Effect of High SUV, etc on staging survival percentages - 1289454

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me53
Effect of High SUV, etc on staging survival percentages - 1289454

I have stage IIIB(p) lung cancer, which gives a 9% chance of survival via traditional staging. How does this interact with more recently discovered individual prognostic markers – eg, I have SUV over 11, presence of intracytoplasmic mucin… Any such individual markers I have are all “associated with a poorer prognosis and a more aggressive tumor” – do I therefore have a much lower than 9% chance of not metastasizing? Is it as low as 1-2C%? The cancer itself is adenosquamous, which is also considered "more aggressive than adeno, more aggressive than squamous," according to studies. I am trying to get a realistic sense of the significance of these correlative factors. Thank you to anyone who knows about this particular area! (I am actually T4, SUV's over 10 in both right lung tumors, had pneumonectomy)

onthemark
Me53,

Me53,

I am not a doctor but since being diagnosed and treated I've read a lot about lung cancer.

Any % figure you are quoting for stage IIIb is lumping in a vast variety of different situations including, in particular, people who are not operated on, degrees of lymph node invasion and other aspects of the disease -- all considered 3B but actually different, like your adenosquamous.

I also know that SUV max goes up with stage so having an SUV max of 11 may be average or low for stage IIIb, rather than high. (I don't know). When people write that something is unfavorable, well that is already taken into account in the IIIb diagnosis, that those tend to be more aggressive tumors than e.g. stage 1.

ADS is not something I know much about. Did you have chemo?

me53
The 9% progn. takes into

The 9% progn. takes into account non-bulky LN. The SUV # is independently correlating to prognosis as I wrote, and that is what my question asks. Maybe someone on here will know the answer?! It is possible that these individual markers (SUV, mucin) differentiate between those in the 9% (7% if bulky nodes, since you raised it) and those in the 91% of the stage, thus affecting prognosis when known. That was in my question. (I don't want to keep restating my question, LOL). I know that within each stage there are a variety of suv #s, so I don't think your statement that suv is taken into account in iiib prognosis is fully correct (ie, your answer to my question, that "something unfavorable is already taken into account in [staging] prognosis) -- again, maybe a doctor or researcher would know the answer to my original question??

onthemark
That SUV may be independently

That SUV may be independently correlated does not address whether your SUV is high or low compared to average for the stage. Also many if not most stage 3B are not resected and that has a big effect on survival.

Have you had chemo?

Are you seen by an expert in adenosquamous. Have you been tested for genetic markers?

me53
I really just want the answer

I really just want the answer to my question from someone who may know, and to keep the thread succinct, not go back and forth on theories, it unfortunately tires me out. Any SUV over 10 is high, as I wrote on my previous attempt of this thread last week. I don't know the average suv or suv spread for iiib - I was hoping to not have to keep researching on my own, but to find someone who can answer this question for me. My question is essentially chance of metastasis, not response to alk meds, etc. That is a separate question, whether high suv is correlated to response to alk meds -- I would guess that is more a function of exons, etc. and not fully known yet.

onthemark
From what I can tell

From what I can tell adenosquamous is really its own beast. Here is a paper on prognosis factors. Post operative chemo is a favourable factor, so is predominant squamous vs. predominant adeno. It's a small study, but it is recent. There are others
Clinicopathological characteristics and prognosis of patients with adenosquamous lung carcinoma

Volume: 35 Issue: 3 Pages: 350-355
DOI: 10.1007/s11596-015-1436-z
Published: JUN 2015
Abstract
This study was aimed to characterize clinicopathological features and prognosis of patients with adenosquamous lung carcinoma (ASC). Among the 2531 patients with lung cancer who underwent surgery between January 2000 and June 2012 in our hospital, 59 were histologically diagnosed as having ASC. The clinicopathological features and follow-up data of ASC patients were collected and analyzed statistically. Superior lobectomy was accomplished in 40 patients, middle and inferior lobectomy in 3, lobectomy plus partial resection of contralateral lung in 5, partial lung resection in 4, and pneumonectomy in 7. Moreover, 22 cases were found to be adenocarcinoma-predominant, and 18 to be squamous cell carcinoma-predominant. The median survival time was 13.6 months, and the 1-, 3-, and 5-year survival rates were 59.9%, 36.4% and 31.2%, respectively. Of the 52 cases with tissue specimens available, 11 had an EGFR mutation (21.2%) and 2 had a KRAS mutation (3.8%). Multivariate analysis showed that histology subtype, pleural invasion, TNM stage, and postoperative treatment were all independent prognostic factors. The data from the current study demonstrated that SCC-predominant histology represents a better prognosis of ASC. Histology subtype,
pleural invasion, TNM stage, and postoperative treatment are independent prognostic factors for ASC and adjuvant therapy may help control the disease.

