Lung cancer in Teesside (UK) and Varese (Italy): a comparison of management and survival

Survival Analysis of Lung Cancer: A 10-Year Real-Life Experience in a Non-University-Based Hospital in Thailand (2012-2021)

BACKGROUND

Over the past decades, several studies have mostly revealed that the overall survival among patients with lung cancer in university hospitals remained poor. However, the data on real-world treatments in non-university tertiary hospitals in Thailand still needs to be discovered. The primary objective was to assess the 10-year real-life overall survival among patients with lung cancer in a non-university hospital.

METHODS

A retrospective cohort study assessed patients diagnosed with lung cancer from a hospital-based lung cancer registry from January 2012 to December 2021 at Hatyai Hospital, Songkhla, Thailand. The demographic data and treatment outcomes were recorded. Kaplan-Meier methods were used for overall survival (OS), and a Log-rank test was used to compare the differences in survival based on different categories of prognostic factors. The prognostic factors for OS were assessed using a Cox-proportional hazard model.

RESULTS

Of 1,528 patients, the median age was 63.2± 12.1years; 1,009 (66%) were male; 981 (64%) had a history of smoking; 1,433 (93.7)% were non-small-cell lung cancer (NSCLC); 1,327 (87%) presented with stage IV disease. The median OS was 7.8 months for all patients, eight months for those with NSCLC, and 6.4 months for those with small cell lung cancer (SCLC). The 1-year, 3-year, and 5-year cumulative survival rates with all patients were 38%, 11%, and 6%. With NSCLC, 39%, 12%, and 6%, whereas for those with SCLC, 29%, 5%, and 4%, respectively. Disease stage III/IV and male gender were significantly associated with an increased risk of death, whereas receiving 1-2 line systemic treatments and curative surgical resection was a significant factor for survival in lung cancer patients.

CONCLUSION

In Thailand, the OS in patients with lung cancer has remained low over the decade. However, providing specific-lung cancer therapies and undergoing curative surgery remains a significant factor in improving their survival.

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Survival of cancer patients with pre-existing heart disease

BACKGROUND

While cancer outcomes have improved over time, in Northern Ireland they continue to lag behind those of many other developed economies. The role of comorbid conditions has been suggested as a potential contributory factor in this but issues of data comparability across jurisdictions has inhibited efforts to explore relationships. We use data from a single jurisdiction of the UK using data from - the Northern Ireland Cancer Registry (NICR), to examine the association between mortality (all-cause and cancer specific) and pre-existing cardiovascular diseases among patients with cancer.

MATERIALS AND METHODS

All patients diagnosed with cancer (excluding non-melanoma skin cancer) between 2011 and 2014 were identified from Registry records. Those with a pre-existing diagnosis of cardiovascular diseases were identified by record linkage with patient hospital discharge data using ICD10 codes. Survival following diagnosis was examined using descriptive statistics and Cox proportional hazards regression analyses. Analyses examined all-cause mortality and cancer specific mortality for lung, colorectal, breast and prostate cancer. As well as cardiovascular diseases, regression models controlled for age, gender (where appropriate), deprivation (as quintiles), stage at diagnosis and other comorbidities.

RESULTS

Almost 35,000 incident cancer cases were diagnosed during the study period of which approximately 23% had a prior heart condition. The pan-cancer hazard ratio for death in the presence of pre-existing cardiovascular diseases was 1.28 (95% CI: 1.18-1.40). All-cause and cancer specific mortality was higher for patients with cardiovascular diseases across lung, female breast, prostate and colorectal cancer groups after controlling for age, gender (where appropriate), deprivation (as quintiles), stage at diagnosis and other comorbidities.

CONCLUSION

Pre-existing morbidity may restrict the treatment of cancer for many patients. In this cohort, cancer patients with pre-existing cardiovascular diseases had poorer outcomes than those without cardiovascular diseases. A high prevalence of cardiovascular diseases may contribute to poorer cancer outcomes at a national level.

Impact on survival of modelling increased surgical resection rates in patients with non-small-cell lung cancer and cardiovascular comorbidities: a VICORI study

Background

The impact of cardiovascular disease (CVD) comorbidity on resection rates and survival for patients with early-stage non-small-cell lung cancer (NSCLC) is unclear. We explored if CVD comorbidity explained surgical resection rate variation and the impact on survival if resection rates increased.

Methods

Cancer registry data consisted of English patients diagnosed with NSCLC from 2012 to 2016. Linked hospital records identified CVD comorbidities. We investigated resection rate variation by geographical region using funnel plots; resection and death rates using time-to-event analysis. We modelled an increased propensity for resection in regions with the lowest resection rates and estimated survival change.

Results

Among 57,373 patients with Stage 1−3A NSCLC, resection rates varied considerably between regions. Patients with CVD comorbidity had lower resection rates and higher mortality rates. CVD comorbidity explained only 1.9% of the variation in resection rates. For every 100 CVD comorbid patients, increasing resection in regions with the lowest rates from 24 to 44% would result in 16 more patients resected and alive after 1 year and two fewer deaths overall.

Conclusions

Variation in regional resection rate is not explained by CVD comorbidities. Increasing resection in patients with CVD comorbidity to the levels of the highest resecting region would increase 1-year survival.

Management of patients with early stage lung cancer - why do some patients not receive treatment with curative intent?

Backgrounds

This study aims to understand the factors that influence whether patients receive potentially curative treatment for early stage lung cancer. A key question was whether indigenous Māori patients were less likely to receive treatment.

Methods

Patients included those diagnosed with early stage lung cancer in 2011–2018 and resident in the New Zealand Midland Cancer Network region. Logistic regression model was used to estimate the odds ratios of having curative surgery/ treatment. The Kaplan Meier method was used to examine the all-cause survival and Cox proportional hazard model was used to estimate the hazard ratio of death.

