I Woolhouse

Demographics, management and survival of patients with malignant pleural mesothelioma in the National Lung Cancer Audit in England and Wales.

INTRODUCTION AND METHODS Malignant pleural mesothelioma (MPM) is an uncommon cancer with poor survival. We have used data collected for the UK National Lung Cancer Audit to assess current practice and to highlight regional variation in the management of mesothelioma patients, as well as to describe survival patterns in subgroups. RESULTS Our data on 8740 cases seen in hospitals in England and Wales is the largest cohort of MPM in the literature and represents approximately 80% of the total incident cases. 83% are male and median age is 73 years. Performance status is recorded in 81% and of these approximately 70% are PS 0-2. Stage is poorly recorded and unreliable in this dataset. The patient pathway is similar to lung cancer with approximately one-fifth having a non-elective referral to secondary care. A histo-cytological diagnosis is made in 87% and varies across organisations. Only 67% have anti-cancer treatment, and this also varies across organisations, but there has been an annual increase in the proportion receiving chemotherapy. Overall median survival was 9.5 months, with a 1YS of 41.4% and 3YS of 12.0%, but was strongly linked to performance status and histological subtype. Median survival also varied by cancer network from 209 days to 349 days, but appeared to increase from of 9.2 months in 2008 to 10.5 months in 2012. CONCLUSION Our data provide a large scale, detailed assessment of MPM epidemiology, treatment choices and outcomes. Incidence is increasing in line with predictions and uptake of treatments has generally mirrored publication of key MPM treatment trials, in particular increasing use of chemotherapy but low uptake of radical surgery. However, there is significant variation in care patterns and outcomes that may reflect limited expertise in area with low incidence. Initiatives to improve outcomes should include improved recording of clinical stage.

Reciprocal peer review for quality improvement: an ethnographic case study of the Improving Lung Cancer Outcomes Project

Background Peer review offers a promising way of promoting improvement in health systems, but the optimal model is not yet clear. We aimed to describe a specific peer review model—reciprocal peer-to-peer review (RP2PR)—to identify the features that appeared to support optimal functioning. Methods We conducted an ethnographic study involving observations, interviews and documentary analysis of the Improving Lung Cancer Outcomes Project, which involved 30 paired multidisciplinary lung cancer teams participating in facilitated reciprocal site visits. Analysis was based on the constant comparative method. Results Fundamental features of the model include multidisciplinary participation, a focus on discussion and observation of teams in action, rather than paperwork; facilitated reflection and discussion on data and observations; support to develop focused improvement plans. Five key features were identified as important in optimising this model: peers and pairing methods; minimising logistic burden; structure of visits; independent facilitation; and credibility of the process. Facilitated RP2PR was generally a positive experience for participants, but implementing improvement plans was challenging and required substantial support. RP2PR appears to be optimised when it is well organised; a safe environment for learning is created; credibility is maximised; implementation and impact are supported. Discussion RP2PR is seen as credible and legitimate by lung cancer teams and can act as a powerful stimulus to produce focused quality improvement plans and to support implementation. Our findings have identified how RP2PR functioned and may be optimised to provide a constructive, open space for identifying opportunities for improvement and solutions.

Patient characteristics, treatment and survival in pulmonary carcinoid tumours: an analysis from the UK National Lung Cancer Audit

Objectives Pulmonary carcinoid (PC) is a rare tumour with good prognosis following surgical resection. However, little is known regarding patient characteristics and use of other treatments modalities. Our objective was to review patient characteristics, treatment and survival for patients with PC and contrast these results with other forms of non-small cell lung cancer (NSCLC). Setting Audit data from UK National Lung Cancer Audit (NLCA) 2008–2013. Participants 184 906 lung cancer cases were submitted to the NLCA. Outcome measures Primary outcome—survival rates between PC and NSCLC. Secondary outcome—differences in performance status, lung function and treatment modality between PC and NSCLC. Results PC histology was recorded in 1341 (0.73%) patients and non-carcinoid NSCLC histology in 162 959 (87.4%) cases. 91% of patients with PC had good performance status (Eastern Cooperative Oncology Group (ECOG) 0–1), compared with only 53% of NSCLC. 66% of PC had localised disease. Of all PC cases, 77% were treated with surgery, 6.2% received chemotherapy and 3.6% received radiotherapy, with the remainder treated with best supportive care. Overall 1-year and 3-year survival rates for PC were 92% and 84.7%, respectively. In contrast, 1-year and 3-year survival rates for NSCLC were 36.2% and 15.6%, However, 3-year survival for PC markedly decreased with worsening performance status and advanced disease to 23.8% for performance status ECOG 3–4 and 33.6% for stage IV disease. Conclusions In contrast to other forms of NSCLC, the majority of patients with PC present with good performance status, preserved lung function and early stage disease amenable to surgical resection. However, 1 in 5 patients with PC has metastatic disease which is associated with poor prognosis, as is poor performance status at presentation. We believe these data will help clinicians provide accurate prognostic predictions stratified according to patient characteristics at presentation, as well as guide future clinical trials.

