Lung cancer in Victoria: are we making progress?

Molecular testing of lung cancer in Australia: consensus best practice recommendations from the Royal College of Pathologists of Australasia in collaboration with the Thoracic Oncology Group of Australasia

Molecular testing plays a critical role in guiding optimal treatment decisions for lung cancer patients across a variety of clinical settings. While guidelines for biomarker testing exist in other jurisdictions, to date no best practice guidelines have been developed for the Australian setting. To address this need, the Royal College of Pathologists of Australasia collaborated with the Thoracic Oncology Group of Australasia to identify state-based pathologists, oncologists and consumer representatives to develop consensus best practice recommendations. Sixteen recommendations were established encompassing appropriate biomarkers, lung cancer subtype, tumour stage, specimen types, assay selection and quality assurance protocols that can inform and standardise best practice in molecular testing of lung cancer. These multidisciplinary evidence-based recommendations are designed to standardise and enhance molecular testing practices for lung cancers and should help ensure laboratories provide high-quality molecular testing of lung cancer for all Australians, including those from regional or remote communities.

Stage-Specific Guideline Concordant Treatment Impacts on Survival in Nonsmall Cell Lung Cancer: A Novel Quality Indicator

BACKGROUND

Lung cancer in Australia contributes 9% of all new cancer diagnoses and is the leading cause of cancer death and burden. Clinical practice guidelines provide evidence-based treatment recommendations for best practice management. We aimed to determine the extent of delivery of guideline-concordant treatment (GCT) and to identify modifiable variables influencing receipt of GCT and survival.

METHODS

Data was sourced from the Victorian Lung Cancer Registry (VLCR) in Victoria, Australia. Descriptive statistics were used to summarize patient and disease characteristics according to treatment type: GCT versus non-GCT versus no/declined treatment. Statistical analyses included multiple logistic regression, multiple COX regression and Kaplan-Meier survival estimates.

RESULTS

52% of patients were treated with GCT, 32.8% non-GCT and 15.2% declined or received no treatment. GCT treated patients were younger, never smoked, had no comorbidities, had better performance status, had early stage cancer, were discussed at a multidisciplinary meeting or had treatment at a higher volume hospital. Overall, patients that received GCT had a 24% lower risk of mortality compared to patients that received non-GCT.

CONCLUSION

Modifiable variables impacting likelihood of receiving GCT included age, smoking status and treating hospital characteristics. Several modifiable variables were identified with positive impacts on survival including increased treatment of the elderly, smoking cessation, delivery of GCT, and treatment in higher volume hospitals. The measurement and reporting of delivery of GCT has positive impacts on survival and therefore merits consideration as an evidence-based quality indicator in the reporting of lung cancer quality and safety outcomes.

Multidisciplinary meeting review in nonsmall cell lung cancer: a systematic review and meta-analysis

BACKGROUND

Lung cancer diagnosis, staging and treatment may be enhanced by multidisciplinary participation and presentation in multidisciplinary meetings (MDM). We performed a systematic review and meta-analysis to explore literature evidence of clinical impacts of MDM exposure.

METHODS

A study protocol was registered (PROSPERO identifier CRD42021258069). Randomised controlled trials and observational cohort studies including adults with nonsmall cell lung cancer and who underwent MDM review, compared to no MDM, were included. MEDLINE, CENTRAL, Embase and ClinicalTrials.gov were searched on 31 May 2021. Studies were screened and extracted by two reviewers. Outcomes included time to diagnosis and treatment, histological confirmation, receipt of treatments, clinical trial participation, survival and quality of life. Risk of bias was assessed using the ROBINS-I (Risk of Bias in Non-randomised Studies - of Interventions) tool.

RESULTS

2947 citations were identified, and 20 studies were included. MDM presentation significantly increased histological confirmation of diagnosis (OR 3.01, 95% CI 2.30-3.95; p<0.00001) and availability of clinical staging (OR 2.55, 95% CI 1.43-4.56; p=0.002). MDM presentation significantly increased likelihood of receipt of surgery (OR 2.01, 95% CI 1.29-3.12; p=0.002) and reduced the likelihood of receiving no active treatment (OR 0.32, 95% CI 0.21-0.50; p=0.01). MDM presentation was protective of both 1-year survival (OR 3.23, 95% CI 2.85-3.68; p<0.00001) and overall survival (hazard ratio 0.63, 95% CI 0.55-0.72; p<0.00001).

DISCUSSION

MDM presentation was associated with increased likelihood of histological confirmation of diagnosis, documentation of clinical staging and receipt of surgery. Overall and 1-year survival was better in those presented to an MDM, although there was some clinical heterogeneity in participants and interventions delivered. Further research is required to determine the optimal method of MDM presentation, and address barriers to presentation.

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.

Persisting Gaps in Optimal Care of Stage III Non-small Cell Lung Cancer: An Australian Patterns of Care Analysis

BACKGROUND

Wide variation exists globally in the treatment and outcomes of stage III patients with non-small cell lung cancer (NSCLC). We conducted an up-to-date patterns of care analysis in the state of Victoria, Australia, with a particular focus on the proportion of patients receiving treatment with radical intent, treatment trends over time, and survival.

MATERIALS AND METHODS

Stage III patients with NSCLC were identified in the Victorian Lung Cancer Registry and categorized by treatment received and treatment intent. Logistic regression was used to explore factors predictive of receipt of radical treatment and the treatment trends over time. Cox regression was used to explore variables associated with overall survival (OS). Covariates evaluated included age, sex, ECOG performance status, smoking status, year of diagnosis, Australian born, Aboriginal or Torres Strait Islander status, socioeconomic status, rurality, public/private status of notifying institution, and multidisciplinary meeting discussion.

RESULTS

A total of 1396 patients were diagnosed between 2012 and 2019 and received treatment with radical intent 67%, palliative intent 23%, unknown intent 5% and no treatment 5%. Radical intent treatment was less likely if patients were >75 years, ECOG ≥1, had T3-4 or N3 disease or resided rurally. Surgery use decreased over time, while concurrent chemoradiotherapy and immunotherapy use increased. Median OS was 38.0, 11.1, and 4.4 months following radical treatment, palliative treatment or no treatment, respectively.

CONCLUSION

Almost a third of stage III patients with NSCLC still do not receive radical treatment. Strategies to facilitate radical treatment and better support decision making between increasing multimodality options are required.

An Overview of the Role of Radiotherapy in the Treatment of Small Cell Lung Cancer - A Mainstay of Treatment or a Modality in Decline?