me53
Look, I appreciate your help

Look, I appreciate your help but I really want to keep this thread to the single question I asked upfront, at least until or if it is answered. The answer will get lost, especially to any later folk interested in it, by expanding it into other areas, including general discussions of adenosquamous or chemo.

JimC
If you have not already seen

If you have not already seen it, perhaps this study will be helpful: http://www.atsjournals.org/doi/full/10.1513/pats.200806-059LC

In this retrospective analysis of various trials, the difficulty of isolating one particular factor is noted, including the varying thresholds used to define "high SUV". There is also discussion of how prognosis can vary based on tumor type and differentiation, as well as the magnitude of decrease in SUV following treatment with chemotherapy or chemoradiation.

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

me53
That study is from 2008 Jim;

That study is from 2008 Jim; much progress has been made in this area in the last 2 years (published studies in last 2 years) -- I am still hoping someone might be able to answer my question itself, with up to date knowledge. Also, my question is not about the effect of suv changes from chemo/rad and how that affects survival, etc. It is a separate issue of suv of tumor on diagnosis and the significance/import of this data. I am frustrated (as this is the second thread in one week I have tried to get an answer to this question, and get farther afield responses only) as answers seem to be attacking my question itself (it's not important, I don't think it has meaning, what about chemo, everyone's different...), which feels insulting to me and not getting me any closer to an answer -- trust me, the question is legitimate and I am not seeking general views on the topic of prognosis or ways to address metastasis. I feel like I am having to write a dissertation in response to answers that aren't really answers, it is tiring me very much (especially as this happened in last thread that spread to several pages and did not have an answer in it, just a host of side discussions).

catdander
Let me preface this with: If

Let me preface this with: If someone has input pertaining please do leave a comment for we still have an unanswered question.

me53,

I'm sorry but I don't think we (forum moderators or oncology facalty) will be able to answer your question. We've tried. We just aren't equipped to answer questions about prognosis past what you've already dug up. Dr. Weiss gave us time and input to no use to you nor did Jim or I or other members provide the prognostic info you need. We are always willing to help with input but there are obvious limits to our forum. I'm sorry our attempts feel like we don't respect your legitimate need to know. As Dr. Weiss stated before, "I’m afraid that I don’t have a lot to add that directly answers the subject under discussion, prognostication. As an oncologist, I have spent little time on vetting the literature and doing research on prognosis (which means factors that predict outcome regardless of choices made). To the contrary, I’ve spent more time on prediction (which means markers that help guide the right thing to do). I understand from a human standpoint why you are interested in everything that you can learn re prognosis, but can’t help much." http://cancergrace.org/topic/importance-of-prognosis-markers/#post-1289395

If you find what your looking for please do share with us. If you find that you need other info give us a try again.

All best,
Janine

catdander
Is this helpful?

Is this helpful? "Intracytoplasmic mucin is associated with specific clinical characteristics and is an independent factor for worse survival in lung adenocarcinoma formerly known as BAC. http://www.lungcancerjournal.info/article/S0169-5002(14)00004-X/abstract?cc=y=
It's only a piece of your personal puzzle though.

catdander
There may be someone

There may be someone associated with this trial that may be willing to help you. https://clinicaltrials.gov/ct2/show/NCT00759382?term=suv%2C+Prognostic+%...

me53
I would like to think that Dr

I would like to think that Dr. West is familiar with the area of my original question (top of thread) and perhaps he has a broader interest than Dr. Weiss and could answer it. That would be wonderful. The second study you list does not complete until 2020, but they should be familiar with knowledge to date, however all are in Belgium (I do speak french, but maybe I can get an American to answer??) The researchers may or may not know how the study intersects with my question. The first study you note is relatively old and simply states the presence of intr.cyto.mucin is associated with a poorer prognosis -- I know this but due to its age and limited findings, I don't think I will find the answer by finding its researchers -- I can try to track down the researchers of the studies I have read (SUV is the most important point), they are all recent but I didn't think I had to do a dissertation on them so did not note cites -- someone active in the field will/should know of what I am talking, though, perhaps/hopefully. And will perhaps be better able to assess how the findings impact prognosis overall in the way I asked (obviously, people should be studying what differentiates the nonmetastasizers from the rest in stage iii)

me53
It is also clear that only a

It is also clear that only a medical professional (research or clinical) would be able to answer my question, it is very specific and requires more than lay knowledge. Ta

onthemark
I think the moderators have

I think the moderators have gone out of their way to provide relevant information.

