Importance: Despite a growing population of survivors of lung cancer, there is limited understanding of the survivorship journey. Survivors of lung cancer experience unmet physical, social, emotional, and medical needs regardless of stage at diagnosis or treatment modalities.Objective: To investigate the association of unmet needs with quality of life (QOL) and financial toxicity (FT) among survivors of lung cancer.Design, Setting, and Participants: This survey study was conducted at Johns Hopkins Sidney Kimmel Comprehensive Cancer Center thoracic oncology clinics between December 1, 2020, and September 30, 2021, to assess needs (physical, social, emotional, and medical), QOL, and FT among survivors of lung cancer. Patients had non–small cell lung cancer of any stage and were alive longer than 1 year from diagnosis. A cross-sectional survey was administered, which consisted of an adapted needs survey developed by the Mayo Survey Research Center, the Comprehensive Score for Financial Toxicity measure, and the European Organization for Research and Treatment of Cancer QLQ-C30 QOL scale. Demographic and clinical information was obtained through retrospective medical record review. Data analysis was performed between May 9 and December 8, 2022.Main Outcomes and Measures: Separate multiple linear regression models, treating QOL and FT as dependent variables, were performed to assess the adjusted association of total number of unmet needs and type of unmet need (physical, emotional, social, or medical) with QOL and FT.Results: Of the 360 survivors of lung cancer approached, 232 completed the survey and were included in this study. These 232 respondents had a median age of 69 (IQR, 60.5-75.0) years. Most respondents were women (144 [62.1%]), were married (165 [71.1%]), and had stage III or IV lung cancer (140 [60.3%]). Race and ethnicity was reported as Black (33 [14.2%]), White (172 [74.1%]), or other race or ethnicity (27 [11.6%]). A higher number of total unmet needs was associated with lower QOL (β [SE], −1.37 [0.18]; P < .001) and higher FT (β [SE], −0.33 [0.45]; P < .001). In the context of needs domains, greater unmet physical needs (β [SE], −1.24 [0.54]; P = .02), social needs (β [SE], −3.60 [1.34]; P = .01), and medical needs (β [SE], −2.66 [0.98]; P = .01) were associated with lower QOL, whereas only greater social needs was associated with higher FT (β [SE], −3.40 [0.53]; P < .001).Conclusions and Relevance: The findings of this survey study suggest that among survivors of lung cancer, unmet needs were associated with lower QOL and higher FT. Future studies evaluating targeted interventions to address these unmet needs may improve QOL and FT among survivors of lung cancer.

In the United States, lung cancer is the third most common cancer and the overall leading cause of cancer death. Due to advances in immunotherapy and targeted therapy, 5-year survival is increasing. The growing population of patients with lung cancer and cancer survivors highlights the importance of comprehensive cancer care, including recognizing and addressing financial toxicity. Financial toxicity is a term used to contextualize the negative effects of the costs of cancer treatment in terms of patient quality of life. The American Society of Clinical Oncology (ASCO) Value Framework places emphasis on high-value care as it evaluates cancer treatments “based on clinical benefit, side effects, and improvements in patient symptoms or quality of life in the context of cost”. Prior studies have shown that risk factors for financial toxicity in patients with lung cancer include lower household income or savings, inability to afford basic necessities, higher than anticipated out of pocket expenses, and taking sick leave. Among lung cancer survivors, patients experience increased unemployment and lower wages compared to the general population underscoring the lasting effects of financial toxicity. Financial toxicity is associated with increased psychosocial distress and decreased quality of life, and bankruptcy is an independent predictor of mortality in patients with cancer. Despite the negative implications of financial toxicity on patients, standardized screening practices and evidence-based interventions are lacking. The “COmphrensive Score for financial Toxicity (COST)” tool has been validated for assessing financial toxicity with correlation with health-related quality of life. Further research is needed to understand the utility of incorporating routine screening for financial toxicity into clinical practice and the efficacy of interventions. Understanding the relationship between financial toxicity and quality of life and survival is critical to providing high-value cancer care and survivorship care.

