Catherine M Free

Lung cancer in England: Information from the National Lung Cancer Audit (LUCADA)

AIMS Our aims were to determine whether the information in the National Lung Cancer Audit database (LUCADA) is influenced by the completeness of reporting and to describe the current socio-demographics and survival of people with lung cancer in England. METHODS Using national registry data as a gold standard we stratified NHS Trusts into quartiles on the basis of their patient ascertainment. We assessed the distribution of patient features across these quartiles using Cox and logistic regression. We then examined overall survival and access to treatment. RESULTS We analysed data for 60,059 patients whose data were entered between 2004 and 2008. There was little variation in key patient features, treatment and median survival across quartiles of data completeness. Socio-economic disadvantage did not influence survival or access to surgery but was related to a decreased use of chemotherapy. CONCLUSION Our findings suggest that LUCADA accurately describes people in England who are diagnosed with lung cancer and can therefore be used to drive health care improvements. Individual patient socio-economic status does not affect survival and has only a limited impact on access to treatment and so NHS Trust level factors should be studied to explain the previously published regional variations in these outcomes.

Inequalities in outcomes for non-small cell lung cancer: the influence of clinical characteristics and features of the local lung cancer service

Background The treatment given to patients with lung cancer and survival vary between and within countries. The National Lung Cancer Audit (NLCA) linked to Hospital Episode Statistics was used to quantify the extent to which these outcomes are influenced by patient features and/or hospital facilities and performance indicators. Methods All patients with a histological diagnosis of non-small cell lung cancer (NSCLC) were included. Logistic regression was used to quantify the independent influence of features of both patients and hospitals on the likelihood of having surgery and Cox regression was used for survival analyses. Results There were 34 513 patients with NSCLC in our dataset. After adjusting for age, sex, performance status, stage and Charlson Index of comorbidity, patients with NSCLC first seen in thoracic surgical centres (27% of the cohort) were 51% more likely to have surgery than those seen in non-surgical centres (adjusted OR 1.51, 95% CI 1.16 to 1.97). Resection rates varied from 13% to 17% between non-surgical and thoracic surgical centres. Surgery was the most powerful determinant of overall survival (adjusted HR 0.41, 95% CI 0.39 to 0.44). Conclusion A minority of patients with NSCLC first seen in a thoracic surgical centre are more likely to have surgery and to benefit from the survival advantage this confers. This finding suggests that there is an opportunity to improve the outcome for patients with lung cancer in England by optimising access to thoracic surgeons in non-surgical centres.

How do patient and hospital features influence outcomes in small-cell lung cancer in England?

Background:Our aim was to systematically determine how features of patients and hospitals influence access to chemotherapy and survival for people with small-cell lung cancer in England.Methods:We linked the National Lung Cancer Audit and Hospital Episode Statistics and used multiple logistic and Cox regression analyses to assess the influence of patient and hospital features on small-cell lung cancer outcomes.Results:There were 7845 patients with histologically proven small-cell lung cancer. Sixty-one percent (4820) of the patients received chemotherapy. Increasing age, worsening performance status, extensive stage and greater comorbidity all reduced the likelihood of receiving chemotherapy. There was wide variation in access to chemotherapy between hospitals in general and patients first seen in centres with a strong interest in clinical trials had a higher odds of receiving chemotherapy (adjusted odds ratio 1.42, 95% confidence interval (CI) 1.06, 1.90). Chemotherapy was associated with a lower mortality rate (adjusted hazard ratio 0.51, 95% CI 0.46, 0.56).Conclusion:Patients first seen at a hospital with a keen interest in clinical trials are more likely to receive chemotherapy, and chemotherapy was associated with improved survival.

