Factors Affecting Survival in Patients With Lung.13

242 Original article
Factors affecting survival in patients with lung cancer

Hend M. Esmaeela, Kamal A. Attaa, Emad E. Nabilb, Mariam A. Naomc,
Abdellah H. Alia
a
Department of Chest Diseases and Background
Downloaded from http://journals.lww.com/ecdt by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
Tuberculosis, Sohag University Hospital, Lung cancer mortality is high all over the globe. A total of three million deaths are
b
Department of Clinical Oncology, Faculty of
Medicine, Sohag University, cSohag Chest
expected to be reached in 2035. There is a rising effort nationally for cancer data
Hospital, Sohag, Egypt documentation and networking. This study is in line with this effort.
Purpose
Correspondence to Hend M. Esmaeel, MBBS,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 06/27/2023
MD (Chest Diseases), Department of Chest This study aimed at assessment of the survival of patients with lung cancer in the
Diseases and Tuberculosis, Sohag University regional locality and assessing factors affecting mortality in the studied population.
Hospital, Sohag, 82524, Egypt. Patients and methods
Tel: +20 100 947 0158; fax: 602693; This retrospective study included patients with lung cancer who were diagnosed
e-mail: hendomr@gmail.com
and received treatment in the Oncology Department, Sohag University Hospital and
Received: 24 September 2020 Sohag Oncology Institute during the period from January 2016 to June 2019. The
Revised: 10 December 2020 available data in patients’ records were collected, and it included medical history,
Accepted: 13 January 2021
Published: 28 May 2021
clinical finding, diagnostic and metastatic workup, treatment, and follow-up for
outcome.
The Egyptian Journal of Chest Diseases and
Results
Tuberculosis 2021, 70:242–248
A total of 160 patients were enrolled in this study. Their median survival time was
1.21 year. Nonsmall-cell lung carcinoma, squamous subtype, showed higher 3-
year survival (35.67%) than other histopathological subtype. Earlier tumor stage,
stage II B, showed better survival than more advanced stages. Presence of positive
local signs, current smoking status, and poorly differentiated tumor were significant
risk factors for mortality in final multivariate analysis.
Conclusion
The study documented bad prognosis of lung cancer in our regional locality. It
emphasized the worse prognosis for advanced stage of tumor and confirmed the
role of smoking not only in development of lung cancer but also as mortality risk
factor, which highlights the importance of smoking cessation programs to be
initiated with focus on public awareness about it.
Keywords:
lung cancer, mortality, survival
Egypt J Chest Dis Tuberc 70:242–248
© 2021 The Egyptian Journal of Chest Diseases and Tuberculosis
2090-9950
more developed countries and tobacco smoking

Introduction
epidemics in less developed countries [3].
The 5-year lung cancer survival rate does not exceed
15%, even in the developed countries, the fact that
This study is one of the hospital-based and institution-
highlights the problem of lacking curable treatment for
based studies. It is consistent with the growing national
this cancer region. However, survival of early stage
effort for cancer data networking.
disease is markedly better in lung cancer stage I or II, 5-
year survival rate reaches 70%, what makes some
This study aimed at evaluating survival of patients
physicians consider using low-dose computed
diagnosed with lung cancer at our regional locality
tomography (CT) scans as a screening tool in high-
and assessing factors affecting mortality in the studied
risk groups between populations [1]. Tobacco smoking
population.
in both active and passive smokers is known as the main
risk factor for lung cancer [2].
Patients and methods
In spite of achieved success in programs related to This retrospective study enrolled patients who were
tobacco cessations, especially in some developed diagnosed with lung cancer and received their
countries, the number of lung cancer deaths is
predicted to level off only in few countries, and it is This is an open access journal, and articles are distributed under the terms
of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0
expected to reach three million deaths in 2035. Two License, which allows others to remix, tweak, and build upon the work
phenomena are supposed to be responsible for the rise non-commercially, as long as appropriate credit is given and the new
in lung cancer deaths globally: aging of populations in creations are licensed under the identical terms.
© 2021 The Egyptian Journal of Chest Diseases and Tuberculosis | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejcdt.ejcdt_144_20
Factors affecting survival in patients with lung cancer Esmaeel et al 243
treatment in the Oncology Department, Sohag factors affecting mortality were done by logistic
University Hospital and Sohag Oncology Institute regression method, odds ratio, and P value. Graphs
during the period from January 2016 to June 2019. were produced by using Excel or STATA program. P
Patient identity and name were kept confidential to value was considered significant if it was less than 0.05.
maintain privacy. The study was approved by the
medical ethics committee of Sohag Faculty of Medicine.
Results
Inclusion criteria
A total of 160 patients were enrolled in this study,
Patients who were finally diagnosed as having primary including 120 male patients and 40 female patients.
Their demographic and smoking characteristics are
lung cancer were included. Patients who were