AIMS

Small cell lung cancer (SCLC) accounts for about 15% of all lung cancers. Chemotherapy, immunotherapy and radiotherapy all play important roles in the management of SCLC. The aim of this study was to provide a comprehensive overview of the role and evidence of radiotherapy in the cure and palliation of SCLC.

MATERIALS AND METHODS

The search strategy included a search of the PubMed database, hand searches, reference lists of relevant review articles and relevant published abstracts.

CLINICALTRIALS

gov was also queried for relevant trials.

RESULTS

Thoracic radiotherapy improves overall survival in limited stage SCLC, but the timing and dose remain controversial. The role of thoracic radiotherapy in extensive stage SCLC with immunotherapy is the subject of several ongoing trials. Current evidence supports the use of prophylactic cranial irradiation (PCI) for limited stage SCLC but the evidence is equivocal in extensive stage SCLC. Whole brain radiotherapy is well established for the treatment of brain metastases but evidence is rapidly accumulating for the use of stereotactic radiosurgery. Further studies will define the role of PCI, whole brain radiotherapy and hippocampal avoidant PCI in the immunotherapy era.

CONCLUSION

Radiotherapy is an essential component in the multimodality management of SCLC. Technological advances have allowed safer delivery of radiotherapy with reduced toxicities. Discussion at multidisciplinary team meetings is important to ensure radiotherapy is considered and offered in appropriate patients.

Development of an Australia and New Zealand Lung Cancer Clinical Quality Registry: a protocol paper

INTRODUCTION

Lung cancer is the leading cause of cancer mortality, comprising the largest national cancer disease burden in Australia and New Zealand. Regional reports identify substantial evidence-practice gaps, unwarranted variation from best practice, and variation in processes and outcomes of care between treating centres. The Australia and New Zealand Lung Cancer Registry (ANZLCR) will be developed as a Clinical Quality Registry to monitor the safety, quality and effectiveness of lung cancer care in Australia and New Zealand.

METHODS AND ANALYSIS

Patient participants will include all adults >18 years of age with a new diagnosis of non-small-cell lung cancer (NSCLC), SCLC, thymoma or mesothelioma. The ANZLCR will register confirmed diagnoses using opt-out consent. Data will address key patient, disease, management processes and outcomes reported as clinical quality indicators. Electronic data collection facilitated by local data collectors and local, state and federal data linkage will enhance completeness and accuracy. Data will be stored and maintained in a secure web-based data platform overseen by registry management. Central governance with binational representation from consumers, patients and carers, governance, administration, health department, health policy bodies, university research and healthcare workers will provide project oversight.

ETHICS AND DISSEMINATION

The ANZLCR has received national ethics approval under the National Mutual Acceptance scheme. Data will be routinely reported to participating sites describing performance against measures of agreed best practice and nationally to stakeholders including federal, state and territory departments of health. Local, regional and (bi)national benchmarks, augmented with online dashboard indicator reporting will enable local targeting of quality improvement efforts.

Impacts of lung cancer multidisciplinary meeting presentation: Drivers and outcomes from a population registry retrospective cohort study

INTRODUCTION

Multidisciplinary Meetings (MDM) are recommended in routine lung cancer care, however its broader impacts demand further evaluation. We assessed the drivers and impacts of MDM presentation in the Victorian Lung Cancer Registry (VLCR).

METHODS

We examined the effect of MDM presentation on receipt of treatment and survival in VLCR patients diagnosed between 2011 and 2020. We compared patient characteristics, drivers of MDM discussion and survival between the two groups.

RESULTS

Of 9,628 patients, 5,900 (61.3%) were discussed at MDM, 3,728 (38.7%) were not. In the non-MDM group, a lower proportion received surgery (22.1% vs. 31.2%), radiotherapy (34.2% vs. 44.4%) and chemotherapy (44.7% vs. 49.0%). Patients were less likely to be discussed if ≥80 years (OR 0.73, p < 0.001), of ECOG performance status (PS) 4 (OR 0.23, p < 0.001), clinical stage IV (OR 0.34, p < 0.001) or referred from regional (OR 0.52, p < 0.001) or private hospital (OR 0.18, p < 0.001). MDM-presented patients had better median survival (1.70 vs 0.75 years, p < 0.001) and lower adjusted mortality risk (HR 0.75; 0.71-0.80, p < 0.001), a protective effect consistent across all hospital types. Undocumented PS, histopathology and clinical stage were associated with lower likelihood of MDM discussion and worse mortality.

CONCLUSIONS

In the VLCR, being male, ≥80 years, of poorer PS, advanced clinical stage and poor clinical characterisation significantly disadvantaged patients in relation to MDM discussion. MDM-discussed patients were more likely to undergo treatment and had a 25% lower risk of mortality. This study supports the use of MDMs in lung cancer and identifies areas of inequity to be addressed.

Lung cancer treatment patterns and factors relating to systemic therapy use in Australia

AIM

Systemic therapies for lung cancer are rapidly evolving. This study aimed to describe lung cancer treatment patterns in New South Wales, Australia, prior to the introduction of immunotherapy and latest-generation targeted therapies.

METHODS

Systemic therapy utilization and treatment-related factors were examined for participants in the New South Wales 45 and Up Study with incident lung cancer ascertained by record linkage to the New South Wales Cancer Registry (2006-2013). Systemic therapy receipt to June 2016 was determined using medical and pharmaceutical claims data from Services Australia, and in-patient hospital records. Factors related to treatment were identified using competing risks regressions.

RESULTS

A total of 1,116 lung cancer cases were identified with a mean age at diagnosis of 72 years and median survival of 10.6 months. Systemic therapy was received by 45% of cases. Among 400 cases with metastatic non-small cell lung cancer, 51% and 28% received first- and second-line systemic therapy, respectively. Among 112 diagnosed with small-cell lung cancer, 79% and 29% received first- and second-line systemic therapy. The incidence of systemic therapy was lower for participants with indicators of poor performance status, lower educational attainment, and those who lived in areas of socioeconomic disadvantage; and was higher for participants with small-cell lung cancer histology or higher body mass index.

CONCLUSION

This population-based Australian study identified patterns of systemic therapy use for lung cancer, particularly small-cell lung cancer. Despite a universal healthcare system, the analysis revealed socioeconomic disparities in health service utilization and relatively low utilization of systemic therapy overall.