Variation in lung cancer resources and workload: results from the first national lung cancer organisational audit

We report the findings of the first national lung cancer organisational audit. The results demonstrate marked variation in service provision and workload of some lung cancer specialists. For example, over half of the clinical nurse specialists report case volumes over recommended numbers. Some trusts have no access to key treatments such as video assisted thoracoscopy (VAT) lobectomy and stereotactic radiotherapy. Multivariate regression analysis demonstrated an association between higher surgical resection rates and the on-site availability of advanced staging and therapeutic modalities, for example, PET scan and VAT lobectomy. We conclude by making a number of recommendations to address the variation in lung cancer care.

S90 Nurse specialist input is independently associated with anti-cancer treatment in lung cancer

Introduction Lung cancer nurse specialists (LCNS) provide an extremely important service to patients. Their skill and expertise are valued very highly by both patients and colleagues, but it has proven difficult to measure their input objectively, leading to a lack of expansion (and in some areas contraction) of the workforce. Earlier this year the National Lung Cancer Audit (NLCA) reported that for 2009, patients who saw an LCNS were more than twice as likely to receive active anti-cancer treatment, but the relevance of this observation is obscured by a lack of case-mix adjustment and a high proportion of unrecorded data. We have sought to examine this finding more closely on the 2010 dataset (with less unrecorded data) by performing case-mix adjustment. Methods Details of all patients from English trusts that were submitted to the NLCA database in 2010 were obtained. We then performed logistic regression analysis based on sex, age, stage and performance status to calculate mutually-adjusted ORs for overall and specific treatments. Since a patient would have reduced opportunity to access an LCNS if their survival were short, a second model was created excluding those patients who had survival of <28 days. Results Of 30 334 in the dataset, 42 were removed due to missing sex (4), in situ disease (2) and occult stage (36). 74.8% were recorded as having been seen by a LCNS, 7.8% were not seen, and in 17.4% the outcome was not recorded. The latter two groups were combined for the remainder of the analysis. ORs for treatment if seen by a nurse in both models are shown below. Conclusions Contact with a LCNS was associated with increased rates of active treatment, particularly chemotherapy or radiotherapy, but not surgery, and this effect was independent of sex, age, disease stage and performance status. While the LUCADA dataset does not contain detailed information on individual reasons for LCNS assessments, this should be investigated further as there may be important additions to the known benefits LCNS provide to patients. However, regardless of the explanation, all lung cancer patients should have the opportunity to benefit from the expertise of a LCNS.Abstract S90 Table 1 Number having treatment (%) OR (95% CI) vs no nurse/unknown Seen by nurse Not seen by nurse/unknown All patients Patients surviving >28 days Anti-cancer treatment 14 631 (64.5%) 3080 (40.4%) 2.04 (1.91 to 2.18) 1.87 (1.74 to 2.01) Surgery 3456 (15.3%) 922 (12.1%) 1.06 (0.97 to 1.17) 1.01 (0.91 to 1.11) Chemotherapy 7708 (34.0%) 1247 (16.4%) 2.05 (1.90 to 1.22) 1.87 (1.72 to 2.02) Radiotherapy 7140 (31.5%) 1474 (19.3%) 1.57 (1.47 to 1.68) 1.47 (1.38 to 1.59)

S90 The National Lung Cancer Audit – No Evidence of a “Seven-Year Itch”

