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Introduction Lung cancer diagnostic and treatment delays have been described for several patient populations. However, few studies have analyzed these intervals among patients treated in contemporary health care systems in the United States. We therefore studied the timing of lung cancer diagnosis and treatment at a U.S. medical center providing care to a diverse patient population within two different hospital systems. Methods We performed a retrospective analysis of consecutive patients diagnosed with non-small cell lung cancer stages I–III from 2000 to 2005 at public and private hospitals affiliated with the University of Texas Southwestern Medical Center. We recorded patient and disease characteristics; dates of initial radiograph suspicious for lung cancer, diagnosis, and treatment; and overall survival. Associations between these factors were assessed using univariate analysis, multivariate logistic regression, and Kaplan-Meier survival analysis. Results A total of 482 patients met criteria for analysis. In univariate analyses, the image-treatment interval was significantly associated with race, age, income, insurance type, and hospital type (76 days for public versus 45 days for private; P<0.0001). In multivariate analysis, only hospital type remained significantly associated with the image-treatment interval; patients in the private hospital setting were more likely to receive timely treatment (HR 1.85; 95% CI, 1.37–2.50; P<0.001). In univariate analysis, the image-treatment interval was not associated with disease stage (P=0.27) or with survival (P=0.42). Conclusion Intervals between suspicion, diagnosis, and treatment of lung cancer vary widely among patients. Health care system factors, such as hospital type, largely account for these discrepancies. In this study, these intervals do not appear associated with clinical outcomes.

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KRAS mutations occur frequently in colorectal cancers (CRC) and predict lack of response to anti-epidermal growth factor receptor (EGFR) monoclonal antibody therapy. CRC BRAF mutations, most commonly at V600E, occur less than 10% of the time, and occur usually in KRAS wild-type tumors, and more frequently in microsatellite instable tumors. Concomitant KRAS and BRAF mutant CRCs are rare (occurring in 0.001%); BRAF mutations should not be routinely tested in patients with KRAS mutant tumors, unless the patients is participating in a clinical trial enriching for the presence of a KRAS or BRAF tumor. Clinical trials treating patients with either KRAS or BRAF mutant tumors should address eligibility of patients with concomitant KRAS and BRAF mutations.

Background Non-small cell lung cancer (NSCLC) presentation, treatment, and outcomes vary widely according to socioeconomic factors and other patient characteristics. To determine whether medical comorbidities account for these observations, we incorporated a validated medical comorbidity index into an analysis of patients diagnosed with stage I–III NSCLC. Patients and Methods We performed a retrospective analysis of consecutive patients diagnosed with stage I–III NSCLC. Demographic, tumor, and comorbidity data were obtained from hospital tumor registries and individual patient records. The association between variables was assessed through multivariate logistic regression and survival analysis. Results A total of 454 patients met criteria for analysis. Median age was 65 years, and 51% were men. Individuals with a higher Charlson Comorbidity Index (CCI) were significantly more likely to present with early stage (stage I–II) NSCLC than were patients with lower CCI (OR 1.72; 95% CI, 1.14 to 2.63; P=0.01), although this association lost statistical significance (P=0.21) in a multivariate model. In multivariate logistic regression, overall survival remained associated with all variables: age, gender, race, insurance type, stage, histology, and CCI (P=0.0007). The CCI was associated with survival for patients with both early stage (P=0.02) and locally advanced (P=0.02) disease. Conclusions In this cohort of patients with stage I–III NSCLC, increasing comorbidity burden had a non-significant association with diagnosis at earlier disease stage. Although comorbidity burden was significantly associated with outcome for both early stage and locally advanced disease, it did not account for survival differences based on multiple other patient and disease characteristics.