Victorian Lung Cancer Service Redesign Project: impacts of a quality improvement collaborative on timeliness and management in lung cancer

BACKGROUND

Lung cancer management is characterised by a high disease burden, poor survival and substantial variation in management and outcomes. Service redesign provides opportunities for quality improvement (QI) and this improvement may be leveraged across multiple sites using QI collaboration.

AIM

This initiative targeted Quality Improvement (QI) in lung cancer management, engaging a QI collaborative using service redesign methodologies in five Victorian hospitals. QI targets included timeliness from referral and diagnosis to treatment, multi-disciplinary meeting (MDM) presentation and supportive care screening. Redesign strategies targeted process sustainability through enhanced team capability.

METHODS

This study engaged a prospective quality improvement cohort design targeting newly diagnosed tissue confirmed lung cancer with 6-month pre-intervention period and 6-month redesign implementation period, between September 2016 and August 2017, evaluated using Interrupted Time Series Analysis. Hospital sites included three regional and two metropolitan hospitals in Victoria. QI redesign targeted time intervals from referral to first specialist appointment (FSA), referral to diagnosis, diagnosis to first treatment (any intent), MDM documented in medical records and Supportive Care Screening Tool documented in medical records.

RESULTS

There was a marked reduction in referral to FSA interval across all sites, with median (interquartile range) falling from 6 (0-15) to 4 (1-10) days, and proportion seen by a specialist within 14 days increased from 74.3% to 84.2%. The interval between diagnosis and treatment was not substantively changed in the 6-month implementation period. The proportion of subjects with documented presentation to the MDM increased from 61% to 67%. The proportion for which Supportive Care Screening documentation remained low at 26.3% post-intervention.

CONCLUSIONS

Data-driven redesign initiatives enable identification and analysis of clinical practice variation and may be utilised to enhance timeliness of cancer care and improve local data service capabilities.

A review on the impact of lung cancer multidisciplinary care on patient outcomes

International guidelines recommend a multidisciplinary approach to the management of lung cancer due to the complexity of both patients and their disease and the multiple treatment options available. This care can be provided through patient discussion at multidisciplinary meetings where relevant medical and allied health staff formulate a consensus management plan taking all factors into consideration. This model can be extended further to include multidisciplinary clinics where the patient is present for assessment and discussion. However, conducting regular multidisciplinary meetings or clinics has significant time, resource and financial costs and therefore, it is important to assess the impact of multidisciplinary care. We aimed to review published evidence, from 2000 to 2019, to evaluate the impact of multidisciplinary care on lung cancer outcomes. There were 29 studies found, 11 evaluating multidisciplinary clinics, 14 studying multidisciplinary meetings and four where the model of care was not defined. There was only one randomised trial and three prospective studies, the remainder being retrospective studies. Despite limitations in trial design and confounding factors, overall, multidisciplinary care in lung cancer was associated with improvements in patient outcomes, in particular improved survival for all stages of lung cancer. Lung cancer patients managed in a multidisciplinary setting were more likely to receive active treatment and had improved utilisation of all treatment modalities: surgery, radiotherapy and chemotherapy. In addition, the treatment recommendations were more likely to be consistent with lung cancer management guidelines. These improved outcomes support the recommendations for a multidisciplinary approach to lung cancer care.

Optimizing lung cancer MDT data for maximum clinical impact-a scoping literature review

Multidisciplinary care in is widely recommended as best practice for lung cancer in many countries and jurisdictions. A number of studies suggest multidisciplinary care benefits patient outcomes, with analyses based on a range of data sources including national, state and local registries as well as multidisciplinary team meeting (MDT)-based data collections, often focused on different questions depending on data sources. MDT data collection and linkage are not standardized and not routine although data collection and feedback are specifically recommended by at least one statutory body. We performed a scoping review of current evidence for lung cancer MDT data collection and analysis, to identify discrete strategies through illustrative examples and to make recommendations for future approaches. Thirteen studies were identified that presented lung cancer MDT-related clinical outcomes, three included MDTs from multiple tumour streams while 10 studies focussed on lung cancer MDT meetings. Eleven studies measured the effect of MDT discussion on clinical outcomes of which eight were positive. Data sources included MDT records (3 studies), medical or hospital records (3 studies), institutional registries (5 studies) and state or national administrative datasets (6 studies), with some overlap. Examples of studies based on different data sources (local MDT, institutional registry, national registry) exemplified the different types of clinical research questions appropriate for each data source. While MDT data collection is not well-defined, the importance of clinical audit and data feedback and the potential for real-time analysis to improve outcomes deserve further investigation. Optimized datasets and linkage strategies are likely to maximize benefits for patients.

Accuracy of lung cancer staging in the multidisciplinary team setting

Accurate staging of lung cancer is of utmost importance in determining the stage-appropriate treatment and prognosis. Imaging tests which include contrast-enhanced computed tomography (CT) examination of the chest to include the liver and adrenal glands and 18-fluoro-2 deoxyglucose positron emission tomography (PET)/CT scan facilitate the initial tumor node metastasis (TNM) staging of the disease and provide guidance on the optimal biopsy site and biopsy method. The diagnostic and staging approach should be tailored to the individual patient according to risk, benefit, patient preferences, and available expertise. Diagnosis and staging should preferably be accomplished with a single procedure or the least number of invasive procedures if more than one is needed. Ideally, centers managing lung cancer patients should have a multidisciplinary thoracic oncology board prescribing personalized evidence-based management tailored to each individual patient. Multidisciplinary team (MDT) meetings provide a platform for key experts from various disciplines to contribute specific advice on the management of each individual patient. As assessment of mediastinal lymph node involvement is an important component of lung cancer staging, optimal mediastinal staging can be achieved with a variety of techniques that can be discussed and performed by the various specialists in the MDT. Despite a relative paucity of quality evidence that MDT contributes to improvements in lung cancer survival outcomes, this approach has evolved to become the standard of care in many centers around the world. Thoracic MDT has resulted in more focused and timely investigations for histopathologic diagnosis and disease staging which translate into earlier treatment initiation. Moreover, there is increasing evidence that MDT care facilitates and allows access to investigations that lead to improved accuracy of tumor and nodal staging. However, there is still a paucity of evidence on the accuracy of lung cancer staging in the MDT setting.

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.

Collaborative implementation of stereotactic ablative body radiotherapy: A model for the safe implementation of complex radiotherapy techniques in Australia

INTRODUCTION

Stereotactic ablative radiotherapy (SABR) for lung cancer is a modality of treatment that has improved outcomes for lung cancer patients. However, radiotherapy for lung cancer is underutilized and fewer than half of elderly patients with non-small cell lung cancer (NSCLC) receive active treatment. The purpose of this study is to report on a collaboration in implementing an NSCLC SABR (stereotactic ablative body radiation) program safely, efficiently, and uniformly across several centers, including regional sites. The first aim of this paper is to detail the collaboration and implementation that started in 2013 and is ongoing. The second aim of this paper is to document early toxicities and quality of life outcomes.