diagnosed as having malignant pleural tumors shown in Table 1.
encountered during the review were also enrolled.
The median survival time was 1.21 year, with range
Exclusion criteria between 0.06 and 5.77 years. The cumulative survival
The following were the exclusion criteria: rate at 3 years was 34.5%. Figure 1 shows
Kaplan–Meier curve for estimation of overall survival
(1) Patients who were diagnosed as other type of in the studied population.
malignancy rather than bronchogenic carcinoma.
(2) Patients presented with lung mass diagnosed as Assessment of survival rate by tumor stage at presentation
granulomatous lung disease like tuberculosis or was done. The highest cumulative survival rate at
sarcoidosis. 3 years was for stage II B (63.49%), whereas the
(3) Patients presented clinically with pulmonary lowest was for stages III C and IV B (0%) (Table 2).
manifestations, either clinically or radiologically
diagnosed as lung metastasis from other distant Table 1 Demographic and smoking characteristics of studied
malignancy. population (N=160 patients)
Variables Summary statistics
Patient records were scanned for the following: detailed Age (years)
medical history; presenting symptoms and signs; and Mean±SD 63.4±9.92
radiological investigations, including plain chest Age group [n (%)]
radiograph, which was done at the time of diagnosis, <40 years old 23 (14.375)
41–60 years old 58 (36.25)
CT scans, where CT chest was done at the beginning of
>60 years old 79 (49.375)
treatment and at the last follow-up, and as needed, other
Sex [n (%)]
CT scans, and bone scan, in requested cases. Laboratory Female 40 (25.00)
investigations included basic investigations including Male 120 (75.00)
complete blood count, liver function test, and renal Residence [n (%)]
function test at the beginning and the end of treatment. Rural 125 (78.13)
Urban 35 (21.88)
Occupation [n (%)]
Histopathological diagnosis and staging of the tumor
Farmer 86 (53.75)
Lung tumors were classified and staged according to
House wife 38 (23.75)
8th edition of TNM classification system for lung [4]. Employee 26 (16.25)
Manual worker 9 (5.63)
Treatment modalities were either chemotherapy, Engineer 1 (0.63)
radiotherapy, or surgical treatment. Smoking status [n (%)]
Nonsmoker 46 (28.75)
Statistical analysis Smokers 114 (71.25)
Data analysis was done using STATA intercooled, Current smoker 46 (28.75)
Exsmoker 54 (33.75)
version 14.2 (Stata Corp., California, USA).
Stop smoking 14 (8.75)
Smoking type [n (%)]
Representation of quantitative data was in the form of Cigarette 33 (28.95)
mean, SD, median, and range. Number and percentage Goza 41 (35.96)
presented the qualitative data. Survival analysis was Mixed cigarette and goza 40 (35.09)
done using Kaplan–Meier method, and comparison Smoking index [n (%)] (N=114)
between two survival curves was done using log-rank Heavy smoker 104 (91.23)
test. Univariate and multivariate analyses for risk Mild to moderate smoker 10 (8.77)
244 The Egyptian Journal of Chest Diseases and Tuberculosis, Vol. 70 No. 2, April-June 2021
Figure 1 Table 2 Survival rate by stage

Stages N=160 [n Cum survival at 3 years % P
(%)] ±SE value
IB 2 (1.25) 50.00±35.00
II A 9 (5.63) 53.33±20.46
II B 21 (13.13) 63.49±11.52
III A 17 (10.63) 40.55±14.53 0.66