Results

In total 419/583 (71.9%) of patients with Stage I and II disease were treated with curative intent - 272 (46.7%) patients had curative surgery. Patients not receiving potentially curative treatment were older, were less likely to have non-small cell lung cancer (NSCLC), had poorer lung function and were more likely to have an ECOG performance status of 2+. Current smokers were less likely to be treated with surgery and more likely to receive treatment with radiotherapy and chemotherapy. Those who were treated with surgery had a 2-year survival of 87.8% (95% CI: 83.8–91.8%) and 5-year survival of 69.6% (95% CI: 63.2–76.0%). Stereotactic ablative body radiotherapy (SABR) has equivalent effect on survival compared to curative surgery (hazard ratio: 0.77, 95% CI: 0.37–1.61). After adjustment we could find no difference in treatment and survival between Māori and non-Māori.

Conclusions

The majority of patients with stage I and II lung cancer are managed with potentially curative treatment – mainly surgery and increasingly with SABR. The outcomes of those being diagnosed with stage I and II disease and receiving treatment is positive with 70% surviving 5 years.

Post-treatment survival difference between lobectomy and stereotactic ablative radiotherapy in stage I non-small cell lung cancer in England

BACKGROUND

Approximately 15%-20% of all non-small cell lung cancer (NSCLC) cases present with stage I disease. Surgical resection traditionally offers the best chance of a cure but some patients will not have this treatment due to older age, comorbidities or personal choice. Stereotactic ablative radiotherapy (SABR) has become an established curative intent treatment option for patients who are not selected for or do not choose surgery. The aim of this study is to compare survival at 90 days, 6 months, 1 year and 2 years for patients who received either lobectomy or SABR.

METHODS

We used data from the 2015 National Lung Cancer Audit database and linked with Hospital Episode Statistics and the radiotherapy dataset to identify patients with NSCLC stage IA-IB and performance status (PS) 0-2 who underwent surgery or SABR treatment. We assessed the likelihood of death at 90 days, 6 months, 1 year and 2 year after diagnosis and procedure date to observe survival between two patient groups.

RESULTS

We identified 2373 patients in our cohort, 476 of whom had SABR. The median difference between date of diagnosis and date of treatment for surgery patients was 17 days while for SABR patients it was 73 days. Increasing age and worsening PS were associated with having SABR rather than surgery. Survival between the two treatment modalities was similar early on but by 1-year people who had surgery did better than those who had SABR (adjusted ORs 2.12, 95% CI 1.35 to 2.31). This difference persisted at 2 years and when the analysis was restricted to patients aged <80 years and with PS 0 or 1 and stage IA only.

CONCLUSION

Our analysis suggests that patients who have lobectomy have a better survival compared with SABR patients; however, we found considerable delays in patients receiving SABR which may contribute to poorer long-term outcomes with this treatment option. Reducing these delays should be a key focus in development and reorganisation of services.

Investigation of the international comparability of population-based routine hospital data set derived comorbidity scores for patients with lung cancer

INTRODUCTION

The International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome.

METHODS

Linked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4-36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons.

RESULTS

It was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable.

CONCLUSION

The results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required.

Lung cancer in symptomatic patients presenting in primary care: a systematic review of risk prediction tools

BACKGROUND

Lung cancer is the leading cause of cancer deaths. Around 70% of patients first presenting to specialist care have advanced disease, at which point current treatments have little effect on survival. The issue for primary care is how to recognise patients earlier and investigate appropriately. This requires an assessment of the risk of lung cancer.

AIM

The aim of this study was to systematically review the existing risk prediction tools for patients presenting in primary care with symptoms that may indicate lung cancer DESIGN AND SETTING: Systematic review of primary care data.

METHOD

Medline, PreMedline, Embase, the Cochrane Library, Web of Science, and ISI Proceedings (1980 to March 2016) were searched. The final list of included studies was agreed between two of the authors, who also appraised and summarised them.

RESULTS

Seven studies with between 1482 and 2 406 127 patients were included. The tools were all based on UK primary care data, but differed in complexity of development, number/type of variables examined/included, and outcome time frame. There were four multivariable tools with internal validation area under the curves between 0.88 and 0.92. The tools all had a number of limitations, and none have been externally validated, or had their clinical and cost impact examined.

CONCLUSION

There is insufficient evidence for the recommendation of any one of the available risk prediction tools. However, some multivariable tools showed promising discrimination. What is needed to guide clinical practice is both external validation of the existing tools and a comparative study, so that the best tools can be incorporated into clinical decision tools used in primary care.

How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes

OBJECTIVE

European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.

DESIGN

Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.

SETTING

A total of 14 countries.

SUBJECTS

Consensus groups of PCPs.

MAIN OUTCOME MEASURES

Probability of initial presentation to a PCP for four clinical vignettes.

RESULTS

There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62).

CONCLUSIONS

There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

Resection rate of lung cancer in Teesside (UK) and Varese (Italy): a comparison after implementation of the National Cancer Plan

BACKGROUND

In a lung cancer survey in 2000 we showed significantly less favourable stage distribution and lower resection rate in Teesside (UK) than in the comparable industrialised area of Varese (Italy). Lung cancer services in Teesside were subsequently reorganised according to National Cancer Plan recommendations.

METHODS

For all new lung cancer cases diagnosed in Teesside (n=324) and Varese (n=260) during the 12 months October 2010 to September 2011 (hereafter 'the 2010 cohort'), demographic, clinico-pathological and disease management data were prospectively recorded using the same database and protocol as the 2000 survey. Findings were analysed focusing on resection rate.

RESULTS

In the 2010 cohort compared with 2000, both in Teesside and Varese emergency referral decreased (p<0.001), performance status improved (p<0.001), but cancer stage shift was not seen; resection rate improved in Teesside, from 7% to 11% (p=0.054), and was unchanged in Varese (24%). Moreover, in Teesside compared with Varese the stage distribution remained less favourable, stage I-II non-small cell lung cancer (NSCLC) proportion being respectively 12% and 19% (p=0.040), and resection rate in all lung cancers remained lower (11% and 24%; p<0.001). On multivariate analysis, resection predictors in Teesside were as follows: stage I-II NSCLC (OR 86.14; 95% CI 31.80 to 233.37), performance status 0-1 (OR 5.02; 95% CI 1.48 to 17.07), belonging to 2010 cohort (OR 2.85; 95% CI 1.06 to 7.64).