Background Socioeconomic disparities in treatment and outcomes of non-small cell lung cancer (NSCLC) are well established. To explore whether these differences are secondary to individual or institutional characteristics, we examined treatment selection and outcome in a diverse population treated at a single medical center. Patient and Methods We performed a retrospective analysis of consecutive patients diagnosed with NSCLC stages I-III from 2000-2005 at the University of Texas Southwestern Medical Center. Treatment selection was dichotomized as “standard” (surgery for stage I-II; surgery and/or radiation therapy for stage III) or “other.” Associations between patient characteristics (including socioeconomic status) and treatment selection were examined using logistic regression; associations between characteristics and overall survival were examined using Cox regression models and Kaplan-Meier survival analysis. Results A total of 450 patients were included. Twenty-eight percent of patients had private insurance, 43% had Medicare, and 29% had an indigent care plan. The likelihood of receiving “standard” therapy was significantly associated with insurance type [indigent plan versus private insurance OR 0.13 (95% CI 0.04-0.43) for stage I-II; OR 0.38 (95% CI 0.14-1.00) for stage III]. For patients with stage I-II NSCLC, survival was associated with age, gender, insurance type (indigent plan versus private insurance HR 1.98; 95% CI 1.16-3.37), stage, and treatment selection. In stage III NSCLC, survival was associated with treatment selection. Conclusion Within a single academic medical center, socioeconomically disadvantaged patients with stage I-III NSCLC are less likely to receive “standard” therapy. Socioeconomically disadvantaged patients with stage I-II NSCLC have inferior survival independent of therapy.

BackgroundThere is no effective systemic therapy for metastatic adrenal cortical carcinoma (ACC) after failure of platinum-based chemotherapy. The efficacies of single-agent oral multikinase inhibitors (MKIs) or salvage immune checkpoint inhibitors (CPIs) have been very limited. It is unknown whether combining CPIs, such as pembrolizumab (PEM), with other therapies, such as MKIs, could yield higher response rates in ACC, yet this combination has shown promise in other cancers. Herein, we describe the first case series using PEM in combination with the MKI lenvatinib (LEN) in patients with progressive, metastatic ACC.MethodsA retrospective case series describing the use of LEN/PEM as salvage therapy in patients with progressive/metastatic ACC.ResultsEight patients were treated with the LEN/PEM combination therapy. Half were female, and the median age at time of diagnosis was 38 years (range 21–49). Three (37.5%) patients had hormonally active ACC. The median number of prior lines of systemic therapy was 4 (range 2–9). Six (75%) patients had had disease progression on prior CPIs and five (62.5%) patients had progressed on prior MKI therapy. The median progression-free survival was 5.5 months (95% CI 1.8–not reached) and median duration of therapy was 8.5 months (range 2–22). Two (25%) patients had a partial response, one (12.5%) patient had stable disease, and five (62.5%) patients had progressive disease. None of the eight patients stopped therapy because of adverse events.ConclusionsIn our small cohort of heavily pretreated patients with ACC, the combination of LEN/PEM was associated with objective responses in a subset of patients without significant toxicity. This combination should be formally investigated in phase II clinical trial with robust correlative studies to identify predictors for response.

Vemurafenib is a targeted therapy that has become standard treatment for patients with advanced melanoma with a V600E BRAF mutation. It has been associated with frequent skin toxicity, including photosensitivity, rash and squamous cell carcinomas. We present an 83-year-old woman with an advanced V600E BRAF-mutant melanoma who developed a severe skin rash and fatigue after taking vemurafenib. The dose was reduced from 960 to 720 to 480 mg twice a day; however, she was subsequently admitted to the hospital with fever, chills, fatigue, confusion and a diffuse skin eruption. She then developed hypoxia and acute renal failure that required hemodialysis. A biopsy of her skin lesions revealed a neutrophilic dermatitis with papillary dermal edema, consistent with Sweet's syndrome. Her symptoms resolved upon discontinuation of vemurafenib and treatment with prednisone. This constellation of symptoms and clinical course are consistent with drug-induced Sweet's syndrome caused by vemurafenib.