III B 14 (8.75) 28.06±16.04
III C 3 (1.88) 0
IV A 90 (56.25) 26.86±7.09
IV B 4 (2.5) 0
Discussion
This study of retrospective type was done aiming to
gather information about survival of patients who were
diagnosed as having primary lung and pleural tumors
and received their treatment in oncology department
in Sohag University Hospital or in Sohag Oncology
Institute during the period from January 2016 to June
2019.
Overall survival.
Analyzing the age distribution of this study revealed
that larger percentage of the studied patients was more
Treatment modality also affected cumulative survival than 60 years old (49.375%). This is similar to other
rate at 3 years of our studied population, as highest studies published in Egypt [5].
survival was for those receiving combined surgical,
chemotherapy, and radiotherapy (66.76%), and Most of the patients included were male (75%) of the
lowest for those patients who treated by either studied population. The male predominance in
surgical and chemotherapy or surgical and patients with lung cancer is a consistent finding in
radiotherapy(0%), and the difference was significant many studies that were published nationally [6] and
statistically (P<0.000) (Fig. 2). internationally [7].
In our study, nonsmall-cell lung carcinoma, More than two-thirds of the patients were smoker
squamous subtype, showed higher 3-year survival (71.25%), and 91.23% of them were heavy smoker.
(35.67%) than other histopathological subtype Smoking is documented as a risk factor for lung cancer.
(Table 3). Even passive smokers are more vulnerable for
occurrence of lung cancer [2].
Logistic regression analysis was used to detect possible
risk factors associated with mortality in our studied There is an agreement that smoking is the fundamental
patients. The first univariate analysis included risk factor for lung cancer in Egypt [8,9].
demographic, smoking, and clinical risk factors.
Current smoking status and presence of local signs The median survival time in this study was 1.21 years,
at first presentation were factors that showed and the cumulative survival rate at 3 years was 34.50%.
significance in this analysis (Table 4). The second
univariate analysis included tumor-related factors. There is little variability in lung cancer survival rates
Stage IV and poorly differentiated tumor showed among countries. The outcome and fate for patients
significant P value (Table 5). diagnosed with lung tumors still being poor globally. In
Egypt, lung cancer is considered one of the widely
Factors that remained at significance in the final encountered tumors. It represents nearly 5.0–7.0% of
multivariate analysis for risk factors of mortality all cancer types [10].
were presence of positive local signs, current
smoking status, and poorly differentiated tumor Mortality rate in Egypt had increased from 9.1 to 32.4/
(Table 6). 100.000 populations and from 2.3 to 12.4/100.000
Figure 2
Survival by treatment modalities.
Table 3 Survival rate by histopathology

Histopathology Number Cum survival at 3 years %±SE P value
NSCLC, adenocarcinoma 117 33.32±5.99
NSCLC, squamous 23 35.67±11.84
Small-cell lung cancer 9 0 0.78
Biphasic Mesothelioma 2 0
Epithelioid mesothelioma 9 33.33±24.85
NSCLC, nonsmall-cell lung carcinoma.
populations, between 2010 and 2014, among males and The highest cumulative survival at 3 years was for those
females, respectively [11]. patients who received combination of surgical,
chemotherapy, and radiotherapy (66.67% survival)
The lung cancer 5-year survival rate at USA (18.6%) is lower followed by those group of patients who received
than many other leading cancer sites, such as colorectal chemotherapy (41.57% survival at 3 years).
(64.5%), breast (89.6%), and prostate (98.2%) [12]. Difference between groups showed statistical
significance. Surgical treatment is still the most
This study recorded that the cumulative survival rate at effective treatment for early localized tumors;
3 years was higher in early stages of lung cancer (I B to however, only a minority of patients have diagnosis
III A) than late stages (III B to IV B). They represent at an early stage. The explanation for its late
about two-thirds of cases (69.4%). The lowest presentation may be that lung cancer is deficient of
percentage related to the studied population who clinical symptomatology and sign at its earlier
presented with stage III B and IV B (0%). It is stages. So, mostly once diagnosed, the tumor is well
difficult to detect lung cancer at an early stage [13]. advanced, and the treatment options are mostly limited
[15].
A national study at the Kasr El-Eini University report
that metastatic disease presents 45% of their first Our results showed that different histopathological had
presentation [14]. different cumulative 3-year survival. It was lowest for
small cell lung cancer and biphasic mesothelioma (0%),
In terms of treatment modality, most of our patients and highest for squamous cell carcinoma (35.67%). In
received chemotherapy followed by combination of the USA, between years 1996 and 2003, the 5-year
chemotherapy and radiotherapy. cumulative survival was nearly 17% for patients with
Table 4 Univariate logistic regression analysis of demographic and smoking risk factors affecting mortality in studied population
(N=160 patients)
Variables Odds ratio (95% confidence interval) P value
Age (years) 0.99 (0.97–1.03) 0.92
Sex
Female 1
Male 0.12 (0.27–1.17) 0.12

Smoking status
Current smoking 0.31 (0.13–0.73) 0.008*
Exsmoker 0.50 (0.22–1.11) 0.09
Stop smoking 1.33 (0.36–4.94) 0.67