METHOD

A tripartite approach was used to develop the protocol and networks required for the implementation of SABR across multiple sites in NSW. Departments starting the programmes were supported and physics credentialing with central site submission was required before commencing the treatment. Additional ongoing support was available via an email discussion group involving all members of the collaboration.

RESULTS

Between July 22, 2013 and February 22, 2016, 41 patients were enrolled with 34 patients in active follow up. The toxicity profile so far is similar to those of published studies with no appreciable effect on quality of life outcomes.

CONCLUSION

The collaboration formed an effective framework in facilitating the implementation of SABR across several sites in NSW and could be used as a model for the safe and uniform implementation of new technologies in Australia.

Clinical impact of data feedback at lung cancer multidisciplinary team meetings: A mixed methods study

AIM

Multidisciplinary team (MDT) meetings can facilitate optimal lung cancer care, yet details of structured data collection and feedback remain sparse. This study aimed to investigate data collection and the impact of feedback to lung cancer MDTs.

METHODS

A mixed-methods study using pre and post-test surveys, semistructured interviews, and observation to evaluate data collection and response to modeled data feedback in three Australian lung cancer MDTs at different locations and development stage (site A: outer metropolitan, established; site B, outer metropolitan, new; and site C, inner metropolitan, established).

RESULTS

MDT attendees (range 13-25) discussed 5-8 cases per meeting. All sites collected data prospectively (80% prepopulated) into local oncology medical information systems. The pretest survey had 17 respondents in total (88% clinicians). At sites A and C, 100% of respondents noted regular data audits, occasional at site B. Regular audit data included number of cases, stage, final diagnosis, and time to diagnosis and treatment. The post-test survey had 25 respondents in total, all clinicians. The majority (88-96%) of respondents found modeled data easy to interpret, relevant to clinical practice and the MDT, and welcomed future regular data presentations (as rated on a 5-point Likert scale mean weighted average 4.5 where > 4 demonstrates agreement). Semistructured interviews identified five major themes for MDTs: current practice, attitudes, enablers, barriers, and benefits for the MDT.

CONCLUSIONS

MDT teams exhibited positive responses to modeled data feedback. Key characteristics of MDT data were identified and may assist with future team research and development.

Improving regional lung cancer optimal care pathway compliance through a rapid-access respiratory clinic

BACKGROUND

Lung cancer is the leading cause of cancer-related morbidity and mortality in Australia and delays in diagnosis and management increase the potential for disease progression. Incidence and mortality from lung cancer in our region, Gippsland, are higher than the national average, yet there is no known standard referral pathway for diagnosis in the region.

AIM

To identify the current standard of care for lung cancer diagnosis and the impact a rapid access clinic, led by a respiratory physician, has on optimal care pathway (OCP) compliance.

METHODS

A retrospective audit of patients with lung cancer managed through our regional hospital between January and December 2018 (Standard Care group), and a prospective audit of a new rapid access, respiratory-physician led, lung lesion assessment clinic over the same period, were conducted. The primary outcomes were compliance with the OCP target for time from initial computed tomography scan identification of a lung lesion to tissue diagnosis and treatment commencement (target 42 days) when malignancy was confirmed.

RESULTS

There were 25 cases audited in the Standard Care group and 21 cases seen through the Rapid Access Clinic. The Standard Care group met the target for treatment commencement in 33.3% of cases whereas the Rapid Access Clinic group achieved this in 77%.

CONCLUSIONS

Our project highlights the disjointed and delayed lung cancer care in our region and the improvements a dedicated rapid access clinic can have on diagnosis and treatment commencement timeframes.

Delays in lung cancer management pathways between rural and urban patients in North Queensland: a mixed methods study

BACKGROUND

Despite advances in medical therapies, disparity in outcome between rural and urban patients remain in Australia and many Western countries.

AIMS

To examine time delays in lung cancer referral pathways in North Queensland (NQ), Australia, and explore patients' perspective of factors causing these delays.

METHODS

Prospective study of patients attending three cancer centres in Townsville, Cairns and Mackay in NQ from 2009 to 2012. Times along referral pathway were divided as follows: Onset of symptoms to treatment (T1), symptoms to general practitioner (GP) (T2), GP to specialist (T3) and Specialist to treatment (T4). Quantitative and qualitative methods were used for analysis.

RESULTS

In total, 252 patients were participated. T1 was influenced by remoteness (125 days in Townsville vs 170 days for remote, P = 0.01), T2 by level of education (91 days for primary education vs 61 days for secondary vs 23 days for tertiary/Technical and Further Education (TAFE), P = 0.006), and age group (14 days for 31-50 years, 61 days for 51-70 years, 45 days for >71 years, P = 0.026), T3 by remoteness (15 days for Townville and 29.5 days for remote, P = 0.02) and T4 by stage of disease (21 days for Stage I, 11 days for Stage II, 34 days for Stage III 18 days for Stage IV, P = 0.041). Competing priorities of family and work and cost and inconvenience of travel were perceived as rural barriers.

CONCLUSION

Remoteness, age and level of education were related to delays in various time lines in lung cancer referral pathways in NQ. Provision of specialist services closer to home may decrease delays by alleviating burden of cost and inconvenience of travel.

Pathways to diagnosis of non-small cell lung cancer: a descriptive cohort study

Little has been published on the diagnostic and referral pathway for lung cancer in Australia. This study set out to quantify general practitioner (GP) and lung specialist attendance and diagnostic imaging in the lead-up to a diagnosis of non-small cell lung cancer (NSCLC) and identify common pathways to diagnosis in New South Wales (NSW), Australia. We used linked health data for participants of the 45 and Up Study (a NSW population-based cohort study) diagnosed with NSCLC between 2006 and 2012. Our main outcome measures were GP and specialist attendances, X-rays and computed tomography (CT) scans of the chest and lung cancer-related hospital admissions. Among our study cohort (N = 894), 60% (n = 536) had ≥4 GP attendances in the 3 months prior to diagnosis of NSCLC, 56% (n = 505) had GP-ordered imaging (chest X-ray or CT scan), 39% (N = 349) attended a respiratory physician and 11% (N = 102) attended a cardiothoracic surgeon. The two most common pathways to diagnosis, accounting for one in three people, included GP and lung specialist (respiratory physician or cardiothoracic surgeon) involvement. Overall, 25% of people (n = 223) had an emergency hospital admission. For 14% of people (N = 129), an emergency hospital admission was the only event identified on the pathway to diagnosis. We found little effect of remoteness of residence on access to services. This study identified a substantial proportion of people with NSCLC being diagnosed in an emergency setting. Further research is needed to establish whether there were barriers to the timely diagnosis of these cases.