Anti-PD-(L)1 immune checkpoint inhibitors (ICI) improve survival in patients with advanced non-small cell lung cancer (aNSCLC). The clinical features, survival, and burden of toxicities of patients with aNSCLC alive >1 year from ICI initiation are poorly understood. We defined ICI survivors as patients alive >1 year after ICI start and retrospectively reviewed demographics, treatment, and immune-related adverse events (irAEs). Long-term irAEs were defined as ongoing irAEs lasting >1 year; burden of toxicity measures were based on percentage of days a patient experienced toxicity. Using linear and logistic regression, we evaluated association between demographics and disease characteristics with burden of toxicity. We identified 114 ICI survivors from 317 patients with aNSCLC. Half (52%) experienced an irAE of any grade, and 23.7% developed long-term irAEs. More ICI survivors with irAES in the first year had never smoked (P = .018) or received ICIs as frontline therapy (P = .015). The burden of toxicity in the first year significantly correlated with the burden of toxicity afterward (ρ = 0.72; P < .001). No patients with progressive disease had a high burden of toxicity, and they experienced 30.6% fewer days with toxicity than those with stable disease. Increased duration of therapy was associated with higher odds of experiencing toxicity. Half of ICI survivors with irAEs were still receiving treatment for unresolved irAEs at time of death or last follow-up. Significant proportions of ICI survivors have unresolved long-term toxicities. These data support a growing need to understand long-term toxicity to optimize management of those treated with ICIs.

PURPOSE: Oncofertility counseling regarding the reproductive risks associated with cancer therapy is essential for quality cancer care. We aimed to increase the rate of oncofertility counseling for patients of reproductive age (18-40 years) with cancer who were initiating systemic therapy at the Johns Hopkins Cancer Center from a baseline rate of 37% (25 of 68, June 2019-January 2020) to 70% by February 2021. METHODS: We formed an interprofessional, multidisciplinary team as part of the ASCO Quality Training Program. We obtained data from the electronic medical record and verified data with patients by phone. We surveyed patients, oncologists, and fertility specialists to identify barriers. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles. RESULTS: We identified the following improvement opportunities: (1) oncologist self-reported lack of knowledge about counseling and local fertility preservation options and (2) lack of a standardized referral mechanism to fertility services. During the first PDSA cycle (February 2020-August 2020, disrupted by COVID-19), we introduced the initiative to increase oncofertility counseling at faculty meetings. From September 2020 to November 2020, we implemented a second PDSA cycle: (1) educating and presenting the initiative at Oncology Grand Rounds, (2) distributing informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. In the third PDSA cycle (December 2020-February 2021), we redesigned the order set to add information (eg, contact information for fertility coordinator) to the patient after-visit summary. Postimplementation (September 2020-February 2021), counseling rates increased from 37% to 81% (38 of 47). CONCLUSION: We demonstrate how a trainee-led, patient-centered initiative improved oncofertility care. Ongoing work focuses on ensuring sustainability and assessing the quality of counseling.

Lung cancer is the leading cause of cancer-related death worldwide, and patients with operable early-stage NSCLC are typically managed surgically. While effective, surgical resection can significantly impact pulmonary function and quality of life. Pulmonary rehabilitation (PR) is a comprehensive, multimodal approach that is an established cornerstone in the treatment of COPD. It has similarly demonstrated multiple benefits in patients with lung cancer who have undergone lobectomy or resection by improving pulmonary function, increasing exercise tolerance, improving nutritional status, providing psychological support, and enhancing quality of life. Despite this, PR for early-stage operable NSCLC is oftentimes not standardized, and challenges to adherence remain. In this review, we examine the components of PR, the role of PR in pre- and postoperative settings in patients with early-stage NSCLC, implementation strategies for PR, and future directions and challenges of PR in operable NSCLC.