Improved long-term survival following pulmonary resections for non-small cell lung cancer: results of a nationwide study from Iceland.

BACKGROUND: We studied the outcome of pulmonary resection with curative intent for non-small cell lung cancer (NSCLC) in a nationwide study covering a 24-year period, focusing on survival. METHODS: All patients who underwent pulmonary resection for NSCLC in Iceland in the period 1991-2014 were reviewed for demographics, TNM stage and survival. Median length of follow-up was 45 months. Three 8-year periods were compared, overall survival was estimated, and prognostic factors for survival were identified. RESULTS: Altogether, 652 surgical resections were performed on 644 individuals (52% females): 492 lobectomies (75%), 77 pneumonectomies (12%), and 83 sublobar resections (13%). Mean age increased from 65 to 68 yrs during the study period (P=0.002). The number of cases operated at stage IA increased substantially between the first and last periods (29% vs. 37%; P<0.001). Survival improved from 75% to 88% at 1 year and from 38% to 53% at 5 years (P<0.001). Independent prognostic factors for mortality were advanced TNM stage (HR =2.68 for stage IIIA vs. I), age (HR =1.04), ischaemic heart disease (HR =1.26), any minor complication (HR =1.26), and sublobar resection (HR =1.33), but surgical margins free from tumour growth (HR =0.59) and treatment during the latter two eight-year periods were predictors of lower mortality. The best survival was seen between 2007 and 2014 (HR =0.61, 95% CI: 0.48-0.78; P<0.001). CONCLUSIONS: Survival of patients who have undergone pulmonary resection for NSCLC has improved significantly in Iceland. This may be explained by the increased number of patients diagnosed at lower stages and improved preoperative staging, with fewer understaged patients.

Resection rate and operability of elderly patients with non-small cell lung cancer: Nationwide study from 1991 to 2014.

OBJECTIVES: An increasing number of elderly patients are diagnosed with non-small cell lung cancer (NSCLC). We compared the surgical resection rate, operability and survival in this age group (≥75 years) to younger patients using centralized databases in Iceland. METHODS: The study population comprised all patients diagnosed with NSCLC in Iceland from 1991 to 2014. A total of 140 elderly patients (≥75 years) with NSCLC underwent pulmonary resection and were compared with 550 surgically resected patients less than 75 years, with respect to resection rate, short and long-term survival and complications of surgery. Reasons for exclusion from surgery were registered for elderly surgical candidates (stages IA-IIB). RESULTS: Surgical resection rate in the elderly group was 18% compared to 32% in the younger age group ( P < 0.001). The most frequent reasons for not operating on elderly patients in stages IA-IIB were poor pulmonary function (58%), heart disease (17%) or multiple comorbidities (17%). The rate of major complications following surgery was comparable in the elderly versus the younger age group, 13 vs 11%, respectively ( P = 0.578). The same was true for 30 day mortality (2 vs 1%, P = 0.397). Five-year overall survival was 40% vs 44% ( P = 0.019) and cancer-specific survival 51% vs 50% ( P = 0.802). CONCLUSIONS: Elderly patients with resectable NSCLC according to stage are frequently excluded from surgery due to comorbid conditions. Although the operated patients may represent a selected group, their favourable 30-day and long-term survival indicate that more elderly patients with NSCLC could be operated on.

Smoking during pregnancy: A population-based study.

AIMS: Tobacco is a major cause of disease and mortality in modern times. The risk of smoking in pregnancy is a serious threat to the development and future health of an unborn child. The aim of this study was to explore the epidemiological factors associated with smoking during pregnancy in a primary healthcare setting. METHODS: All 856 maternity records at the Glaesibaer Health Care Centre in Reykjavik during 2006-2013 were reviewed and information on smoking habits investigated. RESULTS: The records showed that in 108 (12.2%) pregnancies, women smoked at first visit and 63 stopped smoking in early pregnancy, leaving 45 (5.3%) mothers smoking throughout the whole gestational period. The mean age of the smoking women was 27.8 years and for the non-smokers 29.7 years. Low social status (odds ratio (OR) = 2.66; 95% confidence interval (CI): 1.19-5.96), previous mental health diagnosis (OR = 2.7; 95% CI: 1.3-5.6), and unstable relationship with a partner (OR = 3.78; 95% CI: 2.1-7.0) were associated with smoking. Smoking fewer cigarettes was associated with a 0.04-unit lower risk of smoking during pregnancy (OR = 0.04: 95% CI: 0.02-0.08). CONCLUSIONS: Our results indicated that the women who smoked during pregnancy were often heavy smokers and living without a partner. They were younger, had worse mental health, and a lower social status than those pregnant women who did not smoke. Bearing in mind the consequence of smoking in pregnancy, this subgroup should get increased assistance to quit smoking before and during early pregnancy, as well as appropriate medical and social support.

Primary adenocarcinoma of the lung--histological subtypes and outcome after surgery, using the IASLC/ATS/ERS classification of lung adenocarcinoma.

Adenocarcinoma is the most common histological type of lung carcinoma. Recently the histologic classification of adenocarcinomas in the lung was modified to better reflect biologic properties and prognosis. We reviewed the histology of all primary lung adenocarcinomas operated on in Iceland during a 20-year period and assessed the impact of histology on survival. This nationwide study included 285 patients (mean age 67 years, 57% female), who underwent resection in Iceland from 1991 to 2010. Tumors were reclassified according to the current IASLC/ATS/ERS classification system. Overall survival was estimated by the Kaplan-Meier method and Cox regression analysis used to evaluate prognostic factors of overall mortality. Acinar predominant adenocarcinoma was the most common histological subtype (46%) followed by solid-predominant (SPA) with mucin production comprised (23%). Non-invasive carcinomas were rare. A difference in survival between the histological adenocarcinoma subtypes was not seen (p = 0.32) and multivariate analysis showed that advanced stage and age predicted worse outcome, but histologic subtyping of adenocarcinoma did not. In this nation-wide study there was not a statistical difference in survival according to adenocarcinoma subtypes and the histological subtype did not predict mortality. Preinvasive and minimally invasive adenocarcinomas were rare.