CONCLUSIONS

In Teesside the main independent predictor of resection was disease stage; in 2010-2011 compared with 2000, lung cancer service improved but stage shift did not occur, and resection rate increased but remained significantly lower than in Varese.

Inequalities in non-small cell lung cancer treatment and mortality

BACKGROUND

Non-small cell lung cancer (NSCLC) comprises approximately 85% of all lung cancer cases, and surgery is the preferred treatment for patients. The National Health Service established Primary Care Trusts (PCTs) in 2002 to manage local health needs. We investigate whether PCTs with a lower uptake of surgical treatment are those with above-average mortality 1 year after diagnosis. The applied methods can be used to monitor the performance of any administrative bodies responsible for the management of patients with cancer.

METHODS

All adults diagnosed with NSCLC lung cancer during 1998-2006 in England were identified. We fitted mixed effect logistic models to predict surgical treatment within 6 months after diagnosis, and mortality within 1 year of diagnosis.

RESULTS

Around 10% of the NCSLC patients received curative surgery. Older deprived patients and those who did not receive surgery had much higher odds of death 1 year after being diagnosed with cancer. In total, 69% of the PCTs were below the lower control limit of surgery and have predicted random intercepts above the mean value of zero of the random effect for mortality, whereas 40% were above the upper control limit of mortality within 1 year.

CONCLUSIONS

Our main results suggest the presence of clear geographical variation in the use of surgical treatment of NSCLC and mortality. Mixed-effects models combined with the funnel plot approach were useful for assessing the performance of PCTs that were above average in mortality and below average in surgery.

Is chest X-ray screening for lung cancer in smokers cost-effective? Evidence from a population-based study in Italy

Background

After implementation of the PREDICA annual chest X-ray (CXR) screening program in smokers in the general practice setting of Varese-Italy a significant reduction in lung cancer-specific mortality (18 %) was observed. The objective of this study covering July 1997 through December 2006 was to estimate the cost-effectiveness of this intervention.

Methods

We examined detailed information on lung cancer (LC) cases that occurred among smokers invited to be screened in the PREDICA study (Invitation-to-screening Group, n = 5815 subjects) to estimate costs and quality-adjusted life-years (QALYs) from LC diagnosis until death. The control group consisted of 156 screening-eligible smokers from the same area, uninvited and unscreened, who developed LC and were treated by usual care. We calculated the incremental net monetary benefit (INMB) by comparing LC management in screening participants (n = 1244 subjects) and in the Invitation-to-screening group versus control group.

Results

The average number of QALYs since LC diagnosis was 1.7, 1.49 and 1.07, respectively, in screening participants, the invitation-to-screening group, and the control group. The average total cost (screening + management) per LC case was higher in screening participants (€17,516) and the Invitation-to-screening Group (€16,167) than in the control group (€15,503). Assuming a maximum willingness to pay of €30,000/QALY, we found that the intervention was cost-effective with high probability: 79 % for screening participation (screening participants vs. control group) and 95 % for invitation-to-screening (invitation-to-screening group vs. control group).

Conclusions

Based on the PREDICA study, annual CXR screening of high-risk smokers in a general practice setting has high probability of being cost-effective with a maximum willingness to pay of €30,000/QALY.

An evaluation of the impact of large-scale interventions to raise public awareness of a lung cancer symptom

Introduction:

Long-term lung cancer survival in England has improved little in recent years and is worse than many countries. The Department of Health funded a campaign to raise public awareness of persistent cough as a lung cancer symptom and encourage people with the symptom to visit their GP. This was piloted regionally within England before a nationwide rollout.

Methods:

To evaluate the campaign's impact, data were analysed for various metrics covering public awareness of symptoms and process measures, through to diagnosis, staging, treatment and 1-year survival (available for regional pilot only).

Results:

Compared with the same time in the previous year, there were significant increases in metrics including: public awareness of persistent cough as a lung cancer symptom; urgent GP referrals for suspected lung cancer; and lung cancers diagnosed. Most encouragingly, there was a 3.1 percentage point increase (P<0.001) in proportion of non-small cell lung cancer diagnosed at stage I and a 2.3 percentage point increase (P<0.001) in resections for patients seen during the national campaign, with no evidence these proportions changed during the control period (P=0.404, 0.425).

Conclusions:

To our knowledge, the data are the first to suggest a shift in stage distribution following an awareness campaign for lung cancer. It is possible a sustained increase in resections may lead to improved long-term survival.

Comorbidities in lung cancer: prevalence, severity and links with socioeconomic status and treatment

BACKGROUND

Survival from lung cancer remains poor in Scotland, UK. Although the presence of comorbidities is known to influence outcomes, detailed quantification of comorbidities is not available in routinely collected audit or cancer registry data. The aim of the present study was to assess the prevalence and severity of comorbidities in patients with newly diagnosed lung cancer across four centres throughout Scotland using validated criteria.

METHODS

Between 2005 and 2008, all patients with newly diagnosed lung cancer coming through the multidisciplinary teams in four Scottish centres were included in the study. Patient demographics, WHO/Eastern Cooperative Oncology Group performance status, clinicopathological features and primary treatment modality were recorded.

RESULTS

Details of 882 patients were collected prospectively. The majority of patients (87.3%) had at least one comorbidity, the most common being weight loss (53%), chronic obstructive pulmonary disease (43%), renal impairment (28%) and ischaemic heart disease (27%). A composite score was produced that included both number and severity of comorbidities. One in seven patients (15.3%) had severe comorbidity scores. There were statistically significant variations in comorbidity scores between treatment centres and between non-small cell lung carcinoma treatment groups. Disease stage was not associated with comorbidity score.