Introduction The National Lung Cancer Audit, now in its7th year, is run jointly by the Royal College of Physicians and The Information Centre for health and social care, and is commissioned by the Healthcare Quality Improvement Partnership (HQIP). Its development was driven by the realisation that lung cancer outcomes vary widely across the UK and are poor compared to other western countries. The aim of the audit is to facilitate service improvement by recording elements of process and outcomes in lung cancer on a large scale and, using case-mix adjustment, to explain the wide variations noted and improve standards of care. Although several other countries also submit data to the audit, this abstract presents provisional results for UK only. Results In this 7th year of data collection, 31,429 patient records were submitted, making it the most comprehensive annual dataset so far, with year on year improvements in the quality of the data on individual cases. Full details are given in Table 1. Whilst the histological confirmation rate has fallen slightly, it remains well above that recorded in early years. The surgical resection rate has risen and in those patients with NSCLC has gone above 20% for the first time. Almost 80% of patients benefit from the input of a specialist nurses, although in only 60% of cases is the nurse present at the time of diagnosis. Our final presentation will contain further analyses of survival across the audit lifespan. Abstract S90 Table 1 Headline Results by Year Data Completeness 2005 2006 2007 2008 2009 2010 2011 Number of cases 10,920 16,922 20,639 25,757 30,158 30,329 31,429 PS 66% 77% 80% 87% 88% 84% 89% Staging 51% 55% 70% 77% 80% 82% 84% Treatment 66% 72% 79% 82% 89% 89% 91% Process and Outcomes 2005 2006 2007 2008 2009 2010 2011 Confirmed Histological diagnosis 68% 66% 65% 66.7% 69.5% 76.5% 73.8% Histology  NSCLC 44.8% 43.9% 45.5% 52.2% 56% 57% 58.4%  SCLC 10.3% 10% 9.6% 10.3% 10.5% 10.9% 11.1%  Mesothelioma 3.7% 3.5% 4.2% 4.4% 5.0% 5.5% 5.2% NSCLC NOS rate - 36% 32% 33.6% 30% 24% *TBC Discussed at MDT? 79% 84.3% 86.8% 88.6% 93.2% 96.1% 95.9% Any anti-cancer treatment? 45% 50% 52% 54% 58.9% 58.5% 60.5% Overall surgical resection rate 9% 9.4% 10.3% 11.2% 13.9% 13.9% 15.3% NSCLC resection rate 13.8% 14.3% 15.2% 16% 19% 18.3% 21% SCLC chemotherapy rate 57.7% 61.7% 64.5% 63% 66% 65% 68% 1 year survival 35.5% 35.0% 34.6% 34.7% 35.2% 35.8% *TBC Seen by LCNS - - - 50.9% 64.4% 75.5% 79.4% LCNS at diagnosis - - - 28.5% 41% 51.9% 58.7% * TBC=to be confirmed; LCNS=lung cancer specialist nurse; NOS=not otherwise specified. Conclusions This new data provides further evidence of rising standards of care in England, which in some cases now approach those quoted by other international groups. Far from seeing a “Seven Year Itch”, the enthusiasm of lung cancer teams continues to produce cancer audit of a standard that is the envy of other groups both nationally and internationally. Major changes in the recording of cancer intelligence in England, such as the mandated Cancer Outcomes and Services Dataset (COSD), will have significant implications for the future role of the audit and work is ongoing to ensure that the data collected continues to be appropriate and relevant.

S60 Lung cancer surgical survival and volume in england

Introduction The National Lung Cancer Audit has collected data for over 10 years demonstrating gradually rising resection rates in the UK. The Clinical (formerly Consultant) Outcomes Programme (COP) is an NHS England initiative, managed by HQIP, using national audit data to publish quality measures at the level of individual consultants. The lung cancer COP focusses on activity at individual surgeon level, and on survival at unit level. The first lung cancer COP in 2014 demonstrated overall 30 and 90-day survival of 97.8% and 95.5%. Methods Data submitted to the NLCA for patients having curative-intent surgery who underwent surgery in 2013 was sent to the clinical lead at each surgical unit for validation and addition of responsible surgeon GMC number, with the option to add surgical cases if they were not included in the supplied dataset. Date of death was derived by a link to the Office of National Statistics. Units reporting unadjusted survival proportions more than three standard errors outside the national mean (“alarm” level) at 30 or 90 days were identified as statistical outliers. Results All of the 28 surgical units in England participated in the audit, submitting a total of 4892 cases. Median annual unit activity was 156 resections (IQR 99–221, range 39–481). Median annual activity for individual surgeons was 39 (IQR 20–52, range 1–152). Overall 30-day survival was 98% and 90-day survival was 96%. There were no units with statistical outliers at the alarm level at 30-days and 90-days (see Figure). Conclusion Volume of activity varies widely by unit and individual surgeon. Survival after lung cancer surgery is very high, is improving, and is not statistically significantly different across the surgical units in England. This suggests that lung cancer teams may still be risk averse when considering surgical treatment of their patients. Reasons why patients die between 30 and 90 days is worthy of further investigation. Case-mix adjustment will be needed to allow robust comparisons between units. Abstract S60 Figure 1 30 and 90 day survival by trust

