BACKGROUND AND PURPOSE:Low-dose CT screening of high-risk groups has been shown to reduce lung cancer mortality, and the European Council has therefore recommended that member states explore the feasibility and effectiveness of this approach. In this study, we evaluate the implementation of low-dose CT screening for lung cancer in a Swedish female population. Patient/material and methods: Women aged 54-74 years in the Southern Stockholm region were contacted via an electronic questionnaire. Individuals who met the same eligibility criteria as in the NELSON trial (a minimum smoking history of 15 pack-years) were invited. The screening consisted of a baseline low-dose computed tomography (LDCT) scan, with the option for a follow-up scan in cases with intermediate findings. Findings were managed in accordance with modified Fleischner Society guidelines. RESULTS:Between September 2022 and September 2024, 34,580 invitation letters were sent to randomly selected women aged 54-74 years 11,607 individuals (33.4%) completed the questionnaire, whereof 1,106 (10%) met the inclusion criteria. 990 (90%) individuals accepted the invitation and underwent a baseline low-dose CT scan. There were 152 intermediate and 55 positive scans at baseline, and additional eight positive scans at follow-up. Fifteen cases of Lung cancer were found, yielding a positive prediction value (PPV) of 24%. 87% of the lung cancers were in stage IA. INTERPRETATION:Organized lung cancer screening in a Swedish female population proved feasible, demonstrating a good participation rate, and a cancer detection rate consistent with findings from other major screening trials.

INTRODUCTION:A cancer diagnosis affects quality of life, including psychological wellbeing. The risk of depression and suicide has been found to be increased in cancer patients, especially in cancers with poor prognosis. The aim of this study was to examine a broad range of indicators of psychological distress pre- and post-diagnosis in patients with non-small cell lung cancer (NSCLC). METHODS:We used data in a population-based lung cancer research database to compare diagnostic events of depression, anxiety, intoxication, suicide attempt and suicide as well as filled prescriptions for anxiolytics, hypnotics, sedatives and antidepressants between patients with NSCLC and individuals free of lung cancer (comparators). RESULTS:The study population encompassed 47,625 patients diagnosed with NSCLC between January 2006 and May 2022 and 236,492 lung cancer free individuals. Diagnostic rates indicating psychological distress (depression, intoxication, suicide attempt, suicide) were higher in NSCLC patients after diagnosis. Already three months prior to diagnosis, fillings of prescriptions for anxiolytics, hypnotics and sedatives were more common in patients with NSCLC than in comparators and remained higher in the cases during the first year post diagnosis. Following diagnosis, rates of prescriptions for antidepressants were also higher in cases. For all medications except antidepressants, rates of filled prescriptions correlated with severity of disease. CONCLUSION:We found evidence of increased rates of both diagnostic events related to psychological distress and use of psychiatric medications after a diagnosis of NSCLC. Our findings underscore the importance of symptom monitoring post-diagnosis and preparedness to provide adequate support and treatment.