CONCLUSIONS

There is a high prevalence of multiple, severe comorbidities in Scottish patients with lung cancer, and these vary by site and treatment group. Further research is needed to determine the relationship between comorbidity scores and survival in these patients.

A feasibility study examining the effect on lung cancer diagnosis of offering a chest X-ray to higher-risk patients with chest symptoms: protocol for a randomized controlled trial

BACKGROUND

In order to improve lung cancer survival in the UK, a greater proportion of resectable cancers must be diagnosed. It is likely that resectability rates would be increased by more timely diagnosis. Aside from screening, the only way of achieving this is to reduce the time to diagnosis in symptomatic cancers. Currently, lung cancers are mainly diagnosed by general practitioners (GPs) using the National Institute for Health and Clinical Excellence (NICE) guidelines for urgent referral for chest X-ray, which recommend urgent imaging or referral for patients who have one of a number of chest symptoms for more than 3 weeks. We are proposing to expand this recommendation to include one of a number of chest symptoms of any duration in higher-risk patients.

METHODS/DESIGN

We intend to conduct a trial of imaging in these higher-risk patients and compare it with NICE guidelines to see if imaging improves stage at diagnosis and resection rates. This trial would have to be large (and consequently resource-intensive) because most of these patients will not have lung cancer, making optimal design crucial. We are therefore conducting a pilot trial that will ascertain the feasibility of running a full trial and provide key information that will be required in order to design the full trial.

DISCUSSION

This trial will assess the feasibility and inform the design of a large, UK-wide, clinical trial of a change to the NICE guidelines for urgent referral for chest X-ray for suspected lung cancer. It utilizes a combination of workshop, health economic, quality of life, qualitative, and quantitative methods in order to fully assess feasibility.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01344005.

Enabling patients with respiratory symptoms to access chest X-rays on demand: the experience of the walk-in service in Corby, UK

BACKGROUND

UK clinical guidance for lung cancer (NICE 141) includes pathways for chest X-rays (CXRs). Many patients fulfilling the criteria do not receive one, either because they do not consult their doctor or because their doctor does not refer them. The town of Corby, UK, has particularly high incidence and mortality rates for lung cancer and was chosen as a pilot site for a new, patient-requested X-ray service.

METHODS

The number of community-initiated CXRs were compared before and after the introduction of the service and between similar geographical areas. Clinical data and patient questionnaires were analysed for those attending the service.

RESULTS

There was a 63% increase in the total number of community-initiated CXRs in Corby for the year following the introduction of the service, compared with the year before. This was statistically greater than in surrounding geographical areas. Corby General Practitioners also requested 47% more CXRs than in the previous year.

CONCLUSIONS

The implementation of the service was associated with a significant increase in the numbers of clinically indicated CXRs in an area of high lung cancer incidence and mortality. The service attracted a clinically appropriate population. The numbers of cancers detected were in line with statistical expectations.

Lung cancer survival in England: trends in non-small-cell lung cancer survival over the duration of the National Lung Cancer Audit

Background:

In comparison with other European and North American countries, England has poor survival figures for lung cancer. Our aim was to evaluate the changes in survival since the introduction of the National Lung Cancer Audit (NLCA).

Methods:

We used data from the NLCA to identify people with non-small-cell lung cancer (NSCLC) and stratified people according to their performance status (PS) and clinical stage. Using Cox regression, we calculated hazard ratios (HRs) for death according to the year of diagnosis from 2004/2005 to 2010; adjusted for patient features including age, sex and co-morbidity. We also assessed whether any changes in survival were explained by the changes in surgical resection rates or histological subtype.

Results:

In this cohort of 120 745 patients, the overall median survival did not change; but there was a 1% annual improvement in survival over the study period (adjusted HR 0.99, 95% confidence interval (CI) 0.98–0.99). Survival improvement was only seen in patients with good PS and early stage (adjusted HR 0.97, 95% CI 0.95–0.99) and this was partly accounted for by changes in resection rates.

Conclusion:

Survival has only improved for a limited group of people with NSCLC and increasing surgical resection rates appeared to explain some of this improvement.

Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007

BACKGROUND

The authors consider whether differences in stage at diagnosis could explain the variation in lung cancer survival between six developed countries in 2004-2007.

METHODS

Routinely collected population-based data were obtained on all adults (15-99 years) diagnosed with lung cancer in 2004-2007 and registered in regional and national cancer registries in Australia, Canada, Denmark, Norway, Sweden and the UK. Stage data for 57 352 patients were consolidated from various classification systems. Flexible parametric hazard models on the log cumulative scale were used to estimate net survival at 1 year and the excess hazard up to 18 months after diagnosis.

RESULTS

Age-standardised 1-year net survival from non-small cell lung cancer ranged from 30% (UK) to 46% (Sweden). Patients in the UK and Denmark had lower survival than elsewhere, partly because of a more adverse stage distribution. However, there were also wide international differences in stage-specific survival. Net survival from TNM stage I non-small cell lung cancer was 16% lower in the UK than in Sweden, and for TNM stage IV disease survival was 10% lower. Similar patterns were found for small cell lung cancer.

CONCLUSIONS

There are comparability issues when using population-based data but, even given these constraints, this study shows that, while differences in stage at diagnosis explain some of the international variation in overall lung cancer survival, wide disparities in stage-specific survival exist, suggesting that other factors are also important such as differences in treatment. Stage should be included in international cancer survival studies and the comparability of population-based data should be improved.