Examining events leading to the diagnosis of non-small cell lung cancer (NSCLC) in Australia yields insights to guide further research and perhaps improve the pathways to diagnosis. NSCLC is by far the most common form of lung cancer. Researchers, led by the Cancer Institute New South Wales, investigated clinical care contacts leading to diagnosis, using a descriptive cohort study of 894 patients diagnosed between 2006 and 2012. The researchers quantified contact with GPs and lung specialists, hospital admissions and diagnostic imaging procedures. Living in remote locations had little influence on access to services. More than half of the patients did not see a lung specialist during the pathway to diagnosis, while a quarter received their diagnosis in an emergency setting. Further research should investigate whether there are barriers preventing timely diagnosis.

Patient and carer perceived barriers to early presentation and diagnosis of lung cancer: a systematic review

Background

Lung cancer is typically diagnosed at a late stage. Early presentation and detection of lung cancer symptoms is critical to improving survival but can be clinically complicated and as yet a robust screening method for diagnosis is not available in routine practice. Accordingly, the barriers to help-seeking behaviour and diagnosis need to be considered. This review aimed to document the barriers to early presentation and diagnosis of lung cancer, based on patient and carer perspectives.

Methods

A systematic review of databases was performed for original, English language articles discussing qualitative research on patient perceived barriers to early presentation and diagnosis of lung cancer. Three major databases were searched: Scopus, PubMed and EBSCOhost. References cited in the selected studies were searched for further relevant articles.

Results

Fourteen studies met inclusion criteria for review. Barriers were grouped into three categories: healthcare provider and system factors, patient factors and disease factors.

Conclusions

Studies showed that the most frequently reported barriers to early presentation and diagnosis of lung cancer reported by patients and carers related to poor relationships between GPs and patients, a lack of access to services and care for patients, and a lack of awareness of lung cancer symptoms and treatment. Addressing these barriers offers opportunities by which rates of early diagnosis of lung cancer may be improved.

The Victorian Comprehensive Cancer Centre lung cancer clinical audit: collecting the UK National Lung Cancer Audit data from hospitals in Australia

BACKGROUND

Clinical audit may improve practice in cancer service provision. The UK National Lung Cancer Audit (NLCA) collects data for all new cases of thoracic cancers.

AIM

To collect similar data for our Victorian patients from six hospitals within the Victorian Comprehensive Cancer Centre and associated Western and Central Melbourne Integrated Cancer Service.

METHODS

We conducted a retrospective audit of all newly diagnosed patients with lung cancer and mesothelioma in 2013 across the six Victorian Comprehensive Cancer Centre/Western and Central Melbourne Integrated Cancer Service hospitals. The objectives were to adapt the NLCA data set for use in the Australian context, to analyse the findings using descriptive statistics and to determine feasibility of implementing a routine, ongoing audit similar to that in the UK. Individual data items were adapted from the NLCA by an expert steering committee. Data were collated from the Victorian Cancer Registry, Victorian Admitted Episodes Dataset and individual hospital databases. Individual medical records were audited for missing data.

RESULTS

Eight hundred and forty-five patients were diagnosed across the sites in 2013. Most were aged 65-80 (55%) and were male (62%). Most had non-small-cell lung cancer (81%) with 9% diagnosed with small cell lung cancer and 2% with mesothelioma. Data completeness varied significantly between fields. For those with higher levels of completeness, headline indicators of clinical care were comparable with NLCA data. The Victorian population seem to lack access to specialist lung cancer nurse services.

CONCLUSION

Lung cancer care at participating hospitals appeared to be comparable with the UK in 2013. In future, prospective data collection should be harmonised across sites and correlated with survival outcomes. One area of concern was a lack of documented access to specialist nursing services.

Smoking as a risk factor for lung cancer in women and men: a systematic review and meta-analysis

OBJECTIVES

To investigate the sex-specific association between smoking and lung cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed and EMBASE from 1 January 1999 to 15 April 2016 for cohort studies. Cohort studies before 1 January 1999 were retrieved from a previous meta-analysis. Individual participant data from three sources were also available to supplement analyses of published literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Cohort studies reporting the sex-specific relative risk (RR) of lung cancer associated with smoking.

RESULTS

Data from 29 studies representing 99 cohort studies, 7 million individuals and >50 000 incident lung cancer cases were included. The sex-specific RRs and their ratio comparing women with men were pooled using random-effects meta-analysis with inverse-variance weighting. The pooled multiple-adjusted lung cancer RR was 6.99 (95% Confidence Interval (CI) 5.09 to 9.59) in women and 7.33 (95% CI 4.90 to 10.96) in men. The pooled ratio of the RRs was 0.92 (95% CI 0.72 to 1.16; I2=89%; p<0.001), with no evidence of publication bias or differences across major pre-defined participant and study subtypes. The women-to-men ratio of RRs was 0.99 (95% CI 0.65 to 1.52), 1.11 (95% CI 0.75 to 1.64) and 0.94 (95% CI 0.69 to 1.30), for light, moderate and heavy smoking, respectively.

CONCLUSIONS

Smoking yields similar risks of lung cancer in women compared with men. However, these data may underestimate the true risks of lung cancer among women, as the smoking epidemic has not yet reached full maturity in women. Continued efforts to measure the sex-specific association of smoking and lung cancer are required.

Does presentation at multidisciplinary team meetings improve lung cancer survival? Findings from a consecutive cohort study

BACKGROUND

Multidisciplinary team (MDT) presentation in lung cancer has the potential to improve longterm outcomes, although this varies between studies. This study aims to evaluate outcomes including survival, according to MDT presentation and to explore the utility of data obtained from local clinical sources.

PATIENTS AND METHODS

Prospective cases of lung cancer recorded in our institution's cancer registry were analyzed according to MDT presentation for patient and tumour characteristics, adjusted survival and referral to palliative care.