Importance:Lung cancer screening in high-risk populations reduces mortality, yet the effectiveness of a national screening program depends on equitable participation across socioeconomic and demographic groups. Objective:To investigate whether sociodemographic and socioeconomic factors are associated with participation across stages in a risk-based lung cancer screening pilot program in Sweden. Design, Setting, and Participants:Registry-linked cohort study conducted between September 2022 and May 2024. Participants were women aged 55 to 74 years residing in Region Stockholm, Sweden, who were invited to participate in a pilot program for risk-based lung cancer screening. Exposures:Sociodemographic and socioeconomic factors, including educational level, income, region of origin, and area-level living conditions. Main Outcomes and Measures:Three binary outcomes were examined across sequential stages of the screening pathway: (1) participation in the initial risk-assessment questionnaire, (2) meeting eligibility criteria for low-dose computed tomography (LDCT) screening, and (3) attendance at the LDCT examination among eligible women. Results:Of 34 592 invited women (mean [SD] age, 63.2 [5.6] years), 11 509 (33.3%) completed the questionnaire, 1104 (9.6%) met eligibility criteria, and 980 (88.8%) attended baseline LDCT. Participation in the initial questionnaire was higher among women with higher education (risk ratio [RR], 1.71; 95% CI, 1.59-1.84), higher income (RR, 1.72; 95% CI, 1.64-1.81), and residence in areas with favorable living conditions (RR, 1.59; 95% CI, 1.42-1.79). Conversely, women with higher income (RR, 0.64; 95% CI, 0.54-0.77) and education (RR, 0.38; 95% CI, 0.31-0.46) and those living in socioeconomically advantaged areas (RR, 0.55; 95% CI, 0.43-0.72) were less likely to meet the eligibility criteria for screening with LDCT. Among eligible women, attendance at the LDCT examination was largely equitable, with only minor differences by region of origin. Conclusions and Relevance:In this cohort study, attendance among eligible women was equitable regardless of sociodemographic and socioeconomic profile. However, participation in the initial risk-selection stage was socioeconomically patterned, suggesting that the design of the risk-assessment approach is critical for ensuring equitable access and inclusion of socioeconomically disadvantaged groups in a future national lung cancer screening program.

Background: In a previous study, we explored real-world programmed death-ligand 1 (PD-L1) testing and treatment patterns for patients with advanced non-small cell lung cancer (NSCLC) in the era of immune-oncology. The present study aimed to investigate overall survival (OS) with PD-(L)1 inhibitors with longer-term follow-up in the Swedish setting. Materials and methods: Data were extracted from the Swedish National Lung Cancer Registry for patients with NSCLC stage IIIB-IV and ECOG performance status (PS) 0–2 who initiated first-line systemic treatment from 1-April-2017 to 30-June-2021 with data cut-off 30-June-2022. OS and Kaplan–Meier estimates were calculated from start of the PD-(L)1 inhibitor therapy, with subgroups based on nonsquamous/squamous (NSQ/SQ) histology, and further by PS, and PD-L1 status (available from 1-January-2018) provided sufficient sample size. Results: We identified 784 (NSQ:590/SQ:194) patients treated with first-line PD-(L)1 inhibitor monotherapy and 369 (NSQ:305/SQ:64) patients receiving combination regimens. Median OS (95% confidence interval [CI]) was 15.2 (12.4–17.7) and 12.9 (10.6–15.8) months with monotherapy and 17.0 (13.6–23.9) and 18.0 (13.9-NA) months with combination regimens for NSQ/SQ patients. In PS2, median OS with monotherapy was 5.0 (3.7–7.1) and 8.9 (6.2–12.9) months for NSQ/SQ patients (n = 138/59), 5.3 (3.6–13.4) months with combination regimens in NSQ (n = 58) and not evaluable in SQ patients. For PS0-1 patients with tumor cell PD-L1 expression ≥50%, the median OS for NSQ was 23.8 (17.7–29.3) and 27.3 (21.6-NA) months for monotherapy/combination therapy (n = 281/55), while the median OS for combination regimens for PD-L1 <1% and 1–49% was 18.6 (12.1–26.9) and 15.9 (10.8–26.7) months (NSQ; n = 65/87). Interpretation: Real-world OS in Swedish patients receiving first-line PD-(L)1 inhibitor-based regimens was consistent with that observed in clinical trials. Moderate OS rates were observed in PS2, with limited sample sizes. Further research is needed in these patients, as well as in high PD-L1, given the slightly longer OS for combination therapy compared to monotherapy seen for NSQ.

