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Left untreated, malignant pleural mesothelioma (MPM) is associated with uniformly poor prognosis. Better survival has been reported with surgery-based multimodality therapy, but to date, no trial has demonstrated survival benefit of surgery over other therapies. We evaluated whether cancer-directed surgery influenced survival independently from other predictors in a large population-based dataset. The SEER database was explored from 1973 to 2009 to identify all cases of pathologically-proven MPM. Age, sex, race, year of diagnosis, histology stage, cancer-directed surgery, radiation, and vital status were analyzed. The association between prognostic factors and survival was estimated using Cox regression and propensity matched analysis. There were 14,228 patients with pathologic diagnosis of MPM. On multivariable analysis, female gender, younger age, early stage, and treatment with surgery were independent predictors of longer survival. In comparison to no treatment, surgery alone was associated with significant improvement in survival [adjusted hazard ratio (adj HR) 0.64 (0.61-0.67)], but not radiation [adj HR 1.15 (1.08-1.23)]. Surgery and radiation combined had similar survival as surgery alone [adj HR 0.69 (0.64-0.76)]. Results were similar when cases diagnosed between 1973 and 1999 were compared to cases diagnosed between 2000 and 2009. Despite developments in surgical and radiation techniques, the prognosis for MPM patients has not improved over the past 4 decades. Cancer-directed surgery is independently associated with better survival, suggesting that multimodal surgery-based therapy can benefit these patients. Further research in adjuvant treatment is necessary to improve prognosis in this challenging disease.

CD16a triggers antibody-dependent cellular cytotoxicity (ADCC) and phagocytosis by natural killer (NK) cells and macrophages in anti-tumor immunity. However, CD16a undergoes cleavage by ADAM17 that dampens its anti-tumor immunity. We here develop a monoclonal antibody (F9H4) that binds to CD16a and inhibits its cleavage. F9H4 retains CD16a on the surface of NK cells and macrophages, without triggering or blocking CD16a. F9H4 also binds to and inhibits shedding of CD16b by neutrophils, and inhibits CD16a/b shedding by leukocytes in tumor samples from lung cancer patients. F9H4 promotes ADCC against lung cancer cells that are opsonized by cetuximab, an epidermal growth factor receptor antibody that engages CD16a. F9H4 synergizes with cetuximab to inhibit human lung adenocarcinoma development in immunodeficient mice reconstituted with human NK cells. F9H4 combining with cetuximab also inhibits murine lung carcinoma growth in Fc gamma receptor-humanized mice, and such effect is mediated by NK cells and macrophages. The efficacy of F9H4+cetuximab in lung cancer models is the proof-of-concept for this new approach that promotes anti-tumor functions of Fc-enabled antibodies. CD16a triggers antibody-dependent cellular cytotoxicity but CD16a shedding dampens its anti-tumor activity. Here the authors develop a monoclonal antibody (F9H4) that prevents CD16a shedding, which synergizes with a tumor cell opsonizing antibody (cetuximab) to elicit natural killer cell-driven immunity.

Background Few studies have focused on quality of life (QoL) after treatment of malignant pleural mesothelioma (MPM). There are still questions as to which surgical procedure, extrapleural pneumonectomy (EPP) or pleurectomy decortication (P/D) is most effective and results in better survival outcomes, involves fewer complications, and results in better QoL. Here we performed a literature review on MPM patients to assess and compare QoL changes after P/D and EPP. Methods Research articles concerning QoL after mesothelioma surgery were identified through May 2018 in Medline. For inclusion, studies were 1) cohort or randomized controlled trials (RCT) design, 2) included standardized QoL instruments, 3) reported QoL measurement after surgery, 4) described the type of surgery performed (EPP or P/D), 5) were written in English. Measures of lung function (FEV1, FVC) and measures from the EORTC-C30 were compared 6 months following surgery with preoperative values. Results QoL data was extracted from 17 articles (14 datasets), encompassing 659 patients (102 EPP, 432 P/D); the available evidence was of low quality. While two studies directly compared QoL between the two surgical procedures, additional data was available from one arm of two RCTs, as the RCTs were not comparing EPP and P/D. The remaining data was reported from observational studies. While QoL was still compromised 6 months following surgery, from the limited and low quality data available it would appear that P/D patients had better QoL than EPP patients across all measures. Physical function, social function and global health were better at follow-up for P/D than for EPP, while other indicators such as pain and cough were similar. Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were reported in one study only, and were higher at follow-up for P/D compared to EPP. Conclusions Although the existing evidence is limited and of low quality, it suggests that P/D patients have better QoL than EPP patients following surgery. QoL outcomes should be factored into the choice of surgical procedure for MPM patients, and the possible effects on lung function and QoL should be discussed with patients when presenting surgical treatment options.