Smoking index
Mild to moderate smoker 1
Heavy smoker 0.55 (0.15–2.06) 0.38
Underlying comorbid conditions
No 1
Yes 0.91 (0.49–1.71) 0.59
Number of presenting symptoms
One 1
More than one 1.80 (0.66–4.93) 0.25
Presenting local signs
Free 1 <0.0001*
Positive sign 5.47 (2.56–11.67)
*Significant P value.
Table 5 Univariate logistic regression analysis of tumor-related risk factors affecting mortality in studied population (160
patients)
Histopathology
Nonsmall-cell lung cancer adenocarcinoma 1
Nonsmall-cell squamous carcinoma 1.38 (0.55–3.44) 0.49
Small-cell lung cancer 0.44 (0.11–1.86) 0.27
Epithelioid/biphasic mesothelioma 0.51 (0.14–1.82) 0.30
Staging
I/II 2.15 (0.80–5.80) 0.13
III 0.52 (0.25–1.09) 0.08
IV 2.58 (1.12–5.95) 0.03*
Grade of differentiation
Well differentiated 1
Moderately differentiated 1.12 (0.49–2.56) 0.78
Poorly differentiated 3.44 (1.51–7.80) 0.003*
Treatment modality
Chemotherapy 1
Chemotherapy and radiotherapy 0.90 (0.47–1.70) 0.74
Other modality 0.65 (0.14–3.09) 0.59
nonsmall-cell lung carcinoma and only 6% for patients The factors that showed significance in final
with SCLC. In Australia, Canada, and also throughout multivariate analysis in our studied population were
Europe, similar patterns for survival rates were presence of positive local signs on examination at
recorded for different histopathological types [16]. presentation, being current smoker, and poorly
differentiated tumor. A study in Korean patients
To explore possible risk factors associated with reported absence of symptoms at the first diagnosis
mortality, univariate analysis was done: one is a good prognostic factor [17].
included demographic and smoking criteria and
second included tumor-related variables, such as In the literature, other studies reported different
histopathology, stage, grade of differentiation, and factors. In a study in a Tunisian population, absence
treatment modality. of history of lung fibrosis, better performance status,
Table 6 Final multivariate logistic regression analysis of risk factor affecting mortality in studied population (160 patients)
Smoking
Nonsmoker 1 0.007*
Current smoking 0.26 (0.10–0.69) 0.08
Exsmoker 0.44 (0.17–1.12) 0.92
Stop smoking 0.92 (0.22–3.96)

Presenting local signs
Free 1 <0.0001*
Positive sign 5.43 (2.40–12.30)
Grade of differentiation
Well differentiated 1 0.98
Moderately differentiated 1.01 (0.39–2.61) 0.01*
Poorly differentiated 3.48 (1.35–8.99)
absence of metastatic lymph node, and Financial support and sponsorship