The importance of ultrasound in staging and gaining a pathological diagnosis in patients with lung cancer—a two year single centre experience

Background Initial studies on the use of ultrasound in the detection and sampling of supraclavicular lymph nodes in patients with suspected lung cancer show this to be a promising technique, giving both a cytological diagnosis and pathological N3 (pN3) stage. Leicester published its initial experience in 2005 and the aim of this study was to establish if this had been embedded into the diagnostic pathway, and further to examine the use of ultrasound in diagnosing and staging lung cancer by imaging other areas including pleural effusions, chest wall, bone and liver lesions. Methods All patients diagnosed with lung cancer, registered on the Leicester lung cancer database over a two year period between January 2007 and December 2008, had their imaging and pathology retrospectively reviewed; 996 primary lung cancer patients were identified (n=996). Of these, 318 patients underwent an ultrasound examination (n=318), consisting of ultrasound of the neck, pleural cavity, and metastatic lesions potentially amenable to ultrasound guided aspiration/biopsy. Results The overall malignant yield was 45% of patients scanned (95% CI 39.5% to 50.4%) and 81.3% of patients sampled (95% CI 75.5% to 87%). Of the 996 patients, 14.4% (n=143) had a positive ultrasound guided cytological diagnosis (95% CI 12.2% to 16.5%). Of all the pathological diagnoses (n=765), 18.7% were ultrasound guided (95% CI 15.9% to 21.5%). In particular, 32.2% of patients with CT detected neck or mediastinal nodes had a diagnosis and stage achieved by neck ultrasound. Conclusion The use of ultrasound gives a rapid and less invasive method of diagnosing and staging lung cancer and has become embedded into the diagnostic pathway. We advocate its increased use and availability in patients with lung cancer.

Non-small cell lung cancer in young adults: presentation and survival in the English National Lung Cancer Audit

BACKGROUND Non-small cell lung cancer (NSCLC) in young adults is a rare but devastating illness with significant socioeconomic implications, and studies of this patient subgroup are limited. AIM This study employed the National Lung Cancer Audit to compare the clinical features and survival of young adults with NSCLC with the older age groups. DESIGN A retrospective cohort review using a validated national audit dataset. METHODS Data were analysed for the period between 1 January 2004 and 31 December 2011. Young adults were defined as between 18 and 39 years, and all others were divided into decade age groups, up to the 80 years and above group. We performed logistic and Cox regression analyses to assess clinical outcomes. RESULTS Of a total of 1 46 422 patients, 651 (0.5%) were young adults, of whom a higher proportion had adenocarcinoma (48%) than in any other age group. Stage distribution of NSCLC was similar across the age groups and 71% of young patients had stage IIIb/IV. Performance status (PS) was 0-1 for 85%. Young adults were more likely to have surgery and chemotherapy compared with the older age groups and had better overall and post-operative survival. The proportion with adenocarcinoma, better PS and that receiving surgery or chemotherapy diminished progressively with advancing decade age groups. CONCLUSION In our cohort of young adults with NSCLC, the majority had good PS despite the same late-stage disease as older patients. They were more likely to have treatment and survive longer than older patients.

Investigating and managing suspected pulmonary embolism in an outpatient setting: the Leicester experience

Having established an ambulatory service for patients with suspected and proven PE, we reviewed our outcomes. All patients referred from June 2010 to May 2012 were analysed. Of 971 patients referred, 905 underwent complete assessment (66 admitted as ineligible). 754 (77.7%) patients were discharged and required no follow-up. 96 (10.6%) patients had PE confirmed of whom 70 (72.9%) were managed as outpatients. 14 (1.6%) patients have died since attending the clinic; no death was related to PE. This audit shows that ambulatory investigation and management of selected low risk patients with suspected PE is safe and reduces hospital admissions.