RESULTS

1197 cases were included, 295 (24.6%) with MDT presentation and 902 (75.4%) without. 60% of patients were male with median (IQR) age at diagnosis of 70 years (62-78). Histopathology distribution (non-small cell lung cancer and small-cell lung cancer) was similar between the two groups. Compared with the non-MDT group, the MDT group had (1) ECOG score recorded more often (71.9% vs. 47.6%), (2) higher proportion of ECOG 0 cases (31.2% vs. 11.9%) and ECOG 1 cases (28.8% vs. 20.3%), (3) higher proportion of early stage disease (stage I - 23.1% vs. 9.7% stage II - 10.2% vs. 4.8%, stage IIIA - 14.6% vs 6.3%) and (4) lower proportion of metastatic disease (stage IV - 39.3% vs. 56.1%). Referral to palliative care was incompletely recorded in both groups (MDT: n = 116/295, 39.3%; non-MDT: n = 430, 47.7%) but did not differ significantly for stage IV cases. Survival analyzed by stage was greater in the MDT group at 1, 2 and 5 years for all stages except stage IIIB at 1 year post-diagnosis. Adjusted survival analysis for the entire cohort showed improved survival at 5 years for the MDT group (HR 0.7 (0.58-0.85), p < 0.001).

CONCLUSION

MDT presentation is associated with improved adjusted survival for lung cancer in this single institutional cohort in an analysis of local clinical cancer registry data.

The LEAD study protocol: a mixed-method cohort study evaluating the lung cancer diagnostic and pre-treatment pathways of patients from Culturally and Linguistically Diverse (CALD) backgrounds compared to patients from Anglo-Australian backgrounds

Background

Lung cancer is the leading cause of cancer mortality worldwide. Early diagnosis and treatment is a key factor in reducing mortality and improving patient outcomes. To achieve this, it is important to understand the diagnostic pathways of cancer patients. Patients from Culturally and Linguistically Diverse (CALD) are a vulnerable group for lung cancer with higher mortality rates than Caucasian patients. The aim of this study is to explore differences in the lung cancer diagnostic pathways between CALD and Anglo-Australian patients and factors underlying these differences.

Methods

This is a prospective, observational cohort study using a mixed-method approach. Quantitative data regarding time intervals in the lung cancer diagnostic pathways will be gathered via patient surveys, General practitioner (GP) review of general practice records, and case-note analysis of hospital records. Qualitative data will be gathered via structured interviews with lung cancer patients, GPs, and hospital specialists. The study will be conducted in five study sites across three states in Australia. Anglo-Australian patients and patients from five CALD groups (i.e., Arabic, Chinese, Greek, Italian and Vietnamese communities) will mainly be identified through the list of new cases presented at lung multidisciplinary team meetings. For the quantitative component, it is anticipated that 724 patients (362 Anglo-Australian and 362 CALD patients) will be recruited to obtain a final sample of 290 (145 per group) assuming a 50% patient survey completion rate and a 80% GP record review completion rate. For the qualitative component, 60 interviews with lung cancer patients (10 Anglo-Australian and 10 patients per CALD group), 20 interviews with GPs, and 20 interviews with specialists will be conducted.

Discussion

This is the first Australian study to compare the time intervals along the lung cancer diagnostic pathway between CALD and Anglo-Australian patients. The study will also explore the underlying patient, healthcare provider, and health system factors that influence the time intervals in the two groups. This information will improve our understanding of the effect of ethnicity on health outcomes among lung cancer patients and will inform future interventions aimed at early diagnosis and treatment for lung cancer, particularly patients from CALD backgrounds.

Trial registration

The project was retrospectively registered with Australian New Zealand Clinical Trials Registry (registration number: ACTRN12617000957392, date registered: 4th July 2017).

Consensus minimum data set for lung cancer multidisciplinary teams: Results of a Delphi process

BACKGROUND AND OBJECTIVE

While multidisciplinary team (MDT) care in lung cancer is widely practiced, there are few guidelines for MDT on best data collection strategies. MDT meetings need ready access to information for the provision of optimal treatment recommendations (the primary purpose of the meeting), audit of team performance and benchmarking. This study aimed to develop a practical data set designed for these goals through a recognized consensus process with health professionals who participate in formal MDT settings.

METHODS

A modified Delphi process with three iterations (two surveys and one consensus conference) was carried out involving over 100 Australian lung cancer MDT health professionals.

RESULTS

In total, 122 lung cancer MDT health professionals responded to the Round 1 survey from over 350 invitees. Of the 122, 98 were available for invitation to Round 2. Of 98, 52 (53%) invitees responded to the Round 2 survey. After two rounds, 51 data elements across 8 domains (patient demographics, risk factors, biopsy data, staging, timeliness, treatment, follow-up and patient selection) achieved consensus, defined as 80% agreement. For Round 3, 33 MDT lead clinicians were invited to participate in a consensus conference. Of 33, 14 (42%) invitees distilled the 47 data elements into 23 elements across 8 domains to address the study objectives.

CONCLUSION

A practical data set for lung cancer MDT to use for optimal treatment recommendations and to evaluate team performance was developed through recognized consensus methodology. Access to streamlined, relevant and feasible data collection strategies may improve MDT decision-making, audit of team performance and facilitate benchmarking.

Lung cancer interval times from point of referral to the acute health sector to the start of first treatment

Objective The aim of the present study was to compare lung cancer diagnostic and treatment intervals with agreed target measures across three large public health services in Victoria and assess any differences in interval times by treatment type and health service. Methods A retrospective medical record audit of 78 patients admitted with a new diagnosis of lung cancer was conducted. Interval times from referral to diagnosis, diagnosis to first treatment and referral to first treatment were recorded in three treatment types: surgery, chemotherapy and radiotherapy. Results There was a significant difference in the mean number of days from referral to diagnosis by treatment type. Patients who underwent surgery waited significantly longer (mean (± s.d.) 41.6±38.4 days) to obtain a diagnosis than those who received radiotherapy (15.1±18.6 days). Only 47% of surgical patients obtained a diagnosis within the recommended 28 days. Moreover, only 45% and 44% of patients, respectively, met the diagnosis-to-treatment target of 14 days and referral-to-treatment target of 42 days. Conclusion The present study highlights the effect of treatment type on lung cancer referral interval times. It demonstrates the benefits of using evidenced-based interval target times to benchmark and compare performance outcomes in lung cancer. What is known about the topic? Lung cancer is the leading cause of cancer mortality in Australia and has the lowest 5-year survival rate of all cancer types. Delays in the diagnosis of lung cancer can change the prognosis from potentially curable to incurable, particularly in faster-growing tumours. What does this paper add? This study reveals treatment type was a greater factor in explaining variations in diagnosis and treatment than health service. Surgical patients were consistently lower in meeting the recommended interval targets across referral to diagnosis, diagnosis to treatment and referral to treatment. What are the implications for practitioners? This study demonstrates the value of using evidenced-based interval target times to benchmark and compare performance outcomes in lung cancer. Such measures may further improve prognostic outcomes in lung cancer by reducing unwanted delays.