adenocarcinoma type were associated with less Nil.
mortality and longer survival [18].
Conflicts of interest
Identification of current smoking status as a risk factor There are no conflicts of interest.
for mortality emphasizes the importance of initiation of
smoking cessation programs, especially that lung References
cancer rates are expected to increase in the next few 1 Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et
decades in several African countries [19]. al. National Lung Screening Trial Research Team. Reduced lung-cancer
mortality with low-dose computed tomographic screening. N Engl J Med
2011; 365:395–409.
Study limitation 2 Devesa SS, Bray F, Vizcaino AP, Parkin DM. International lung cancer
trends by histologic type: male: female differences diminishing and
The number of included patients (n=160) who were adenocarcinoma rates rising. Int J Cancer 2005; 117:294–299.
diagnosed with lung cancer and whose files of 3 Noronha V, Dikshit R, Raut N, Joshi A, Pramesh CS, George K, et al.
investigations were available throughout 3 and half Epidemiology of lung cancer in India: focus on the differences between non-
smokers and smokers: a single-centre experience. Indian J Cancer 2012;
years may be lower than expected. This may be 49:74–81.
explained by the facts that some patients may be 4 Detterbeck F, Chansky K, Groome P, Bolejack V, Crowley J, Shemanski L,
et al. IASLC Staging and Prognostic Factors Committee, Advisory Boards,
transferred to the oncology center available at their and Participating Institutions. The IASLC Lung Cancer Staging Project:
governorate. methodology and validation used in the development of proposals for
revision of the stage classification of NSCLC in the forthcoming (eighth)
edition of the TNM classification of lung cancer. J Thorac Oncol 2016;
11:1433–1446.
Conclusions 5 Omar A, Abo Elfadl A, Ahmed Y, Hamed R, Zaky AH. Primary lung cancer in
Lung cancer carries a worse prognosis and higher Assiut University Hospitals: pattern of presentation within four years
(January 2011: December 2014). Egypt J Chest Dis Tuberc 2017;
mortality than other malignant tumors all over 66:675–680.
the globe. The cumulative survival rate at 3 years 6 Akl YM, Emam RH, Sabry IM, Ali AA. Clinico-pathological profile of
was 34.5%, for our studied group. Tumor stage, bronchogenic carcinoma cases presented to Chest Department, Cairo
University in the last 10 years. Egypt J Chest Dis Tuberc 2013; 62:705–712.
histopathological type, and treatment modality all 7 Siddiqui S, Ali MU, Ali MA, Shah N, Nasreen SH. Lung carcinoma: its profile
affect the survival rate at different degree. Presence and changing trend. J Ayub Med Coll Abbottabad 2010; 22:116–119.
of local signs at presentation, current smoking status, 8 Larbi ABID. AMAAC Workshop, Algiers; 2011.
9 Curado MP, Edwards B, Shin HR, Storm H, Ferlay J, Heanue M, et al.
and poorly differentiated tumor are factors associated Cancer incidence in five continents, vol. IX. Lyon: IARC; 2007.
with mortality risk in this study. 10 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global
cancer statistics 2018: GLOBOCAN estimates of incidence and mortality
worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;
Recommendation 68:394–424.
Smoking cessation programs are needed to be initiated 11 Dubey AK, Gupta U, Jain S. Epidemiology of lung cancer and approaches
for its prediction: a systematic review and analysis. Chin J Cancer 2016;
with effective public announcement and involvement. 35:71.
There is an urgent need for lung cancer screening 12 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin
protocols for high-risk groups to be adopted by 2019; 69:7–34.
13 Yadav AK, Tomar D, Agarwal S. Clustering of lung cancer data using foggy
national health authorities because earlier tumor k-means. International conference on recent trends in information
stage has better prognosis. technology (ICRTIT), USA: IEEE; 2013 13–18.
14 Khalil EM, Anwar MM, Sherwief MA. Pattern of treatment and clinico- Statistical tables. Cancer Series No. 19 (AIHW Cat. No. CAN 14).
epidemiological analysis of 804 lung and pleura cancer patients treated Canberra: AIHW and AACR; 2001. Available at: www.aihw.gov.au/
in radiation oncology department, NCI-Egypt. Egypt J Chest Dis Tuberc publications/ can/csa01part2/csa01part2.pdf. . [Accessed March 20, 2007].
2016; 65:271–278. 17 Park CK, Kim SJ. Trends and updated statistics of lung cancer in Korea.
15 Verdecchia A, Francisci S, Brenner H, Gatta G, Micheli A, Mangone L, Tuberc Respir Dis 2019; 82:175–177.
Kunkler I, EUROCARE-4 Working Group. Recent cancer survival in 18 Melki B, Aouadi S, Gahrsalli H, Bejar D, Laabidi S, Maâlej S, Douik El
Europe: a 2000–02 period analysis ofEUROCARE-4 data. Lancet Oncol Gharbi L. Survival in lung cancer: associated factors in Tunisian patients.
2007; 8:784–796. Eur Respir J 2015; 46:PA4310.
16 Australian Institute of Health and Welfare, Australasian Association 19 Parkin DM, Bray F, Ferlay J, Jemal A. Cancer in Africa 2012. Cancer
of Cancer Registries. Cancer survival in Australia, 2001. Part 2: Epidemiol Biomarkers Prev 2014; 23:953–966.

Factors Affecting Survival in Patients With Lung.13

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Factors Affecting Survival in Patients With Lung.13

Uploaded by

Copyright:

Available Formats

242 Original article

Factors affecting survival in patients with lung cancer

more developed countries and tobacco smoking

lung cancer were included. Patients who were

Figure 1 Table 2 Survival rate by stage

III A 17 (10.63) 40.55±14.53 0.66

Survival by treatment modalities.

Table 3 Survival rate by histopathology

Male 0.12 (0.27–1.17) 0.12

Stop smoking 1.33 (0.36–4.94) 0.67

Stop smoking 0.92 (0.22–3.96)

absence of metastatic lymph node, and Financial support and sponsorship

You might also like