P104 Results of the first analysis of national lung cancer audit data based on cancer registration data

Introduction The National Lung Cancer Audit (NLCA) has collected data for over 10 years, but in early 2015 a transition to using the Cancer Outcomes and Services Dataset (COSD) and cancer registration was begun and has now entirely superseded the legacy LUCADA dataset. An online portal (CancerStats) has been developed with a bespoke section providing near real time analysis of unprocessed COSD data for the NLCA. This portal currently focusses on data completeness, with plans to add process and treatment data in the near future. We report the results of the first 12 months of data collection using the new system (2015), and have compared this to the last year of LUCADA submissions (2014). Methods The COSD was submitted monthly by English trusts on patients diagnosed with invasive lung cancer throughout 2015. This raw data was used to populate the data completeness tables on the CancerStats portal. An algorithm was developed to allocate a “trust first seen” to each patient record. Our presentation will include data from the final processed cancer registration records that have been validated using all available data sources within the National Cancer Registration Service (NCRAS). Welsh data submitted via their CANISC system will be available for our presentation. Results 35,000 individual cases of invasive lung cancer were submitted by English Trusts. Data completeness results are shown in Table 1. Our final presentation will be updated with data from the processed cancer registration records that have been validated using all available data sources within the National Cancer Registration Service (NCRAS), as well as results from Welsh trusts. Conclusion COSD submissions appear to capture more cases of lung cancer than LUCADA. During this transition period, the quality of the data was less good than previous years with significant variation across organisations. However, data completeness for stage and treatment is expected to be better than indicated since final registered cases use data from a variety of other sources. CancerStats offers the opportunity for teams to monitor their data quality and to iteratively improve their internal processes to deliver robust data for future years, in particular patient factors such as performance status which is not available elsewhere. Abstract P104 Table 1 Comparison of LUCADA (2014) and cancer registration data (2015) Measure National average (Range by Strategic Clinical Network) LUCADA 2014 Number of diagnoses 33,465 27,995 Gender 100% 96% Ethnicity 86% (70–96) N/A Performance Status 69% (59–76) 89% FEV1% 24% (9–35) 20% Smoking status 43% (27–57) N/A Basis of Diagnosis 95% (87–100) 99% Pre-treatment stage 72% (54–77) 92% Treatment modality 83% (66–93) 57%

P103 Apples and pears? a comparison of two sources of lung cancer data in england

Introduction In 2014, the contract to deliver the National Lung Cancer Audit (NLCA) was awarded to the Royal College of Physicians. Data were previously submitted using a bespoke dataset (LUCADA), but will now be submitted via the nationally mandated Cancer Outcome and Services Dataset (COSD) and linked to additional cancer registry datasets. For patients diagnosed in 2014, NLCA data were submitted using LUCADA for 132 of 151 English trusts. Trusts also submitted data via COSD and registry data were produced by the National Cancer Registration Analysis Service (NCRAS), providing the opportunity to compare both datasets for data completeness and reliability. Methods We have linked the LUCADA and cancer registration datasets at patient level and assessed completeness of key patient variables including age, sex, stage, performance status and pathological confirmation, as well as recording/dates of treatment received. We assessed the inter-rater/data agreement of these variables using Cohen’s kappa statistics (k). Finally, we carried out a qualitative assessment on a subset of cases to explore reasons why patients were represented in one dataset but not the other. Results There were 26,001 patients in both datasets (94% of LUCADA data) with more in the registry dataset and not LUCADA than vice versa. Recorded sex and age were highly congruent, as was trust first seen which was the same in 96%. 56% of the patients had the same date of diagnosis, 74% were ± 7 days and 86% were ± 14 days of each other. The cancer registry data had a larger proportion of patients with missing PS (27% vs 11%) with agreement on PS (where available) being 97% (k = 0.91). Agreement on stage was 94% (k = 0.81). Agreement for surgery, chemotherapy and radiotherapy was 0.86, 0.88 and 0.77 respectively. Details of the qualitative work and trust first seen algorithms will be provided in the presentation. Conclusion Results suggest that cancer registry data accurately describe key patient features. Compared with LUCADA, the national cancer registry: identified more patients has a higher proportion pathological confirmation identified more patients with surgery, chemotherapy and radiotherapy has a higher proportion of missing data for PS which could be due to data entry transition Abstract P103 Table 1 Key Variables Cancer registry database n (%) LUCADA database n (%) Agreement% Kappa (κ) Sex Female 11990 (46) 11987 (46) Male 14011 (54) 14014 (54) 99% 0.99 Age <65 6032 (23) 6025 (23) 65–80 14249 (55) 14242 (55) >80 5720 (22) 5734 (22) 99% 0.99 Pathology Confirmed No 6341 (24) 7664 (29) Yes 19660 (76) 18337 (71) 89% 0.73 Lung Cancer Type Small Cell 2975 (11) 2958 (11) Carcinoid 189 (1) 234 (1) Non-small cell 22837 (88) 22809 (88) 97% 0.87 Performance Status 0 3816 (15) 4278 (16) 1 6550 (25) 7869 (30) 2 4025 (15) 5109 (20) 3 3553 (14) 4527 (17) 4 1152 (4) 1424 (5) 97% 0.91†‡ Missing 6905 (27) 2794 (11) 83% 0.57† Stage IA 2976 (8) 2226 (9) IB 2296 (6) 1714 (7) IIA 1405 (4) 1087 (4) IIB 1236 (4) 1025 (4) IIIA 3981 (11) 3330 (13) IIIB 2844 (8) 2470 (9) IV 16758 (47) 12258 (47) 96% 0.90†‡ Missing 4022 (11) 1891 (7) 94% 0.81† † Weighted Kappa κ ‡ Excluding missing data