BACKGROUND:We investigated the impact of time to adjuvant chemotherapy (AC) on survival after surgical resection (<8 weeks or 8-16 weeks) for patients with non-small cell lung cancer (NSCLC) by applying a target-trial emulation. MATERIAL AND METHODS:We used Swedish population-based healthcare registries to emulate a hypothetical target trial, with treatment arms of 'initiate AC <8 weeks postoperatively' and 'initiate AC 8-16 weeks postoperatively'. The clone-censor-weight approach was used in which all patients were cloned and all clones were assigned to each treatment arm. Clones were then censored when the assigned treatment was no longer compatible with the actual treatment. RESULTS:We included 510 patients in the hypothetical target trial, of whom 51% received AC and 150 (57%) started AC within 8 weeks. More than half of the patients were female (52.5%) and the mean age was 69 years. The 5-year disease-free survival (DFS) in the emulated trial for the group who initiated AC <8 weeks postoperatively was 50.3% and the 5-year overall survival (OS) was 58.1%. For the group who initiated AC 8-16 weeks postoperatively, the emulated trial showed a 5-year DFS and OS of 49.1% and 57.1%, respectively. CONCLUSION:By using target trial emulation, our study supports earlier data on timing for AC after surgical resection for NSCLC. However, further research is needed and our data indicate that a randomized controlled trial could be conducted without major harm to the experimental group (>8 weeks).

Non-small-cell lung cancer (NSCLC) is the leading cause of cancer-related death worldwide, with ~40–50% of patients diagnosed with non-metastatic disease (stages IA–IIIC). The treatment landscape is evolving rapidly as immunotherapies and targeted therapy are introduced in the non-metastatic setting, creating a need to assess patient outcomes prior to their introduction. This real-world study using Swedish National Lung Cancer Registry data examined outcomes (overall survival (OS) and time to next treatment or death (TTNTD)) and treatment patterns for adults diagnosed with non-metastatic NSCLC. Baseline characteristics and OS from diagnosis were described for all patients; OS, treatment patterns, and TTNTD from treatment start were described for the treatment subgroup (patients diagnosed from 2014 onwards), stratified by disease stage and initial treatment. OS and TTNTD were described using the Kaplan–Meier estimator. The overall population (2008–2019) included 17,433 patients; the treatment subgroup included 5147 patients. Median OS (interquartile range) overall ranged from 83.3 (31.6–165.3) months (stage I patients) to 10.4 (4.3–24.2) months (stage IIIB patients). Among the treatment subgroup, median OS and TTNTD were longest among patients receiving surgery versus other anticancer treatments. These findings provide a baseline upon which to evaluate the epidemiology of non-metastatic NSCLC as newer treatments are introduced.

Background and purpose: The treatment landscape for patients with advanced non-small cell lung cancer (NSCLC) has evolved significantly since the introduction of immunotherapies. We here describe PD-L1 testing rates, treatment patterns, and real-world outcomes for PD-(L)1 inhibitors in Sweden. Materials and methods: Data were obtained from the Swedish National Lung Cancer Registry for patients with advanced NSCLC and Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0–2 who initiated first-line ­systemic treatment from 01 April 2017 to 30 June 2020. PD-L1 testing was available in the registry from 01 January 2018. Kaplan-Meier was used for overall survival (OS) by type treatment and histology. Results: A total of 2,204 patients with pathologically confirmed unresectable stage IIIB/C or IV NSCLC initiated first-line treatment, 1,807 (82%) with nonsquamous (NSQ) and 397 (18%) with SQ. Eighty-six per cent (NSQ) or 85% (SQ) had been tested for PD-L1 expression, a proportion that increased over time. The use of platinum-based therapy as first-line treatment decreased substantially over time while there was an upward trend for PD-(L)1-based therapy. Among patients with PS 0–1 initiating a first-line PD-(L)1 inhibitor monotherapy, the median OS was 18.6 and 13.3 months for NSQ and SQ NSCLC patients, respectively, while for the PD-(L)1 inhibitor and chemotherapy combination regimen, the median OS was 24.0 months for NSQ and not evaluable for SQ patients. Interpretation: The majority of advanced NSCLCs in Sweden were tested for PD-L1 expression. Real-world OS in patients with PS 0–1 receiving first-line PD-(L)1 inhibitor-based regimens was similar to what has been reported in pivotal clinical trials on PD-(L)1 inhibitors.