It is not at all clear that SUV max is prognostic for stage III lung cancer. Here is a recent, serious study that says it is not. Other finding from PET are, however.

Pretreatment PET and Overall Survival
At the time of database locking, median survival time after study registration was 19.9 months, and 159 patients (74.3%) had died. Univariate Cox proportional hazards testing revealed that pretreatment MTV (HR = 1.04 per 10cm3 increase, 95% CI = 1.03 to 1.06, P < .001) and pretreatment TGA (HR = 1.33 per natural log increase, 95% CI = 1.15 to 1.54, P < .001) were statistically significant predictors of mortality, while SUVmax was not prognostic (HR = 1.01, 95% CI = 0.99 to 1.03, P = .38)."

Pretreatment FDG-PET Metrics in Stage III Non–Small Cell Lung Cancer: ACRIN 6668/RTOG 0235
http://jnci.oxfordjournals.org/content/107/4/djv004.full

me53
This is what I'm talking

This is what I'm talking about - I asked a question, and I keep having to field hostile responses from nonprofessionals who DON"T know enough to answer but keep "doing so" as if I should accept their take as an answer or be reprimanded for continuing to want a knowledgeable answer, and forcing me to keep typing, tiring me and separating any actual answer from the question up top. That said, I understand that this LONG study (report), which is older than the recent SUV studies I read (mostly 2015 and 2016), and mostly deals with inapposite matters, says the opposite of what I was referring to, it is not helpful. I am trying to make sense of large recent studies and raised a specific question - citing other studies that are older and peripherally say something else does not actually help me. I am ending up spending so much time on this it is depressing me - I was hoping this forum could be a substitute for work and help in analyzing recent studies, not a forum of lay people addressing this and pulling up random older studies.

JimC
me53,

me53,

I am sorry that you feel that we have not made good faith attempts to respond to your question; I don't think we will be able to provide you with the answer you seek. In this post I will try to explain in some detail why we have been responding as we have. Therefore, this post will not provide you with an answer, so please feel free to stop reading at this point.

As you describe, the five-year survival rate for stage IIIb lung cancer is around 9 percent, but it includes three broad categories of patients. First, there are those whose cancer never recurs after initial surgery and/or chemoradiation. Second, there are patients whose cancer recurs locally but through subsequent treatment is eliminated or kept in check to at least the five-year mark. Third, some patients' cancers will recur and spread distantly, making them stage IV, but treatment may also control these cancers to the five-year point. It's not simply that 91 percent recur or metastasize and don't make it, while 9 percent will neither recur nor metastasize and will survive.

Each of these patients will contribute to the 9 percent statistic, and the recent advances of which you speak will be most helpful to those in the second two groups, as chemotherapy agents and radiation techniques have improved. That is why I cited the study that I did, despite its age. One of the conclusions is that higher SUV may not be as relevant as response to treatment and degree of reduction in SUV post-treatment. The only element that may have changed is that better therapies may have increased the number of patients whose cancer is controlled and whose SUV has significantly decreased. The response to subsequent treatment remains a more important factor, according to that meta-analysis.

[continued in following post]

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

JimC
[continued from previous post

[continued from previous post]

In your situation, a relatively high SUV is a negative prognostic factor. It probably increases your chance of recurrence. But so far, your cancer has not recurred, and that is terrific; the longer you go without recurrence, the better your chance to reach five-year survival. If you do recur, your response to treatment will be critical. If you are eight months out from surgery, your chances likely are already better than 9 percent, since one would expect a particularly aggressive cancer to recur sooner rather than later.