Indigenous Australians with non-small cell lung cancer or cervical cancer receive suboptimal treatment

BACKGROUND

Lung cancer and cervical cancer are higher in incidence for Indigenous Australians and survival is worse compared with non-Indigenous Australians. Here we aim to determine if being Indigenous and/or other factors are associated with patients receiving "suboptimal treatment" compared to "optimal treatment" according to clinical guidelines for two cancer types.

METHODS

Data were collected from hospital medical records for Indigenous adults diagnosed with cervical cancer and non-small cell lung cancer (NSCLC) and a frequency-matched comparison group of non-Indigenous patients in the Queensland Cancer Registry between January 1998 and December 2004. The two cancer types were analyzed separately.

RESULTS

A total of 105 women with cervical cancer were included in the study, 56 of whom were Indigenous. Indigenous women had higher odds of not receiving optimal treatment according to clinical guidelines (unadjusted OR 7.1; 95% CI, 1.5-33.3), even after adjusting for stage (OR 5.7; 95% CI, 1.2-27.3). Of 225 patients with NSCLC, 198 patients (56% Indigenous) had sufficient information available to be analyzed. The odds of receiving suboptimal treatment were significantly higher for Indigenous compared to non-Indigenous NSCLC patients (unadjusted OR 1.9; 95% CI, 1.0-3.6) and remained significant after adjusting for stage, comorbidity and age (adjusted OR 2.1; 95% CI, 1.1-4.1).

CONCLUSIONS

The monitoring of treatment patterns and appraisal against guidelines can provide valuable evidence of inequity in cancer treatment. We found that Indigenous people with lung cancer or cervical cancer received suboptimal treatment, reinforcing the need for urgent action to reduce the impact of these two cancer types on Indigenous people.

Histologic Distribution of Pulmonary Tumors in Lebanon: A 5-Year Single Institution Experience

BACKGROUND

To compare the current histologic distribution of lung cancer in Lebanon to the worldwide trends, according to the 2004 WHO Classification.

MATERIALS AND METHODS

1,760 patients with a pulmonary pathology examination at Hotel-Dieu de France University Hospital between July 2009 and July 2014 were included.

RESULTS

Some 676 out of the total investigated patients (38.4%) had a lung tumor. In 665 (98.4%) the tumors were malignant, with a mean age at diagnosis of 63.8 years and a male/female (M/F) sex ratio of 1.7:1. Among the malignant tumors, 86.2% were epithelial tumors with a mean age at diagnosis of 64.8 years and an M/F sex ratio of 1.9. Other malignant tumors consisted of metastatic tumors (10.2%), lymphoproliferative tumors (2.1%) and mesenchymal tumors (1.5%). Most common carcinoma subtypes were adenocarcinoma (48.0%), squamous cell carcinoma (23.0%) and small cell carcinoma (13.3%). Carcinoid tumors were the only carcinoma subtype with an M/F sex ratio below 1 (0.7). Salivary gland tumors were the carcinoma with lowest mean age at diagnosis (45.5 years).

CONCLUSIONS

The histologic distribution of lung tumors in Lebanon is similar to that in developed countries. We believe this resemblance is due to common smoking habits, known to be responsible for the increase of lung adenocarcinoma at the expense of other subtypes.

Improving outcomes in lung cancer: the value of the multidisciplinary health care team

Lung cancer is a major worldwide health burden, with high disease-related morbidity and mortality. Unlike other major cancers, there has been little improvement in lung cancer outcomes over the past few decades, and survival remains disturbingly low. Multidisciplinary care is the cornerstone of lung cancer treatment in the developed world, despite a relative lack of evidence that this model of care improves outcomes. In this article, the available literature concerning the impact of multidisciplinary care on key measures of lung cancer outcomes is reviewed. This includes the limited observational data supporting improved survival with multidisciplinary care. The impact of multidisciplinary care on other benchmark measures of quality lung cancer treatment is also examined, including staging accuracy, access to diagnostic investigations, improvements in clinical decision making, better utilization of radiotherapy and palliative care services, and improved quality of life for patients. Health service research suggests that multidisciplinary care improves care coordination, leading to a better patient experience, and reduces variation in care, a problem in lung cancer management that has been identified worldwide. Furthermore, evidence suggests that the multidisciplinary model of care overcomes barriers to treatment, promotes standardized treatment through adherence to guidelines, and allows audit of clinical services and for these reasons is more likely to provide quality care for lung cancer patients. While there is strengthening evidence suggesting that the multidisciplinary model of care contributes to improvements in lung cancer outcomes, more quality studies are needed.

Association of sarcopenia and observed physical performance with attainment of multidisciplinary team planned treatment in non-small cell lung cancer: an observational study protocol

BACKGROUND

Non-small cell lung cancer (NSCLC) frequently presents in advanced stages. A significant proportion of those with reportedly good ECOG performance status (PS) fail to receive planned multidisciplinary team (MDT) treatment, often for functional reasons, but an objective decline in physical performance is not well described. Sarcopenia, or loss of muscle mass, is an integral part of cancer cachexia. However, changes in both muscle mass and physical performance may predate clinically overt cachexia, and may be present even with normal body mass index. Physical fitness for treatment is currently subjectively assessed by means of the PS score, which may be inadequate in predicting tolerance to treatment. This study aims to evaluate whether measuring physical performance and muscle mass at baseline in NSCLC patients, in addition to PS score, is able to predict commencement and successful completion of MDT-planned treatment.

METHODS/DESIGN

This is a prospective, single-centre exploratory study of NSCLC patients attending a Rapid Access Lung Cancer clinic. Baseline data collected are (methods in brackets): physical performance (Short Physical Performance Battery), muscle mass (bioelectrical impedance ± dual energy x-ray absorptiometry), patient and physician-assessed PS (ECOG and Karnofsky), nutritional status and presence of cachexia. Longitudinal data consists of receipt and completion of MDT treatment plan. The primary outcome measure is commencement of MDT-planned treatment, and important secondary outcomes include successful completion of treatment, length of stay in surgical patients, and risk of chemotherapy- and radiotherapy-related side effects.