Failure of the broadcaster’s duty of care

The ITV show I’m a Celebrity Get Me Out of Here! has recently been back on UK television. Celebrity contestants live a basic existence in the Australian jungle, deprived of comforts and given only meagre food rations. One thing that is not limited, however, is the supply of cigarettes. …

P226 Managing suspected pulmonary embolism in an ambulatory setting: the Leicester experience

Introduction Suspected Pulmonary Embolism (PE) is a significant cause of admission to hospital. The objective of this study was to establish the feasibility and safety of managing suspected and proven PE in an out-patient setting. Methods Criteria for low risk patients with suspected PE suitable for treatment in an ambulatory setting were established based on modified Pulmonary Embolism Severity Score (PESI) criteria. Patients deemed low risk were referred to a nurse-led clinic. Clinical pre-test probability of PE was recorded for all patients and those with a low/intermediate probability had D-dimer testing. Patients with a high pre-test probability or D-dimer=0.5 μg/ml had radiological investigations. Data were collected prospectively. Missing information was completed from pathology, imaging systems and case-note review. Results 362 patients (Median age 46, Female 70%) with suspected PE were referred to the ambulatory clinic in 12 months from June 2010. 269 (74%) patients presented with chest pain. 145 patients (40%) had a negative D-dimer and were discharged. 210 patients (58%) had subsequent imaging in the form of 65 (31%) VQ scan, 138 (66%) CT scan, 7 (3%) both. Median time to imaging was 1 day (range 0–5 days). 34 patients were diagnosed with PE (9%). 11 patients (3%) were admitted, of which 5 (45%) were due to right heart strain. Likelihood of PE correlated strongly to clinical probability (low 2%, intermediate 14%, high 42%). One patient with a negative D-Dimer and intermediate clinical probability was diagnosed with PE. 294 (81%) patients were discharged with no follow-up, 28 (8%) patients were followed-up by consultant care. One patient admitted as they did not meet criteria for ambulatory care (tachycardia) had a cardiorespiratory arrest as an inpatient due to massive PE but was successfully resuscitated. To date three patients have (0.8%) died since attending the clinic, no death was related to PE. Savings to PCTs were estimated at £120 000 over 12 months. Conclusion Selected patients with suspected and proven PE may be managed safely in an ambulatory PE clinic setting resulting in significant savings to the healthcare community.

P9 Determining the appropriate D-dimer cut-off to exclude pulmonary emboli in an ambulatory care setting using different thresholds based on pre-test probability

Introduction Currently the same threshold value is used to identify a positive D-dimer result for all patients presenting to our ambulatory clinic with suspected pulmonary emboli (PE). It has been suggested that adjusting the threshold value according to the pre-test probability would exclude PE in more patients than using the same cut-off point regardless of clinical probability. Methods Data from 362 consecutive patients presenting to the ambulatory PE clinic was collected. A pre-test probability of PE was recorded for all patients and those with a high pre-test probability had radiological investigations. Patients with a low or intermediate pre-test probability had a latex agglutination D-dimer test. If this result was =0.5 μg/ml they had further investigations, otherwise they were discharged. The diagnosis of PE was made if a VQ scan showed ventilation/perfusion mismatch or CTPA report demonstrated PE. Receiver operating characteristic curve analysis was performed separately for patients with low and intermediate probability and the optimum cut-off value to exclude PE determined. Sensitivity, specificity, negative predictive value and positive predictive value for different cut-off points were determined. Results 362 patients were included in the analysis, 207 (57%) had low, 129 (36%) intermediate and 26 (7%) high pre-test probability. Prevalence of PE was 2% in the low probability group, 14% in the intermediate probability group and 42% in the high probability group. No patients with a D-dimer of <0.5 μg/ml who were discharged without further tests have re-presented with similar symptoms. In the low pre-test probability group, a cut-off point of 1.07 improved the specificity from 64% to 89% while maintaining a sensitivity of 100% and negative predictive value of 100%. Analysis in patients in the intermediate risk group suggested that a cut-off of 0.5 μg/ml was appropriate. By adjusting the D-dimer threshold to >1.0 μg/ml in the low probability group, a further 53 patients could have been discharged home without need for radiological investigation. Conclusion The diagnostic accuracy of D-dimer testing may be improved in patients with a low pre-test probability by adjusting the cut-off threshold.