Increasing the surgical resection rate for lung cancer in the UK: the debate

SUMMARY The UK has historically had poorer survival statistics for lung cancer and, indeed, most other cancers than major comparator countries. While there have been modest improvements in survival for lung cancer patients internationally in recent years, the gap between the UK and a number of other western countries has not narrowed. In parallel with this, the surgical resection rate for lung cancer patients in the UK has historically been very much lower than those reported from many other countries. Since surgery is the treatment that is most likely to result in long-term survival, it seems likely that the two findings are related. It is also clear that resection rates vary widely across the UK, that there is a positive correlation between resection rate and survival and that when specialist thoracic surgeons are employed in lung cancer multidisciplinary teams, resection rates rise quickly and dramatically. Effective auditing of the standards of care through the National Lung Cancer Audit project has identified problems at a national and local level and, with support from professional bodies, the UK has nearly doubled the number of specialist thoracic surgeons since 2005. A dramatic increase in resection rates followed, from approximately 3000 per annum in 2005 to 5000 per annum in 2010. There are parallels with a wide range of nonsurgical interventions in lung and other cancers, pointing to the fact that efforts need to be made to ensure that all patients have access to the optimum care from an expert multidisciplinary clinical team at all stages of their care.

Social deprivation does not affect lung cancer stage at presentation or disease outcome

INTRODUCTION

Lung cancer mortality rates are higher in more deprived populations. This may simply reflect higher incidence of the disease, or additionally delayed presentation and worse outcomes amongst more deprived patients. Low socio-economic status (SES) has also been linked to cancer fatalism which might account for such differences. We determined the interaction between SES, patient's characteristics at presentation with lung cancer, and disease outcome at a large UK teaching hospital.

METHODS

Stage, PS at presentation, treatment and survival data, index of multiple deprivation score and ACORN group (geo-demographic segmentation tool) were analysed for 1432 patients.

RESULTS

There were no significant differences in stage or PS distribution by IMD quintile or ACORN group. When patients with stage I/II disease were considered, there were no differences in IMD or ACORN group for those undergoing or not undergoing surgical resection. Similarly when the whole cohort was considered, there were no differences in these parameters between those receiving and not receiving any anti-cancer therapy. There was a non-significant trend to lower IMD score (i.e. less deprivation) in the stage IIIb/IV patients receiving palliative chemotherapy compared to those not receiving chemotherapy. There was no significant difference in median survival or one-year survival according to IMD quintile or ACORN group.

CONCLUSION

In our patient cohort, deprivation does not appear to affect stage or performance status at presentation, nor survival from lung cancer. If cancer fatalism is more prevalent in deprived populations, this does not appear to lead to later diagnosis nor worse disease outcome.

Assessment of lung cancer mortality reduction after chest X-ray screening in smokers: a population-based cohort study in Varese, Italy

BACKGROUND

The effectiveness of screening for lung cancer (LC) in smokers on a population level, as distinct from the special circumstances that may apply in a randomized trial of selected volunteers, has not been thoroughly investigated. Here we evaluate by the standardized mortality ratio (SMR) indicator the impact of a chest X-ray (CXR) screening programme carried out at community level on LC mortality in smokers.

METHODS

All smokers of >10 pack-years, of both genders, ages 45-75 years, resident in 50 communities of the Province of Varese, Italy, screening-eligible, in 1997 were invited by their National Health Service (NHS) general practitioner physicians to a nonrandomized programme of five annual CXR screenings. The entire invitation-to-screen cohort (n=5815 subjects) received NHS usual care, with the addition of CXR exams in volunteer participants (21% of invitees), and was observed through December 2006. To overcome participants' selection bias of LC mortality assessment, for the entire invitation-to-screen cohort we estimated the LC-specific SMR, based on the local reference population receiving the NHS usual care.

RESULTS

Over the 8-year period 1999-2006, a total of 172 cumulative LC deaths were observed in the invitation-to-screen cohort; 210 were expected based on the reference population. Each year in the invited cohort the observed LC deaths were fewer than expected. The cumulative LC SMR was 0.82 (95% CI, 0.67-0.99; p=0.048), suggesting that LC mortality was reduced by 18% with CXR screening.

CONCLUSION

Implementation of a CXR screening programme at community level was associated with a significant reduction of LC mortality in smokers.

Eliciting symptoms interpreted as normal by patients with early-stage lung cancer: could GP elicitation of normalised symptoms reduce delay in diagnosis? Cross-sectional interview study

OBJECTIVES

To investigate why symptoms indicative of early-stage lung cancer (LC) were not presented to general practitioners (GPs) and how early symptoms might be better elicited within primary care.

DESIGN, SETTING AND PARTICIPANTS

A qualitative cross-sectional interview study about symptoms and help-seeking in 20 patients from three south England counties, awaiting resection of LC (suspected or histologically confirmed). Analysis drew on principles of discourse analysis and constant comparison to identify processes involved in interpretation and communication about symptoms, and explain non-presentation.

RESULTS

Most participants experienced health changes possibly indicative of LC which had not been presented during GP consultations. Symptoms that were episodic, or potentially caused by ageing or lifestyle, were frequently not presented to GPs. In interviews, open questions about health changes/symptoms in general did not elicit these symptoms; they only emerged in response to closed questions detailing specific changes in health. Questions using disease-related labels, for example, pain or breathlessness, were less likely to elicit symptoms than questions that used non-disease terminology, such as aches, discomfort or 'getting out of breath'. Most participants described themselves as feeling well and were reluctant to associate potentially explained, non-specific or episodic symptoms with LC, even after diagnosis.

CONCLUSIONS

Patients with early LC are unlikely to present symptoms possibly indicative of LC that they associate with normal processes, when attending primary care before diagnosis. Faced with patients at high LC risk, GPs will need to actively elicit potential LC symptoms not presented by the patient. Closed questions using non-disease terminology might better elicit normalised symptoms.

Exploring variations in lung cancer care across the UK--the 'story so far' for the National Lung Cancer Audit

The National Lung Cancer Audit was developed to improve the quality and outcomes of services for patients with lung cancer, knowing that outcomes vary widely across the UK and are poor compared to other western countries. After five years the audit is capturing approximately 100% of the expected number of incident cases across hospitals in England, Wales, Scotland, Northern Ireland and Jersey. Measures of process and outcome have improved over the audit period, such as the histological confirmation rate (64-76%), the proportion of patients discussed in a multidisciplinary team meeting (78-94%), and the proportion of patients having anti-cancer treatment (43-59%), surgical resection (9-14%) and small cell lung cancer chemotherapy (58-66%). These national averages hide wide variations between hospitals providing lung cancer care which cannot be accounted for by differences in casemix. This paper describes the evolution of the audit, and describes the ways in which it may have improved clinical practice.