You have stated that you have read recent studies linking high SUV with decreased survival, although you no longer have the links, but that Dr. West or other medical professionals would/should be familiar with them. I will respectfully disagree with you on this point. Oncologists review many studies, but they focus on the conclusions which may have an effect on clinical practice and/or further research. The effect of a particular marker/factor tends to be looked at in terms of median time to progression or median survival rather than a percentage chance of reaching five years. For example, if a patient is two years out from surgery, no matter what the initial SUV that patient's chance of five-year survival is most likely much higher than 9 percent, as the risk of recurrence drops significantly as time goes on. As Dr. Weiss stated, such a study might only be critical to oncology practice in the sense that it may dictate treatment choices. If you had links, it would be easier for us to provide some interpretation, but since the doctors here contribute their time without charge, it is not practical for them to spend large amounts of their time to find those particular studies.

[continued in the following post]

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

JimC
[continued from previous post

[continued from previous post]

That is why the discussion turned to adjuvant therapy; the higher SUV may lead to a certain choice of treatment. For example, a high SUV in a stage II resected tumor will make adjuvant therapy more advisable, although the same risk/benefit considerations you faced would also apply. Since you had already very reasonably declined adjuvant therapy, your non-recurrence is now a much more significant factor, and if you do recur, your response to treatment will be as well.

Several years ago our friend Neil, one of the original GRACE moderators, posted this non-scientific take on survival statistics: http://cancergrace.org/forums/index.php?topic=826.msg4326#msg4326

Please do not feel any need to respond if you feel that this information duplicates what already has been provided.

JimC

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

me53
Jim, I understand what the

Jim, I understand what the statistics mean, even if I've summarized it in a way that's more clear cut. I do really want an answer to the recent study info, how it integrates with TNM staging prognosis. My feedback/thought is that moderators who are not doctors are great for answering questions to which they know the answer, questions which have come up before, and for which they can access answers. This is likely a large variety of questions. When novel questions come up, and questions that are asking for medical -level analysis/view, interpreting recent results, I think that is where a moderator should flag the question and pass it along to the doctors "supra-monitoring" the site. Where, as here, even the first doctor you passed it to professed not knowing the answer (yet you and others keep posting as if YOU know, and in good faith but not helpfully throwing in things), then seeing if there is a doctor on the forum who follows this info and can put it in context would seem appropriate and helpful. Especially considering how much effort I have put in trying to get this info, how much repetitive "what about chemo," "what does prognosis really mean," "everyone's different" long posts that I have spent my finite energy addressing and asking over and over for it to stop, for just an answer to my question by someone in a position to know, it is staggering to me, I think this site used to be called Ask Dr. West, which is why I thought of it as a source of doctor info - as I repeatedly pointed out, my question to be answered requires someone who is a professional to do so; much misinformation has been spouted and that doesn't help anyone, nor does separating an answer so far from the question. Since you posted, I'll add you keep throwing in anapposite items - I am not asking about effect of treatment response suv, that is different; my question, and its parameters, were really very clear, and a medical professional is more likely to have understood that. Please s

me53
I guess to finish commenting

I guess to finish commenting on the things you are posting, I am not at all sure what effect going 8 months has - metastasis peaks at 1.5 years, and doesn't usually start till end of 10th month -- but that is not my question. You are making assumptions about the importance of the suv findings which I do not share -- any doctor following lung cancer, beyond a narrow chemo view, will know of them I think and could put this NEWly established info into context for a cancer patient who is in my position -- it is part of understanding prognosis, and potentially a newer, additional tool and I want to know how it intersects with TNM staging -- my question was short and deserved to be reviewed by someone who knows re this -- if Dr. West himself doesn't know, I'd think it's something he would want to take a look at, but I'd suspect he does. You have tortured me with so much time typing and responding to people who are not in a position to answer the question but feel free to keep trying to get me to accept their take or that "no one knows" or can -- this is just not true coming from a lay person. Stop making my question buried in extraneous, voluminous extraneous stuff calling it into question as a question -- that you are making assumptions dr. west would not be familiar with these studies is rich and really not your place in my view. And adjuvant chemo does not aid survival more than 5% or so, so something that does not help 95% of those who take it is hardly worth so much talking about, especially as you know I chose not to do it; it's also not clear how suv correlates to response to chemo, but it may mean higher suv less response, I don't really care it is not my question or my situation. (and as to tki's, 53-61% respond to alk meds meaning a significant portion don't -- it's like all the drug discussion assumes you will be kept alive, but for many people, you are not; general chemo close to 70% don't reply -- but, again, it has nothing to do with MY question.

onthemark
The 5 year survival rate of

The 5 year survival rate of stage 3B lung cancer is not 9% as has been erroneously reported in this thread. I hope whoever might stumble across this wouldn't get unduly discouraged by this incorrect information.