Background For early-stage cancer surgery is often curative, yet refusal of recommended surgical interventions may be contributing to disparities in patient treatment. This study aims to assess predictors of early-stage cancers surgery refusal, and the impact on survival. Methods Patients recommended surgery with primary stage I and II lung, prostate, breast, and colon cancers, diagnosed between 2007–2014, were identified in the Surveillance, Epidemiology and End Results database ( n  = 498,927). Surgery refusal was reported for 5,757 (1.2%) patients. Associations between sociodemographic variables and surgery refusal by cancer type were assessed in adjusted multivariable logistic regression models. The impact of refusal on survival was investigated using adjusted Cox-Proportional Hazard regression in a propensity score-matched cohort. Results Increasing age ( p  < 0.0001 for all four cancer types), non-Hispanic Black race/ethnicity (OR adjBREAST 2.00, 95% CI 1.68–2.39; OR adjCOLON 3.04, 95% CI 2.17–4.26; OR adjLUNG 2.19, 95% CI 1.77–2.71; OR adjPROSTATE 2.02, 95% CI 1.86–2.20; vs non-Hispanic White), insurance status (uninsured: OR adjBREAST 2.75, 95% CI 1.89–3.99; OR adjPROSTATE 2.10, 95% CI 1.72–2.56; vs insured), marital status (OR adjBREAST 2.16, 95% CI 1.85–2.51; OR adjCOLON 1.56, 95% CI 1.16–2.10; OR adjLUNG 2.11, 95% CI 1.80–2.47; OR adjPROSTATE 1.94, 95% CI 1.81–2.09), and stage (OR adjBREAST 1.94, 95% CI 1.70–2.22; OR adjCOLON 0.13, 95% CI 0.09–0.18; OR adjLUNG 0.71, 95% CI 0.52–0.96) were all associated with refusal; patients refusing surgery were at increased risk of death compared to patients who underwent surgery. Conclusions More vulnerable patients are at higher risk of refusing recommended surgery, and this decision negatively impacts their survival.

The effect of insurance type on lung cancer diagnosis, treatment, and survival in Asian patients living in the United States is still under debate. We have analyzed this issue using the Surveillance, Epidemiology, and End Results database. There were 102,733 lung cancer patients age 18–64 years diagnosed between 2007 and 2013. Multilevel regression analysis was performed to identify the association between insurance types, stage at diagnosis, treatment modalities, and overall mortality in Asian and non‐Hispanic White (NHW) patients. Clinical characteristics were significantly different between Asian and NHW patients, except for gender. Asian patients were more likely to present with advanced disease than NHW patients (ORadj = 1.12, 95% CI = 1.06–1.19). Asian patients with non‐Medicaid insurance underwent lobectomy more than NHW patients with Medicaid or uninsured; were more likely to undergo mediastinal lymph node evaluation (MLNE) (ORadj = 1.98, 95% CI = 1.72–2.28) and cancer‐directed surgery and/or radiation therapy (ORadj = 1.41, 95% CI = 1.20–1.65). Asian patients with non‐Medicaid insurance had the best overall survival. Uninsured or Medicaid‐covered Asian patients were more likely to be diagnosed with advanced disease, less likely to undergo MLNE and cancer‐directed treatments, and had shorter overall survival than their NHW counterpart. This study describes the association between insurance types and lung cancer stage at diagnosis, cancer‐specific treatments (surgery and radiotherapy), and overall survival according to race using the SEER database. In Asian patients living in United States, lack of insurance/Medicaid coverage is associated with advanced disease at presentation, less cancer‐directed surgery and/or radiotherapy, less mediastinal lymph node evaluation, and higher overall mortality compared to Asian patients with non‐Medicaid insurance.

Background Patients with early-stage non–small-cell lung cancer (NSCLC) have high survival rates, but patients often say they did not anticipate the effect of the surgery on their postsurgical quality of life (QoL). This study adds to the literature regarding patient and surgeon interactions and highlights the areas where the current approach is not providing good communication. Design Since its start in 2016, the Initiative for Early Lung Cancer Research on Treatment (IELCART), a prospective cohort study, has enrolled 543 patients who underwent surgery for stage I NSCLC within the Mount Sinai Health System. Presurgical patient and surgeon surveys were available for 314 patients, postsurgical surveys for 420, and both pre- and postsurgical surveys for 285. Results Of patients with presurgical surveys, 31.2% said that their surgeon recommended multiple types of treatment. Of patients with postsurgical surveys, 85.0% felt very well prepared and 11.4% moderately well prepared for their postsurgical recovery. The median Functional Assessment of Cancer Therapy–Lung Cancer score and social support score of the patients who felt very well prepared was significantly higher than those moderately or not well prepared (24.0 v. 22.0, P < 0.001) and (5.0 [interquartile range: 4.7–5.0] v. 5.0 [IQR: 4.2–5.0], p = 0.015). Conclusions This study provides insight into the areas where surgeons are communicating well with their patients as well as the areas where patients still feel uninformed. Most surgeons feel that they prepare their patients well or very well for surgical recovery, whereas some patients still feel that their surgeons did not prepare them well for postsurgical recovery. Surgeons may want to spend additional time emphasizing postsurgical recovery and QoL with their patients or provide their patients with additional avenues to get their questions and concerns addressed. Highlights Pretreatment discussions could help surgeons understand patient priorities and patients understand the anticipated outcomes for their surgeries. There is an association between feeling prepared for surgery and higher quality of life and social support scores after adjustment for confounders. Despite these pretreatment discussions, patients still feel that they are not well prepared about what to expect during their postsurgical recovery.

