Lung Cancer Care in General Hospitals

Diagnosis and First-Line Treatment of Breast Cancer in Italian General Hospitals

The quality of the diagnostic and therapeutic process of 1262 newly diagnosed breast cancer patients was evaluated in 63 Italian general hospitals over the period March 1983 - April 1984. Most of the patients (91 %) discovered their own lesion, which was a nodule in 83 % of the cases. Practice of breast self examination was reported by 418 (33 %) patients, only 28 % of whom did that on a regular monthly basis. A diagnostic delay > 3 months was present in 36 % of the patients. Among the preoperative work-up examinations, skeletal X-ray or bone scan was not performed in 20 % of patients, whereas other essential examinations were done in most. The Patey type of radical mastectomy was the most frequent surgical procedure; quadrantectomy was performed in only 26 % of eligible patients, more frequently in younger (34 %) than in older patients (21 %). Adjuvant chemotherapy was recommended for 11 % and 6 % of pre- and postmenopausal N— patients, and for 78 % and 47 % of pre- and postmenopausal N+ patients. Forty-three of the 63 participating hospitals reported they adhered to the guidelines defined by the Italian Breast Cancer Task Force (F.O.N.Ca.M.) but this was not associated with substantial evidence of better quality of care. Similarly, no associations emerged between several hospitals' organizational features and adherence to recommended treatment guidelines. The study is ongoing to assess the quality of postsurgical treatment and to measure its impact on patients' survival.

Patterns of Care and Survival in Non Small Cell Lung Cancer: 15 Years’ Experience in a General Hospital

Background

Transferring results derived from clinical research into practice is particularly difficult in lung cancer where clear indications for treatment are defined only for selected subgroups of patients. Studies on hospital-based lung cancer population could provide data for quantifying this issue.

Patients and methods

This was a follow-up study of consecutive, first-diagnosis cases referred to the in-and outpatient cancer clinics of a large italian general hospital between January 1975 and December 1990. Data were collected from medical records and recorded on ad hoc standardized forms. Analysis focused on changes in distribution over time of patient-related characteristics, prevalence of specific treatment strategies and survival of the study population.

Results

1345 primary non small cell lung cancer cases were reviewed and 1125 were fully evaluable. In early stages (510/1125, 45%) only 237 patients actually underwent surgery. In this group surgery increased from 36 to 69% whereas chemotherapy decreased from 58 to 15%. In the advanced group (615/1125, 55%) chemotherapy was the preferred treatment but combined modalities tripled over time (from 4 to 12%). No significant changes in survival were observed within each group over time.

Conclusion

Despite changes in the therapeutic approaches, mortality from lung cancer does not seem reduced over time. Since the proportion of cases that could potentially benefit from “active” treatments is small, for the large majority of patients a switch in clinical research from a cure to a careoriented strategy should be considered.

Clinical Characteristics, Diagnosis and Treatment of Elderly Patients with Lung Cancer at Non-Surgical Institutions: A Multicenter Study

A multicenter retrospective study was undertaken in northern Italy to assess clinical characteristics and pattern of care of elderly patients (> 70 years) with lung cancer seen in 1984, at 14 non-surgical institutions. Overall, 1 out of 5 patients with lung cancer was elderly. Eighty-four percent of the 264 elderly patients under study were males, and overall, their median age was 76 years. Squamous cell carcinoma was the most frequent histologic type (53%), and most of the patients (61%), after a rather intensive diagnostic workup, had loco-regional disease. Sixty-three percent of patients underwent radiotherapy, which was mostly classified as palliative. Chemotherapy was given to 13% of patients, mostly with small cell histology. Response to radiotherapy and chemotherapy was observed in about 50% of the patients; however, 3 out of 34 (10%) patients treated with chemotherapy died from toxicity. The median survival time from diagnosis was 9.9 months; survival time was not related, in this population of elderly patients, to age. Throughout the study, the quality of data recording during the patient's illness was often found to be suboptimal. In conclusion, elderly patients with lung cancer appear to be actively staged and treated outside a protocol context in the clinical practice of cooperating nonsugical institutions in northern Italy. This stresses the importance of prospective studies aimed to evaluate the cost/effectiveness of the various procedures used and the impact of treatments used (or even of a policy of no treatment) on the survival and quality of life of these patients.

Diagnosis and First-Line Treatment of Patients with Lung Cancer in Italian General Hospitals

The quality of diagnostic and therapeutic care was examined in a series of 380 consecutive newly diagnosed cases of primary lung cancer seen in 20 Italian general hospitals between January and June 1987. At diagnosis most patients (78%) had one or more symptoms related to the tumor, and in an additional 9 % symptoms were related to the presence of distant metastases. The median diagnostic time lag between first symptoms and final diagnosis was 50 days with a significantly longer delay in patients first seen by their general practitioner compared with those who sought first care in hospital outpatient departments. The diagnostic process was satisfactorily carried out in fewer than two-thirds of the patients leading to complete ascertainment of disease stage and histology in 58% cases with significantly better performance in more specialized institutions. Analysis of the first-line treatment profile indicated a rather aggressive therapeutic attitude In the case of patients with non-small cell lung cancer – 28% of them had chemotherapy despite the lack of any proof of efficacy in controlled clinical trials – and a failure to identify among the patients with small cell disease those amenable to more aggressive treatment. The lack of progress in the treatment of lung cancer over the last decades seems to have resulted in widely varying practice patterns where a mixture of aggressive and laissez-faire attitudes does not take into account that in the absence of effective therapies a more conservative attitude would at least have some advantage in terms of quality of remaining life for many patients.

Process and outcome of care for patients with ovarian cancer

The process and outcome of care for a group of patients with ovarian cancer treated over two years in two groups of Italian general hospitals were investigated. The quality of diagnostic and therapeutic measures did not substantially differ in specialised and non-specialised centres when selected indicators of quality of care were examined. Similarly, no differences in survival emerged for the two groups of hospitals. Overall results of the Italian series compared well with statistics of survival published by international centres for cancer, suggesting that when the yield of available treatments is limited both the process and outcome of care should be evaluated to obtain a reliable picture of quality of care. In the light of these results there are useful implications for planning future clinical trials and ways of caring.