (RCCEP), patients with RCCEP had higher ORR (60% vs. 28.6%). Treatment-related adverse events (AEs) occurred in 69.0% of patients (all Grade), and the most common were RCCEP (37.9%), pneumonitis (6.9%), and chest congestion (6.9%). Treatment-related grade 3 to 4 adverse events occurred in 10.3% of patients.ConclusionsIn patients with previously treated advanced NSCLC, camrelizumab demonstrated improved ORR and DCR, compared with historical data of the 2nd line chemotherapy, with a manageable safety profile. While patients with RCCEP derived greater benefit from camrelizumab. Further studies are needed in large sample size trials.

scholarly journals Plasma Biomarkers Screening by Multiplex ELISA Assay in Patients with Advanced Non-Small Cell Lung Cancer Treated with Immune Checkpoint Inhibitors

Cancers ◽  
2020 ◽  
Vol 13 (1) ◽  
pp. 97
Author(s):  
Adrien Costantini ◽  
Paul Takam Kamga ◽  
Catherine Julie ◽  
Alexandre Corjon ◽  
Coraline Dumenil ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Growth Factor ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Advanced Nsclc ◽  
Checkpoint Inhibitors ◽  
Small Cell ◽  
Elisa Assay ◽  
Small Cell Lung ◽  
Plasma Biomarkers

Immune checkpoint inhibitors (ICIs) are commonly used in patients with advanced non-small cell lung cancer (NSCLC). An unmet need remains for new biomarkers associated with ICIs. In this study, consecutive patients with advanced NSCLC treated with nivolumab or pembrolizumab were included. Plasma at ICIs initiation was prospectively collected and a multiplex ELISA assay testing 48 cytokines and growth factors was performed. Exploratory endpoints were the association between plasma biomarkers with outcome and grade III–IV immune related adverse events (irAEs). Thirty-five patients were included. Patients without clinical benefit (n = 22) had higher pre-ICI soluble Hepatocyte Growth Factor (sHGF) (210.9 vs. 155.8 pg/mL, p = 0.010), lower pre-ICI soluble Fibroblast Growth Factor (sFGF) (4.0 vs. 4.8 pg/mL, p = 0.043) and lower pre-ICI interleukine-12 (IL-12) (1.3 vs. 2.2 pg/mL, p = 0.043) concentrations. Patients with early progression (n = 23) had higher pre-ICIs sHGF (206.2 vs. 155.8 pg/mL, p = 0.025) concentrations. Patients with low sHGF levels at ICIs initiation had longer progression-free survival and overall survival than those with high sHGF levels: respectively 2.5 vs. 8.0 months (p = 0.002), and 5.5 vs. 35.0 months (p = 0.001). TNF-α, IL-16, IL-12p40 and MCP3 were associated with high grade irAEs. This study shows the potential association between several plasma biomarkers with outcome and grade 3–4 IrAEs in advanced NSCLC treated with ICIs.

scholarly journals Development of nomogram based on immune-related gene FGFR4 for advanced non-small cell lung cancer patients with sensitivity to immune checkpoint inhibitors

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Li Wang ◽  
Zhixuan Ren ◽  
Bentong Yu ◽  
Jian Tang
Keyword(s):  
Lung Cancer ◽  
Small Cell Lung Cancer ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Advanced Nsclc ◽  
Cancer Genomics ◽  
Checkpoint Inhibitors ◽  
Small Cell ◽  
Small Cell Lung ◽  
Nsclc Patients

Abstract Introduction Immune checkpoint inhibitors (ICIs) have become a frontier in the field of clinical technology for advanced non-small cell lung cancer (NSCLC). Currently, the predictive biomarker of ICIs mainly including the expression of PD-L1, TMB, TIICs, MMR and MSI-H. However, there are no official biomarkers to guide the treatment of ICIs and to determine the prognosis. Therefore, it is essential to explore a systematic nomogram to predict the prognosis of ICIs treatment in NSCLC Methods In this work, we obtained gene expression and clinical data of NSCLC patients from the TCGA database. Immune-related genes (IRGs) were downloaded from the ImmPort database. The detailed clinical annotation and response data of 240 advanced NSCLC patients who received ICIs treatment were obtained from the cBioPortal for Cancer Genomics. Kaplan–Meier survival analysis was used to perform survival analyses, and selected clinical variables to develop a novel nomogram. The prognostic significance of FGFR4 was validated by another cohort in cBioPortal for Cancer Genomics. Results 3% of the NSCLC patients harbored FGFR4 mutations. The mutation of FGFR4 were confirmed to be associated with PD-L1, and TMB. Patients harbored FGFR4 mutations were found to have a better prolonged progression-free survival (PFS) to ICIs treatment (FGFR4: P = 0.0209). Here, we built and verified a novel nomogram to predict the prognosis of ICIs treatment for NSCLC patients. Conclusion Our results showed that FGFR4 could serve as novel biomarkers to predict the prognosis of ICIs treatment of advanced NSCLC. Our systematic prognostic nomogram showed a great potential to predict the prognosis of ICIs for advanced NSCLC patients.

scholarly journals How patients being treated for non-small cell lung cancer value treatment benefit despite side effects

2021 ◽  
Author(s):  
Mona L. Martin ◽  
Julia Correll ◽  
Andrew Walding ◽  
Anna Rydén
Keyword(s):  
Lung Cancer ◽  
Side Effects ◽  
Small Cell Lung Cancer ◽  
Cell Lung Cancer ◽  
Advanced Nsclc ◽  
Small Cell ◽  
Small Cell Lung ◽  
Treatment Benefit ◽  
Treatment Expectations ◽  
Treatment Benefits

Abstract Purpose To describe symptoms and side effects experienced by patients with advanced non-small cell lung cancer (NSCLC), assess how patients allocate sensations (i.e. symptoms or side effects) to either the disease or its treatment, and evaluate how patients balance side effects with treatment benefits. Methods Qualitative sub-studies were conducted as part of two clinical trials in patients treated for advanced NSCLC (AURA [NCT01802632]; ARCTIC [NCT02352948]). Results Interviews were conducted with 23 patients and 19 patients in the AURA and ARCTIC sub-studies, respectively. The most commonly experienced symptoms/side effects were respiratory (81% of patients), digestive (76%), pain and discomfort (76%), energy-related (71%), and sensory (62%). Patients identified a sensation as a treatment side effect if they had not experienced it before, if there was a temporal link between the sensation and receipt of treatment, and/or if their doctors consistently told or asked them about it in relation to side effects. Themes that emerged when patients talked about their cancer treatment and its side effects related to the serious nature of their advanced disease and their treatment expectations. Patients focused on treatment benefits, wanting a better quality of life, being hopeful, not really having a choice, and not thinking about side effects. Conclusions In these two qualitative sub-studies, patients with advanced NSCLC valued the benefits of their treatment regardless of side effects that they experienced. Patients weighed their options against the seriousness of their disease and expressed their willingness to tolerate their side effects in return for receiving continued treatment benefits.

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