To date, the impact, timeline and duration of COVID‐19 pandemic remains unknown and more than ever it is necessary to provide safe pathways for cancer patients. Multiple triage systems for nonemergent surgical procedures have been published, but potentially curative cancer procedures are essential surgery rather than elective surgery. In the present and future scenario of our country, thoracic oncology teams may have the difficult decision of weighing the utility of surgical intervention against the risk for inadvertent COVID‐19 exposure for patients and medical staff. In consequence, traditional pathways of surgical care must be adjusted to reduce the risk of infection and the use of resources. It is recommended that all thoracic cancer patients should be offered treatment according to the accepted standard of care until shortage of services require a progressive reduction in surgical cases. Here, we present a consensus of recommendations discussed by a multidisciplinary panel of experts on thoracic oncology and based on the best available evidence, and hope it will provide a modifiable framework of guidance for local strategy planners in thoracic cancer care services in Mexico. Key points Significant findings of the study This article provides recommendations to guarantee the continuity of surgical care for thoracic oncology cases during COVID‐19 pandemic, whilst maintaining the safety of patients and medical staff. What this study adds This guideline is the result of an expert consensus on thoracic surgical oncology with recommendations adapted to medical, economic and social realities of Mexico. Consensus statement to guide the practice of thoracic surgical oncology during COVID‐19 pandemic in México.

PurposeLung cancer (LC) is a highly prevalent disease with more survivors diagnosed and treated at earlier stages. There is a need to understand psychological and lifestyle behavior needs to design interventions for this population. Furthermore, understanding the needs and role of family caregivers, especially given the risks associated with second-hand smoke, is needed.MethodsThirty-one early-stage (stages I or IIA) LC survivors of (52% men) and 22 (50% women) caregivers (N = 53 total) completed surveys after surgery (baseline) and at 3- and 6-month follow-ups. Participants reported on psychological functioning, smoking, and physical activity (PA) as well as intervention preferences.ResultsSurvivors reported low levels of psychological distress and 3% were current smokers during the study. Approximately 79% were sedentary and not meeting national PA guidelines. Caregivers also reported minimal psychological distress and were sedentary (62% not meeting guidelines), but a larger proportion continued to smoke following the survivor’s cancer diagnosis (14%). Both survivors and caregivers expressed interest in home-based PA interventions but differed regarding preferred format for delivery. Most (64%) caregivers preferred a dyadic format, where survivors and caregivers participate in the intervention together. However, most survivors preferred an individual or group format (57%) for intervention delivery.ConclusionBoth LC survivors and family caregivers could benefit from PA interventions, and flexible, dyadic interventions could additionally support smoking cessation for family caregivers.

Background A clear definition of video-assisted thoracic surgery (VATS) lobectomy is lacking in the current peer-reviewed literature. Reported cases vary from four to six incisions in number, 4.0 to 10.0 cm in length, and with and without rib spreading; in addition, they include direct visualization through a utility incision. Described is a complete standardized three-incision thoracoscopic technique that maximizes the benefits of minimally invasive surgery without compromising oncologic principles. Methods Patients with clinically suspected stage I non-small-cell lung cancer (NSCLC) were selected for VATS lobectomy on the basis of thoracic computed tomography. VATS lobectomies were performed using a standardized three-incision technique: a 2-cm camera port, a 2-cm posterior port, and a 4 cm utility incision without rib spreading. Hilar structures were individually ligated, fissures were completed, and lymph node dissection was performed entirely under thoracoscopic visualization. Results From May 2002 to December 2009, VATS lobectomy was performed successfully in more than 600 patients at our institution. There were no operative deaths, and the median length of stay was 4 days. Conclusions Standardized VATS lobectomy is feasible, expeditious, and safe. This standardized three-incision technique utilizing a 4-cm utility incision without rib spreading may allow valid comparisons of conventional procedures in clinical trials.

Primary lung myoepithelial carcinomas are rare neoplasms arising from the salivary glands of the respiratory epithelium. Given the rare occurrences and reports of these tumors, appropriate recommendations for resection are difficult to formulate. Although classified as low-grade neoplasms, these tumors have a significant rate of recurrence and distant metastasis.