S72 Improving lung cancer survival in England evidenced through multiple data sources

Introduction We have collated data from several sources to demonstrate that efforts made over the last 10 years to use data to drive service improvement and improved patient outcomes for UK patients with lung cancer have been successful. Methods We used data submitted to the National Lung Cancer Audit (NLCA), National Cancer Registration Service (NCRS), Office for National Statistics (ONS) and Society of Cardiothoracic Surgeons (SCTS) from 1995–2013. We calculated numbers and proportions undergoing surgery, case-mix adjusted hazard ratios for death, and actual and predicted (using hybrid analyses) 1-year and 5-year survival for lung cancer patients in England. An international comparison has been made using data from the CONCORD-2 study. Results In the NLCA, the proportion of NSCLC patients undergoing resection has risen from 14% (2005) to 23% (2013). Over this period, annual primary lung cancer resections have risen from 3,220 to 6,713. NLCA data, adjusted for age, sex, stage and PS, indicates a gradually falling hazard ratio for death (2013 HR 0.87, 95% CI 0.85–0.89 compared to 2008). ONS data demonstrates a gradual improvement in both 1 yr and 5 yr, and mirrors the increase in the number of resections carried out over the lifetime of the NLCA. Comparison of 1YS with other countries suggests that England has passed the survival measured in Denmark in 2004–07 (35%), but still lags behind Canada (42%) and Sweden (46%). In another analysis using NCRS data, comparing stage-specific 1 yr survival in England in 2004–07 and 2012, improvements are most marked in patients with early stage disease. Conclusion Whilst many changes have taken place in the management of lung cancer over the last 10 years, the close temporal association between the date of the first NLCA report (2005), the numbers of resections carried out and the significant improvements in 1 and 5 yr survival (weighted towards earlier stages) and mortality we report here, would strongly suggest that the NLCA has been successful in its aim to improve standards of care and outcomes for patients. These improvements in survival bring England close to parity with other westernised countries, though there is still more work to do.Abstract S72 Table 1 Resections, actual/predicted survival and incremental survival improvements over study period Year Number of resections 1 yr survival% 5 yr survival (%) (actual or predicted*) Improvement in 1 yr survival Improvement in 5 yr survival 1995 3220 (mean) 23.2 6.5 +0.73%/yr +0.22%/yr 1996 23.3 6.7 1997 25.1 7.4 1998 25.0 7.2 1999 26.1 7.4 2000 27.4 8.0 +0.48%/yr +0.12%/yr 2001 27.7 8.2 2002 28.0 8.0 2003 29.2 9.1 2004 29.2 8.5 2005 30.3 9.1 +0.79%/yr +0.65%/yr 2006 3740 30.1 9.1 2007 4100 32.2 10.3 2008 4350 32.5 10.8 2009 4500 33.5 11.8* 2010 5250 34.8 12.7* +2.15%/yr +1.05%/yr 2011 6360 36.3 13.8* 2012 6474 39.0 14.9* 2013 6713 n/a 16.0*