According to the "The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in theForthcoming (Eighth) Edition of the TNMClassification for Lung Cancer"

report in 2016, the 5 year survival rate of stage 3B lung cancer is

19% (according to 7th edition criteria)
26% (according to 8th edition criteria)

The eight edition made some changes including introducing the new category stage 3C, which has lower survival. This is why survival for 3B went up in 8th ed. compared to 7th.

I know about these changes because my category also changed for different reasons.

https://www.ncbi.nlm.nih.gov/pubmed/26762738

ME53, if you want to challenge this please provide a publication for reference.

me53
What an odd tone for a post

What an odd tone for a post of this nature. Thank you for posting proposals for changing the TNM prognosis guidelines -- whether those proposals will be enacted should be established shortly, as what you post is from Sept. 2015 (and reprinted in Jan. 2016). My question itself remains, of course, which is the effect of primary tumor suv on tnm staging. Needless to say, multiple sources cite the current tnm %'s, the one relevant to me 9%.

me53
What you've posted really

What you've posted really should have its own thread for discussion. It is odd that they say 7th ed. has such high rates of survival for iiib - no where else has posted this - it is simply not accepted; perhaps it includes their alterations of staging (moving people from different stages by redefining them). The 8th edition should be out soon they say, we'll see then. Please let's set up a second page if you want to discuss this proposed change to staging and prognosis and keep this thread for my question for now. Odd no one in USA on their list (or maybe not!)

onthemark
I have already posted a paper

I have already posted a paper that shows that SUV max is not prognostic in stage 3 lung cancer. Indeed there are other recent papers showing the same. However other features of pre-treatment PET are found to be prognostic for stage III but not SUV max. You have not posted any papers to justify your claims. Why don't you read the paper I posted?

About the large database giving the survival stats for the 7th edition and 8th edition Stage IIIB (7th would have been in place in 2015) this is it:

"The new IASLC database has information on 94,708 new patients diagnosed of lung cancer between 1999 and 2010. They originated from 35 sources in 16 countries, and 4,667 were submitted via the online electronic data capture system. Europe contributed 46,560 patients, Asia: 41,705, North America: 4,660, Australia: 1,593, and South America: 190. After exclusions, 77,156 (70,967 with nonsmall cell lung cancer and 6,189 with small cell lung cancer) remained for analysis. This database will be analyzed according to established objectives for the T, the N, and the M components to inform the eighth edition of the TNM classification of lung cancer due to be published in 2016. "

https://www.ncbi.nlm.nih.gov/pubmed/25436796

Again you have not posted any paper to justify your use of 9% survival.

Maybe this is good news for you?

Dr West
I cannot give you exact

I cannot give you exact numbers, nor do I believe anyone can, because there are not large studies of people that get as granular as your question. Current staging analyses that provide prognostic assessments do not include either PET SUV or intracellular mucin because these are not reliable indicators in large studies, even if they are factors that tend to be associated with a worse prognosis.

I would consider it very likely that with T4 disease, very PET-avid disease in more than one node, the probability of recurrence is quite high -- not 100%, but likely higher than 90-95%. I don't think it's possible to put a finer point on it -- there just aren't data on populations of patients with T4, high SUV, adenosquamous NSCLC to guide expectations.

Good luck.
-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

me53
Thank you for helping me make

Thank you for helping me make sense of the data, Dr. West. I do wonder if tracking SUVmax within stages might be helpful as the spread within stages, even of high in stage I and low in stage IV suggests there might be a hidden connection (are the survivors in stage IV all or most low SUV? Do the high SUVmax in stage I partly account for its death rate)? Or perhaps your statement that they are not reliable indicators in large studies means it has been looked at...

Dr West
The trials basically show

The trials basically show that, stage for stage, patients with a poorly differentiated cancer and/or high SUV tend to do worse. I don't know that you can say that a high SUV accounts for a death rate, but there's a definite correlation -- it just hasn't been precisely quantified. It is fair to say that a low SUV on PET tends to go with a more indolent pattern of progression and longer survival, while a higher SUV is associated with a more rapid rate of progression, higher risk of recurrence in earlier stage, etc. -- it's just that there are definitely people with a high SUV cancer who never have their cancer recur after surgery or chemo/radiation, etc.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education