Around 40%-50% of patients with NSCLC are diagnosed with non-metastatic disease (stages I-III). Considering the rapidly expanding treatment landscape for non-metastatic NSCLC, there is a need to characterise treatment pathways and survival outcomes in these patients. We report on a multi-country analysis of real-world patient characteristics, initial treatment, and overall survival (OS) for patients diagnosed with non-metastatic NSCLC between 2008 and 2020.

In a nation-wide cohort of NSCLC patients, reflex tested for driver mutations by NGS, we present detailed results on demographics, clinical baseline characteristics and survival associated with KRAS mutation status. We demonstrate significant differences between patients with KRAS G12C and other KRAS mutations related to male-female sex distribution, metastatic patterns associated with CNS disease, and impact on overall survival. Background: Real-world data on demographics related to KRAS mutation subtypes are crucial as targeted drugs against the p.G12C variant have been approved. Method: We identified 6183 NSCLC patients with reported NGSbased KRAS status in the Swedish national lung cancer registry between 2016 and 2019. Following exclusion of other targetable drivers, three cohorts were studied: KRAS-G12C (n = 848), KRAS-other (n = 1161), and driver negative KRAS-wild-type (wt) (n = 3349). Results: The prevalence of KRAS mutations and the p.G12C variant respectively was 38%/16% in adenocarcinoma, 28%/13% in NSCLC-NOS and 6%/2% in squamous cell carcinoma. Women were enriched in the KRAS-G12C (65%) and KRAS-other (59%) cohorts versus KRAS-wt (48%). A high proportion of KRASG12C patients in stage IV (28%) presented with CNS metastasis (vs. KRAS-other [19%] and KRAS-wt [18%]). No difference in survival between the mutation cohorts was seen in stage I-IIIA. In stage IV, median overall survival (mOS) from date of diagnosis was shorter for KRAS-G12C and KRAS-other (5.8 months/5.2 months) vs. KRAS wt (6.4 months). Women had better outcome in the stage IV cohorts, except in KRAS-G12C subgroup where mOS was similar between men and women. Notably, CNS metastasis did not impact survival in stage IV KRAS-G12C, but was associated with poorer survival, as expected, in KRAS-other and KRAS-wt. Conclusion: The KRAS p.G12C variant is a prevalent targetable driver in Sweden and significantly associated with female sex and presence of CNS metastasis. We show novel survival effects linked to KRAS p.G12C mutations in these subgroups with implications for clinical practice.

KRAS mutations represent common genetic driver aberrations in NSCLC. Real world data on demographics and outcome linked to different KRAS mutation subtypes is crucial as targeted drugs against the p.G12C variant become available in clinical practice. We used data from the National Swedish Lung Cancer Registry to evaluate 6183 patients diagnosed with NSCLC during 2016-2019 with reported NGS-based KRAS-status. Following exclusion of other targetable driver aberrations, three cohorts were studied further with regard to age, sex, smoking status, disease stage, performance status, histology, metastatic patterns and overall survival (OS, from diagnosis); KRAS-G12C (n=848), KRAS-other (n = 1161), driver negative (WT, n = 3349). Study sponsored by Amgen. The prevalence of KRAS driver mutations and KRAS-G12C respectively was 32%/14% in NSCLC, 38%/16% in adenocarcinoma, 28%/13% in NSCLC-NOS and 6%/2% in squamous cell carcinoma. Women were more common in the KRAS-G12C cohort (65%) compared to KRAS-other (59%) and WT (48%). Never smokers were rare in KRAS-G12C (2.5%) as opposed to KRAS-other and WT patients (7.2% and 12.3%). A high percentage of KRAS-G12C patients in stage IV (28%) had CNS metastases at diagnosis compared to KRAS-other or WT (19% and 18%). In stage I–IIIA disease we found no differences in OS between the three cohorts. In stage IV, both KRAS-G12C (5.8 months) and KRAS-other (5.2 months) had shorter median OS than the WT group (6.4 months). Women had better outcome in all stage IV mutational subgroups except in KRAS-G12C where OS was comparable between men and women (median 6.6 vs 6.1 months). Stage IV patients with KRAS-G12C, with and without CNS metastases had similar OS (median 6.1 months vs 6.2 months), as opposed to KRAS-other and WT where CNS metastasis was associated with poorer survival. In an unselected Swedish NSCLC population the KRAS-G12C mutation was associated with female sex, smoking, adenocarcinoma histology and linked to presence of CNS metastases. The relationship between OS, female sex and CNS metastases at diagnosis in the KRAS-G12C subgroup need to be further explored with regard to biological mechanisms and confounding clinical factors.