A population-based cohort study of chest x-ray screening in smokers: lung cancer detection findings and follow-up

BACKGROUND

Case-control studies of mass screening for lung cancer (LC) by chest x-rays (CXR) performed in the 1990s in scarcely defined Japanese target populations indicated significant mortality reductions, but these results are yet to be confirmed in western countries. To ascertain whether CXR screening decreases LC mortality at community level, we studied a clearly defined population-based cohort of smokers invited to screening. We present here the LC detection results and the 10-year survival rates.

METHODS

The cohort of all smokers of > 10 pack-years resident in 50 communities of Varese, screening-eligible (n = 5,815), in July 1997 was invited to nonrandomized CXR screening. Self-selected participants (21% of cohort) underwent screening in addition to usual care; nonparticipants received usual care. The cohort was followed-up until December 2010. Kaplan-Meier LC-specific survival was estimated in participants, in nonparticipants, in the whole cohort, and in an uninvited, unscreened population (control group).

RESULTS

Over the initial 9.5 years of study, 67 LCs were diagnosed in screening participants (51% were screen-detected) and 178 in nonparticipants. The rates of stage I LC, resectability and 5-year survival were nearly twice as high in participants (32% stage I; 48% resected; 30.5% 5-year survival) as in nonparticipants (17% stage I; 27% resected; 13.5% 5-year survival). There were no bronchioloalveolar carcinomas among screen-detected cancers, and median volume doubling time of incidence screen-detected LCs was 80 days (range, 44-318), suggesting that screening overdiagnosis was minimal. The 10-year LC-specific survival was greater in screening participants than in nonparticipants (log-rank, p = 0.005), and greater in the whole cohort invited to screening than in the control group (log-rank, p = 0.001). This favourable long-term effect was independently related to CXR screening exposure.

CONCLUSION

In the setting of CXR screening offered to a population-based cohort of smokers, screening participants who were diagnosed with LC had more frequently early-stage resectable disease and significantly enhanced long-term LC survival. These results translated into enhanced 10-year LC survival, independently related to CXR screening exposure, in the entire population-based cohort. Whether increased long-term LC-specific survival in the cohort corresponds to mortality reduction remains to be evaluated.

TRIAL REGISTRATION NUMBER

ISRCTN90639073.

Variation in comorbidity and clinical management in patients newly diagnosed with lung cancer in four Scottish centers

BACKGROUND

Treatment and survival rates within Scotland for patients with lung cancer seem lower than in many other European countries. No study of lung cancer has attempted to specifically investigate the association between variation in investigation, comorbidity, and treatment and outcome between different centers.

METHODS

Patient demographics, World Health Organization/Eastern Cooperative Oncology Group performance status, and primary treatment modality were recorded. In addition to recording the comorbidities present in each patient, the severity of each comorbidity was graded on a 4-point scale (0-3) using validated severity scales. Data were collected as the patient was investigated and entered in an anonymized format into a database designed for the study.

RESULTS

Prospectively collected data from 882 patients diagnosed with lung cancer in four Scottish centers. A number of statistically significant differences were identified between centers. These included investigation, treatment between centers (i.e., surgical rates), age, tumor histology, smoking history, socioeconomic profile, ventilatory function, and performance status. Predictors of declining performance status included increasing severity of a number of comorbidities, age, lower socioeconomic status, and specific centers.

CONCLUSIONS

This study has identified many significant intercenter differences within Scotland. We believe this to be the first study to identify nontumor factors independent of performance status that together limit the ability to deliver radical, possibly curative, therapy to our lung cancer population. It is only by identifying such factors that we can hope to improve on the relatively poor outlook for the majority of Scottish patients with lung cancer.

Radiologic features, staging, and operability of primary lung cancer in the Western cape, South Africa: a 1-year retrospective study

INTRODUCTION

This retrospective study was performed to evaluate the radiologic features, staging, and resectability of lung cancer at the time of presentation in patients from the Western Cape of South Africa.

METHOD

We included all patients with primary lung cancer reviewed during a 12-month period (January 2009 to December 2009) who had a definite tissue diagnosis and whose staging computed tomography scans were available. Fifteen radiologic parameters were assessed.

RESULTS

Data were complete in 204 patients. The proportion and median size of the various histologic subtypes were as follows: adenocarcinoma 53.9%, 53.4 mm; squamous cell 25.9%, 80.2 mm; small cell 14.2%, 80.8 mm; large cell 2.4%, 74.2 mm; bronchioloalveolar carcinoma 1.5%, 50.0 mm; and others 2%, 57.6 mm, respectively. The overall median size of tumor was 61.5 mm. Tumors were located centrally in 43.6%, peripherally in 46.6%, indeterminate in 9.8%, mediastinal in 11.3%, right lung in 53.4%, and in the left lung in 35.3%. Tuberculosis-related lung fibrosis was present in 16%, but only 5.4% patients had coexisting tumor and fibrosis at the same site. We observed no difference in the proportion of coexisting fibrosis between adenocarcinoma and squamous carcinoma. Only 16.2% of the patients were potential candidates for radical treatment, with an actual resection rate of 4.4%.

CONCLUSIONS

In the Western Cape, adenocarcinoma is the commonest histologic subtype of bronchogenic carcinoma. Most patients present with late-stage primary tumors, and the percentage of patients with potentially resectable cancer is much lower than in Europe.

Predictors of long-term survival of lung cancer patients in a Norwegian community

INTRODUCTION

Few population-based studies are available on more than 5 years survival of lung cancer patients.

OBJECTIVES

The aims of this report were to study the survival and the predictors of survival in all lung cancer patients in a defined population and to determine whether and how the length of time from symptom onset to confirmed diagnosis (delay time) influenced survival.