[Outcome of surgical treatment for Pancoast lung carcinoma in Iceland]. / Árangur skurdmedfedar vid Pancoast-lungnakrabbameini á Íslandi.

OBJECTIVE: Pancoast tumors are lung carcinomas that invade the apical chest wall and surrounding structures. Treatment is complex and often involves surgery together with radio- and chemotherapy. We studied the outcome of surgical resection for Pancoast tumors in Iceland. MATERIALS AND METHODS: A retrospective study including all patients that underwent resection of a Pancoast tumor with curative intent in Iceland in the years 1991-2010. Data on symptoms, complications, TNM-stage, relapse and survival were analyzed. RESULTS: Twelve patients were operated on; 7 on the right lung. Shoulder pain (n=5) and/or chest pain (n=3), cough (n=6) and weight loss (n=5) were the most common presenting symptoms. Adenocarcinoma (n=5) and squamous cell carcinoma (n=4) were the most frequent histological types. Average tumor size was 5,9 cm (range: 2,8-15). Five cases were stage IIB and 7 stage IIIA according to operative staging. In 10 cases (83%) the surgical margins were free of tumor. All patients survived surgery and only one patient suffered a major operative complication, an intraoperative bleeding. In one case induction chemo-radiation prior to surgery was administrated, and 8 patients received postoperative radiotherapy. Recurrent disease was diagnosed in 9 patients; four had local or regional recurrence, four had distant metastases and one patient was diagnosed with both local and distant recurrences simultaneously. Survival at 5 years was 33% and median survival was 27,5 months (range: 4-181). CONCLUSIONS: Operative and short-term outcomes for patients with Pancoast tumors in Iceland are excellent. However, long-term outcomes are not as favorable and recurrence rate is high compared to other studies, possibly due to incomplete preoperative staging and less use of chemo-radiation therapy prior to surgery among these patients.

[Postoperative complications following lobectomy for lung cancer in Iceland during 1999-2008]. / Fylgikvillar bladnámsadgerda vid lungnakrabbameini á Islandi 1999-2008.

OBJECTIVE: Non small cell lung cancer (NSCLC) is the second most common cancer in Iceland. We studied the indications and surgical outcome of lobectomy for NSCLC in Iceland. MATERIALS AND METHODS: 213 consecutive patients underwent lobectomy for NSCLC between 1999 and 2008. Data on indications, histology, TNM-stage and complications were analysed, and logistic regression used to assess outcome predictors. RESULTS: The majority of patients (60%) were referred because of symptoms, whereas 40% were asymptomatic. Adenocarcinoma (62%) and squamous cell carcinoma (29%) were the most frequent histological types. Operative staging showed that 59.6% of cases were stage I, 17.8% were stage II, 7% were stage IIIA and 14.6% were stage IIIB or IV. Mediastinoscopy was performed in 13.6% of cases. Mean operative time was 128 min., operative bleeding 580 ml and median hospital stay 10 days. Sixteen patients (7.5%) had major complications and 36 (17.5%) had minor complications, such as atrial fibrillation and pneumonia. Twelve patients required reoperation, most often due to bleeding, but two had empyema and one had a bronchopleural fistula. Older patients with high ASA scores and extensive smoking history were at increased risk for complications. No patient died within 30 days of surgery whereas two (0,9%) died within 90 days of surgery. CONCLUSIONS: The results of lobectomy for NSCLC in Iceland are excellent in relation to operative mortality and short term complications.

[Factors predictive of survival after lobectomy for non-small cell lung cancer in Iceland during 1999-2008]. / Forspárbaettir lífshorfa eftir bladnám vid lungnakrabbameini á Islandi 1999-2008.

OBJECTIVE: To study the impact of TNM stage and various preoperative functional parameters on survival in patients who underwent lobectomy for non-small cell lung cancer (NSCLC) in Iceland from 1999 to 2008. MATERIALS AND METHODS: Retrospective study including 213 patients (mean age 66.9 yrs, equal male/female ratio) that underwent lobectomy for NSCLC. Tumors were staged by the TNM staging system, survival was estimated by the Kaplan-Meier method and prognostic factors of survival studied using the Cox proportional hazards regression model. RESULTS: Survival at 1 year was 82.7% and 45.1% at 5 years. Operative mortality at 30 days was 0%. Most tumors were found to be in stage I (59.6%) or stage II (17.8%) and 7% were stage IIIA, whereas 14.6% were in stage IIIB or IV. Using multivariate analysis; advancing stage, increasing tumor size, reduced lung function and history of arrhythmia, predicted worse survival, whereas adenocarcinoma histology was a positive prognostic factor (HR 0.5, p=0.002) when compared to other histological types. CONCLUSIONS: Survival for patients undergoing lobectomy for operable non-small cell lung cancer in Iceland is comparable with other studies. Advanced stage, tumor size, reduced lung function and arrhythmia were negative predictors of survival, but in contrast to many but not all studies adenocarcinoma histology predicted a better prognosis compared to other tumor types.