Since the introduction of immune-oncology therapies (IO) as treatment for advanced non-small cell lung cancer (aNSCLC), the treatment landscape for patients with aNSCLC has evolved significantly. This study aims to describe the PD-L1 testing rates, treatment patterns and associated real-world outcomes in the Swedish setting.

Background Results from studies addressing age-related patterns of cancer care have found evidence of unjustified differences in management between younger and older patients. Methods We examined associations between age and clinical presentation, management and mortality in patients diagnosed with non-small cell lung cancer (NSCLC) between 2002 and 2016. Analyses were adjusted for comorbidity and other factors that may have affected management decisions and outcomes. Results The study population encompassed 40,026 patients with NSCLC. Stage at diagnosis did not differ between age groups <= 84. The diagnostic intensity was similar in age groups <80 years. In patients with stage IA-IIB disease and PS 0-2, surgery was more common in the youngest age groups and decreased with increasing age, and was rarely performed in those >= 85 years. The use of stereotactic body radiotherapy (SBRT) increased with age (<= 69 years 5.4%; >= 85 years 35.8%). In patients with stage IIIA disease and PS 0-2, concurrent chemoradiotherapy was more common in younger patients (<= 69 years 55.3%; >= 85 years 2.2%). In stage IA-IIIA disease, no major differences in treatment-related mortality was observed. In stage IIIB-IV and PS 0-2, chemotherapy was more common in patients <80 years. However, 58.1% of patients 80-84 years and 30.3% >= 85 years received treatment. In stage IA-IIIA, overall and cause-specific survival decreased with increasing age. No age-differences in survival were observed in patients with stage IIIB-IV NSCLC. Conclusion Treatments were readily given to older patients with metastatic disease, but to a lesser degree to those with early stage disease. Significant differences in cause specific survival were observed in early, but not late stage disease. Our findings underscore the importance of individualized assessment of health status and life expectancy. Our results indicate that older patients with early stage lung cancer to a higher extent should be considered for curative treatment.

Background Lung cancer is the number one cancer-related cause of death in Sweden and worldwide. In most countries, five-year survival estimates vary between 10% and 20% with evidence of improved survival over time. Over the last decades, the management of lung cancer has changed including the introduction of national guidelines, new diagnostic procedures and treatments. This study aimed to investigate temporal trends in lung cancer survival both overall and in subgroups defined by established prognostic factors (i.e., sex, stage, histopathology and smoking history). Materials and methods We estimated one-, two-, and five-year relative survival, and excess mortality, in patients diagnosed with squamous cell carcinoma or adenocarcinoma of the lung between 1995 and 2016 in Sweden. We used population-based information available in a national lung cancer research database (LCBaSe) generated by cross-linkage between the Swedish National Lung Cancer Register and several Swedish health and sociodemographic registers. Results We included 36,935 patients diagnosed with squamous cell carcinoma or adenocarcinoma of the lung between 1995 and 2016. The overall one-, two- and five-year survival estimates increased between 1995 and 2016, from 38% to 53%, 21% to 37%, and 14% to 24%, respectively. Over the study period, we also found improved survival in subgroups, for example in patients with stages III-IV disease, patients with adenocarcinoma, and never-smokers. The excess mortality decreased over the study period, both overall and in all subgroups. Conclusion Lung cancer survival increased over time in the overall lung cancer population. Of special note was evidence of improved survival in patients with stage IV disease. Our results corroborate a previously observed global trend of improved survival in patients with lung cancer.