METHODS

In a retrospective study, all incident cases from the Norwegian Cancer Registry and the hospital records in the Haugalandet area from 1990 to 1996 were followed until 31 December 2008. The dates of symptom onset, diagnosis, and death and information about demographics, initial stage, performance status, histology and initial symptoms were recorded.

RESULTS

Of a total of 271 patients, 57 (21%) were women, and the mean age at diagnosis was 67.4 years. One-year survival was 29.2%, and five- and 10-year survival was 8.5% and 5.5%, respectively. The median (inter quartile range, IQR) survival time was 5.7 (1.9, 14.1) months and the median (IQR) delay time was 2.2 (1.1, 3.7) months. Twenty-five patients (10% of those who died) had a non-lung cancer cause of death. No weight loss at the time of diagnosis was a significant predictor for long survival in addition to younger age, limited stage, good functional performance and surgical treatment, but delay time for diagnosis had no effect on survival time for lung cancer.

CONCLUSION

In the whole population of lung cancer patients, long-term survival remains poor and is not influenced by the diagnostic delay time.

Primary care radiography in the early diagnosis of lung cancer

Finding an abnormality on a plain chest radiograph is usually the first definite evidence of a lung cancer, so this investigation is currently pivotal in the diagnosis of the disease. Although the National Institute for Clinical Excellence (NICE) has produced guidance on when a chest radiograph should be done for putative lung cancer presentations, cancer will usually be only one of a number of possible diagnoses, so this is somewhat artificial. Neither is there any evidence that obtaining a chest radiograph for these features leads to an improved outcome. Another major concern is the poor public awareness of the symptoms for which a chest radiograph is recommended. This article discusses the role of the chest radiograph in the early diagnosis of lung cancer with particular emphasis on the limited value of a single negative result and on the potential implications of interventions to increase the number of chest radiographs done in primary care.

Social variations in access to hospital care for patients with colorectal, breast, and lung cancer between 1999 and 2006: retrospective analysis of hospital episode statistics

OBJECTIVES

To determine the extent to which type of hospital admission (emergency compared with elective) and surgical procedure varied by socioeconomic circumstances, age, sex, and year of admission for colorectal, breast, and lung cancer.

DESIGN

Repeated cross sectional study with data from individual patients, 1 April 1999 to 31 March 2006.

SETTING

Hospital episode statistics (HES) dataset.

PARTICIPANTS

564 821 patients aged 50 and over admitted with a diagnosis of colorectal, breast, or lung cancer.

MAIN OUTCOME MEASURES

Proportion of patients admitted as emergencies, and the proportion receiving the recommended surgical treatment.

RESULTS

Patients from deprived areas, older people, and women were more likely to be admitted as emergencies. For example, the adjusted odds ratio for patients with breast cancer in the least compared with most deprived fifth of deprivation was 0.63 (95% confidence interval 0.60 to 0.66) and the adjusted odds ratio for patients with lung cancer aged 80-89 compared with those aged 50-59 was 3.13 (2.93 to 3.34). There were some improvements in disparities between age groups but not for patients living in deprived areas over time. Patients from deprived areas were less likely to receive preferred procedures for rectal, breast, and lung cancer. These findings did not improve with time. For example, 67.4% (3529/5237) of patients in the most deprived fifth of deprivation had anterior resection for rectal cancer compared with 75.5% (4497/5959) of patients in the least deprived fifth (1.34, 1.22 to 1.47). Over half (54.0%, 11 256/20 849) of patients in the most deprived fifth of deprivation had breast conserving surgery compared with 63.7% (18 445/28 960) of patients in the least deprived fifth (1.21, 1.16 to 1.26). Men were less likely than women to undergo anterior resection and lung cancer resection and older people were less likely to receive breast conserving surgery and lung cancer resection. For example, the adjusted odds ratio for lung cancer patients aged 80-89 compared with those aged 50-59 was 0.52 (0.46 to 0.59). Conclusions Despite the implementation of the NHS Cancer Plan, social factors still strongly influence access to and the provision of care.

The size of the prize for earlier diagnosis of cancer in England

BACKGROUND

This supplement presents a wide range of observations, reviews, novel research and analyses underpinning the National Awareness and Early Diagnosis Initiative (NAEDI). The preceding three papers present and discuss different aspects of the data from European cancer survival comparison studies. I conclude here by attempting to quantify the extent to which delayed diagnosis in England accounts for observed survival differences and by outlining areas for further research.

METHODS

Analysis of indirect evidence related to late diagnosis, surgical intervention rates and utilisation of radiotherapy and chemotherapy in England and other European countries in the late 1990s for breast, colorectal and lung cancer.

RESULTS

Late diagnosis was almost certainly a major contributor to poor survival in England for all three cancers. Low surgical intervention rates are very likely to have contributed to low survival rates for lung cancer and possibly for the other two cancers. Any differences in the use of radiotherapy or chemotherapy are likely to have had only a minor impact on survival differences.

CONCLUSION

Between 5000 and 10000 deaths within 5 years of diagnosis could be avoided every year in England if efforts to promote earlier diagnosis and appropriate primary surgical treatment are successful. Detailed international benchmarking studies are to be recommended.

Gene profiling of clinical routine biopsies and prediction of survival in non-small cell lung cancer

RATIONALE

Global gene expression analysis provides a comprehensive molecular characterization of non-small cell lung cancer (NSCLC).

OBJECTIVES

To evaluate the feasibility of integrating expression profiling into routine clinical work-up by including both surgical and minute bronchoscopic biopsies and to develop a robust prognostic gene expression signature.

METHODS

Tissue samples from 41 chemotherapy-naive patients with NSCLC and 15 control patients with inflammatory lung diseases were obtained during routine clinical work-up and gene expression profiles were gained using an oligonucleotide array platform (NovaChip; 34'207 transcripts). Gene expression signatures were analyzed for correlation with histological and clinical parameters and validated on independent published data sets and immunohistochemistry.