DISCUSSION

A more comprehensive assessment of phenotype, particularly with regards to physical performance and muscle mass, will provide additional discriminatory information of patients' fitness for treatment. If positive, this study has the potential to identify targets for early intervention in those who are at risk of deterioration. This will subsequently enable optimisation of performance of patients with NSCLC, in anticipation of systemic treatment.

Prognostic factors affecting survival in non-small cell lung carcinoma patients with malignant pleural effusions

BACKGROUND AND AIMS

Lung cancer is the most common cause of malignant pleural effusions (MPEs). For patients with lung cancer and MPE, median survival is only 3-4 months. The aim of this study was to evaluate lung cancer patients with MPE by clinical and laboratory findings on admission, and determine 2-year survival rate and prognostic factors.

METHODS

Between 2008 and 2011, we examined 199 cases of non-small cell lung carcinoma with MPE. Demographic factors of patients, tumor characteristics, treatment delivered and laboratory parameters affecting prognosis were evaluated. Survival rates were estimated by Kaplan-Meier method. Significance of each prognostic factors selected by univariate analysis were confirmed using Cox regression model.

RESULTS

The study included 139 (69.8%) male and 60 (30.2%) female patients with a median age of 64 (30-85) years. Median overall survival was 4.4 months. Adenocarcinoma was the leading cause of MPE with 80.4%. A univariate analysis showed that factors affecting mortality included gender (P < 0.001), MPE with distant metastasis (P = 0.025), lower serum albumin (P < 0.0001), lower pleural protein (P < 0.0001), increased serum lactate dehydrogenase (P = 0.003), increased serum C-reactive protein (CRP) (P < 0.0001), increased white blood cells (P < 0.0001), histopathological type (P = 0.004) and treatment decision (P < 0.0001). A multivariate analysis revealed that patients who had high level of serum CRP (P = 0.017), lower serum albumin (P = 0.009) and lower pleural protein (P = 0.003), MPE with distant metastasis (P = 0.003) and those who were chemotherapy naive (P < 0.0001) had shorter survival.

CONCLUSION

High level of serum CRP, lower serum albumin and lower pleural protein, MPE with distant metastasis were most important prognostic factors for non-small cell lung carcinoma in patients with MPEs.

International patterns of radiotherapy practice for non-small cell lung cancer

Radiotherapy is an important treatment modality for non-small cell lung cancer (NSCLC). There are models of radiotherapy utilization that estimate the proportion of patients with NSCLC who have an evidence-based indication for radiotherapy. These estimates range from 46%-68% for radiotherapy utilization at diagnosis and 64%-75% overall. However, actual radiotherapy utilization throughout much of the world is lower than this, ranging from 28%-53%, with the largest differences between actual and estimated radiotherapy utilization seen in stage III NSCLC. Some of this discrepancy is attributable to the assumptions in the models that are based on broad factors such as stage and performance status. Characteristics of the population with underlying lung cancer that often has comorbidities or compromised respiratory function also influence the ability to deliver radiotherapy safely. Sociodemographic factors such as race and income have been found to affect access to radiotherapy in certain jurisdictions. The type of clinician or medical setting the patient presents to initially can also influence radiotherapy use in NSCLC. Potential solutions to improve appropriate radiotherapy utilization for NSCLC include restructuring models of care to ensure that all patients with lung cancer are managed within a multidisciplinary team including a radiation oncologist.

Patients with localized non-small cell lung cancer miss out on curative surgery with distance from specialist care

BACKGROUND

To determine whether increasing distance to the nearest accessible specialist hospital (NASH, a public hospital with a thoracic surgical service) increases a patient's likelihood of missing out on curative surgery for localized non-small cell lung cancer (NSCLC).

METHOD

Population-based study of cancer registry records for 27 033 people with lung cancer diagnosed in New South Wales, Australia, between 2000 and 2008 linked to hospital admission records. This analysis includes 3240 patients with localized NSCLC admitted to hospital within 12 months of diagnosis.

RESULTS

Patients who lived 100+ km from the NASH were more likely to have no surgery (50.6%) than those living 0-39 km away (37.6%) and more likely to attend general hospitals for their care (52.2% at 100+ km, 14.8% at 0-39 km). Relative to patients living 0-39 km from the NASH and attending a specialist hospital for their care, the odds ratio (OR) of not having surgery was high if patients attended a general hospital (adjusted OR 5.99, 95% confidence interval (CI) 3.87-9.26, for those 0-39 km distant) and even higher as distance from the NASH increased (24.68, 95% CI 12.37-49.13 for 40-49 km and 30.10, 95% CI 18.2-49.40 for 100+ km). For patients treated in specialist hospitals (public or private), the trend with distance was opposite: relative to 0-39 km, the OR was 0.29 (95% CI 0.15-0.50) at 40-99 km and 0.14 (95% CI 0.08-0.26) at 100+ km.

CONCLUSIONS

Patients with localized NSCLC are most likely to have no potentially curative surgery if they live distant from a specialist hospital and attend a general hospital for their care.

Survival of Australian lung cancer patients and the impact of distance from and attendance at a thoracic specialist centre: a data linkage study

BACKGROUND

Lung cancer patients have better survival when treated in thoracic surgical (specialist) centres.

AIMS

To determine whether outcome of non-small cell lung cancer (NSCLC) patients is poorer with increasing distance to the nearest accessible specialist hospital (NASH).

METHODS

We linked cancer registry, hospital and death records of 23,871 NSCLC patients; 3240 localised, 2435 regional and 3540 distant stage patients hospitalised within 12 months of diagnosis were analysed. Distance from patients' residences to the NASH was measured using geographical coordinates. Cox proportional hazards models examined predictors of NSCLC death.

RESULTS

Having a resection of the cancer, which admission to a specialist hospital made more likely, substantially reduced hazard of NSCLC death. Distance influenced hazard of death through both these variables; a patient was less likely to be admitted to a specialist hospital than a general hospital and less likely to have a resection the further they lived from the NASH. However, patients who lived distant from the NASH and were admitted to a specialist hospital were more likely to have a resection and less likely to die from NSCLC than patients admitted to a specialist hospital and living closer to the NASH. These patterns varied little with lung cancer stage.

CONCLUSIONS

NSCLC outcome is best when patients are treated in a specialist hospital. Greater distance to the NASH can affect its outcome by reducing the likelihood of being treated in a specialist hospital. Research is needed into patient and health service barriers to referral of NSCLC patients for specialist care.