Objectives While studies have found lower cancer risks and better cancer survival in immigrant populations, it is debated whether cancer care is offered on equal terms to all residents regardless of background. Our aim was to study patterns of care and outcomes in immigrants in a country with a tax-financed universal health care system. Material and methods We used a population-based database to compare clinical presentation, management and mortality between Swedish-born and immigrant patients with non-small cell lung cancer (NSCLC). Analyses were adjusted for potential confounders. Results We identified 40,075 patients diagnosed with NSCLC of which 84% were born in Sweden, 7% in Nordic and 9% in Non-Nordic countries. Non-Nordic immigrants were to a higher extent male, smokers, younger at diagnosis, had a better performance status and a higher educational level. No differences were seen regarding comorbidity burden or stage at diagnosis. Non-Nordic immigrants more often underwent positron emission tomography (PET) (aHR 1.32; 95% CI 1.19–1.45) and were more often discussed in a multidisciplinary team setting (aHR 1.30; 95% CI 1.17–1.44). There were no differences in treatment modalities following adjustment for age, with the exception of concurrent chemoradiotherapy in stage IIIA disease which was more common in Non-Nordic immigrants (aOR 1.34; 95% CI 1.03–1.74). Both overall and cause specific survival in non-metastatic disease were higher among Non-Nordic immigrants. Overall mortality in stage I-II: HR 0.81; 95% CI 0.73–0.90 and stage IIIA: HR 0.75; 95% CI 0.65–0.86. Following full adjustments, cause-specific mortality in stage I-II was aHR 0.86, 95% CI 0.75–0.98. Conclusion Taken together, only minor differences in management and outcomes were observed between Swedish-born and immigrant patients. We conclude that lung cancer care is offered on equal terms. If anything, outcomes were better in Non-Nordic immigrants with early stage NSCLC.

Linda Will en , Anders Berglund , Stefan Bergstr€ om , Johan Isaksson , Michael Bergqvist , Gunnar Wagenius and Mats Lambe Center for Research and Development, Uppsala University/Region G€avleborg, G€avle, Sweden; Department of Radiation Sciences and Oncology, Umeå University, Umeå, Sweden; Department of Oncology, G€avle Hospital, G€avle, Sweden; EpiStat, Uppsala, Sweden; Department of Pulmonary Medicine, G€avle Hospital, G€avle, Sweden; Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden; Division of Oncology, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Regional Cancer Center Central Sweden, Uppsala, Sweden

Aim To examine patterns of recent pre-diagnostic fillings of antibiotics as an indicator of early symptoms of lung cancer. Methods Individuals diagnosed with lung cancer (cases) in 2009–2016 were identified in the Swedish National Lung Cancer Register, a population-based register, and randomly matched with up to five individuals free of lung cancer (controls) from the general population. Conditional logistic models were used to estimate odds ratios for the association between lung cancer and a recent history of filled antibiotic prescriptions. Results The study included 27,017 cases and 129,355 controls. The likelihood of recent exposure was approximately two times higher in cases compared to controls. The magnitude of the effect size became more pronounced with proximity to the diagnosis of lung cancer and an increasing number of filled prescriptions. While the magnitude of the effect size did not differ by sex or educational level, it became attenuated with increasing age. There was no evidence supporting a trend in the magnitude of the effect size for the association between lung cancer and a history of repeated fillings by cancer stage. Conclusion Lung cancer was associated with an increased likelihood of a recent history of filled antibiotic prescriptions. However, there was no evidence of an association between repeated fillings and a diagnostic delay, as reflected by stage. Our findings underscore the importance of clinical reassessment to rule out lung cancer following pneumonia treatment, especially for patients with multiple treatment cycles.