MEASUREMENTS AND MAIN RESULTS

Diagnostic signatures for adenocarcinoma and squamous cell carcinoma reached a sensitivity of 80%/80% and a specificity of 83%/94%, respectively, dependent on the proportion of tumor cells. Sixty-seven of the 100 most discriminating genes were validated with independent observations from the literature. A 13-gene metagene refined on four external data sets was built and validated on an independent data set. The metagene was a strong predictor of survival in our data set (hazard ratio = 7.7, 95% CI [2.8-21.2]) and in the independent data set (hazard ratio = 1.6, 95% CI [1.2-2.2]) and in both cases independent of the International Union against Cancer staging. Vascular endothelial growth factor-beta, one of the key prognostic genes, was further validated by immunohistochemistry on 508 independent tumor samples.

CONCLUSIONS

Integration of functional genomics from small bronchoscopic biopsies allows molecular tumor classification and prediction of survival in NSCLC and might become a powerful adjunct for the daily clinical practice.

Preinvasive lesions of the bronchus

Preinvasive lesions are considered the precursors of squamous cell carcinoma of the bronchus. Treatment at the preinvasive stage, before the potential for metastasis, may improve survival from squamous cell carcinoma. An understanding of the natural history and outcome of preinvasive lesions is essential for the accurate interpretation studies of their treatment, and decisions regarding the management of individual lesions. The natural history of preinvasive lesions has only been reported in a small number of highly selected patients and uses different inclusion criteria, treatment criteria. and time-periods of follow-up, making it difficult to draw definitive conclusions. High-grade preinvasive lesions carry a risk of progression to carcinoma but most patients have multiple lesions and a significant probability of developing new lesions over time. Distinguishing lesions with malignant potential, the targets for therapy, from those that will regress or remain indolent is difficult. The American College of Chest Physicians guidelines recommend bronchoscopic follow-up of severe dysplasia and carcinoma-in situ. This review of the evidence regarding the natural history and outcome of preinvasive lesions supports this view, but also shows that further studies in individuals at risk for lung cancer are necessary before guidelines for the management of preinvasive lesions can be developed.

Geographical variation in radiotherapy services across the UK in 2007 and the effect of deprivation

AIMS

Modelling of demand has shown substantial underprovision of radiotherapy in the UK. We used national audit data to study geographical differences in radiotherapy waiting times, access and dose fractionation across the four countries of the UK and between English strategic health authorities.

MATERIALS AND METHODS

We used a web-based tool to collect data on diagnosis, dose fractionation and waiting times on all National Health Service patients in the UK starting a course of radiotherapy in the week commencing 24 September 2007. Cancer incidence for the four countries of the UK and for England by primary care trust was used to model demand for radiotherapy aggregated by country and by strategic health authority.

RESULTS

Across the UK, excluding skin cancer, 2504 patients were prescribed 33 454 fractions in the audit week. Waits for radical radiotherapy exceeded the recommended 4 week maximum for 31% of patients (range 0-62%). Fractions per million per year ranged from 17 678 to 36 426 and radical fractions per incident cancer ranged from 3.0 to 6.7. Patients who were treated received similar treatment in terms of fractions per radical course of radiotherapy (18.2-23.0). Access rates ranged from 25.2 to 48.8%, nearing the modelled optimum of 50.7% in three regions. Fractions per million prescribed as a first course of treatment varied from 43.9 to 90.3% of modelled demand. The percentage of patients failing to meet the 4 week Joint Council for Clinical Oncology target for radical radiotherapy rose as activity rates increased (r=0.834), indicating a mismatch of demand and capacity. In England, a comparison between strategic health authorities showed that increasing deprivation was correlated with lower rates of access to radiotherapy (r=-0.820).

CONCLUSIONS

There are substantial differences across the UK in the radiotherapy provided to patients and its timeliness. Radiotherapy capacity does not reflect regional variations in cancer incidence across the UK (3618-5800 cases per million per year). In addition, deprivation is a major unrecognised influence on radiotherapy access rates. In regions with higher levels of deprivation, fewer patients with cancer receive radiotherapy and the proportion treated radically is lower. This probably reflects late presentation with advanced disease, poor performance status and co-morbid illness. To provide an equitable, evidence-based service, the needs of the local population should be assessed using demand modelling based on local cancer incidence. Ideally this should include data on deprivation, performance status and stage at presentation. The results should be compared with local radiotherapy activity data to understand waits, access and dose fractionation in order to plan adequate provision for the future. The development of a mandatory radiotherapy data set in England will facilitate this, but to assist change it is essential that the results are analysed and fed back to clinicians and commissioners.

Lung cancer survival in Spain and prognostic factors: A prospective, multiregional study

Lung cancer survival varies greatly from one European country to another. Differences in data collection may account for some of the variations observed. The aim of this work was to ascertain the survival rate in diverse Spanish regions and to analyse the influence of age and other prognostic factors. This was a prospective, observational, multiregional study carried out in 10 hospitals from 8 different Spanish regions. Epidemiological and clinical data, diagnostic and therapeutic procedures, and 3-year survival were recorded according to a common protocol and uniform criteria in 1027 patients with lung cancer diagnosed in 2003. Thirteen (1.26%) were lost to follow-up. The average 3-year survival rate in the remaining 1014 patients was 13.8% with regional rates varying from 6.7% to 19.7%. The resection rate also varied greatly. Early TNM stage, surgical treatment, and asymptomatic status at diagnosis were good independent prognostic factors. Cardiovascular comorbidity and weight loss had an adverse influence on survival. Patients over the age of 70 years were more often asymptomatic at diagnosis; they had less advanced disease and more comorbidity, received less active treatment and had worse survival. The average long-term survival rate in this Spanish series was similar to that reported for other European countries. It varied widely between regions depending on the resection rate. We conclude that although older patients are diagnosed at less advanced stages of disease, they have worse survival because they are less likely to receive effective therapy.