M.D. Peake

Chemotherapy versus supportive care in advanced non-small cell lung cancer: improved survival without detriment to quality of life

Background: In 1995 a meta-analysis of randomised trials investigating the value of adding chemotherapy to primary treatment for non-small cell lung cancer (NSCLC) suggested a small survival benefit for cisplatin-based chemotherapy in each of the primary treatment settings. However, the meta-analysis included many small trials and trials with differing eligibility criteria and chemotherapy regimens. Methods: The aim of the Big Lung Trial was to confirm the survival benefits seen in the meta-analysis and to assess quality of life and cost in the supportive care setting. A total of 725 patients were randomised to receive supportive care alone (n = 361) or supportive care plus cisplatin-based chemotherapy (n = 364). Results: 65% of patients allocated chemotherapy (C) received all three cycles of treatment and a further 27% received one or two cycles. 74% of patients allocated no chemotherapy (NoC) received thoracic radiotherapy compared with 47% of the C group. Patients allocated C had a significantly better survival than those allocated NoC: HR 0.77 (95% CI 0.66 to 0.89, p = 0.0006), median survival 8.0 months for the C group v 5.7 months for the NoC group, a difference of 9 weeks. There were 19 (5%) treatment related deaths in the C group. There was no evidence that any subgroup benefited more or less from chemotherapy. No significant differences were observed between the two groups in terms of the pre-defined primary and secondary quality of life end points, although large negative effects of chemotherapy were ruled out. The regimens used proved to be cost effective, the extra cost of chemotherapy being offset by longer survival. Conclusions: The survival benefit seen in this trial was entirely consistent with the NSCLC meta-analysis and subsequent similarly designed large trials. The information on quality of life and cost should enable patients and their clinicians to make more informed treatment choices.

National comparisons of lung cancer survival in England, Norway and Sweden 2001–2004: differences occur early in follow-up

Background Countries with a similar expenditure on healthcare within Europe exhibit differences in lung cancer survival. Survival in lung cancer was studied in 2001–2004 in England, Norway and Sweden. Methods Nationwide cancer registries in England, Norway and Sweden were used to identify 250 828 patients with lung cancer from England, 18 386 from Norway and 24 886 from Sweden diagnosed between 1996 and 2004, after exclusion of patients registered through death certificate only or with missing, zero or negative survival times. 5-Year relative survival was calculated by application of the period approach. The excess mortality between the countries was compared using a Poisson regression model. Results In all subcategories of age, sex and follow-up period, the 5-year survival was lower in England than in Norway and Sweden. The age-standardised survival estimates were 6.5%, 9.3% and 11.3% for men and 8.4%, 13.5% and 15.9% for women in the respective countries in 2001–2004. The difference in excess risk of dying between the countries was predominantly confined to the first year of follow-up. The relative excess risk ratio during the first 3 months of follow-up comparing England with Norway 2001–2004 varied between 1.23 and 1.46, depending on sex and age, and between 1.56 and 1.91 comparing England with Sweden. Conclusion Access to healthcare and population awareness are likely to be major reasons for the differences, but it cannot be excluded that diagnostic and therapeutic activity play a role. Future improvements in lung cancer management may be seen early in follow-up.

Is England closing the international gap in cancer survival

Background:We provide an up-to-date international comparison of cancer survival, assessing whether England is ‘closing the gap’ compared with other high-income countries.Methods:Net survival was estimated using national, population-based, cancer registrations for 1.9 million patients diagnosed with a cancer of the stomach, colon, rectum, lung, breast (women) or ovary in England during 1995–2012. Trends during 1995–2009 were compared with estimates for Australia, Canada, Denmark, Norway and Sweden. Clinicians were interviewed to help interpret trends.Results:Survival from all cancers remained lower in England than in Australia, Canada, Norway and Sweden by 2005–2009. For some cancers, survival improved more in England than in other countries between 1995–1999 and 2005–2009; for example, 1-year survival from stomach, rectal, lung, breast and ovarian cancers improved more than in Australia and Canada. There has been acceleration in lung cancer survival improvement in England recently, with average annual improvement in 1-year survival rising to 2% during 2010–2012. Survival improved more in Denmark than in England for rectal and lung cancers between 1995–1999 and 2005–2009.Conclusions:Survival has increased in England since the mid-1990s in the context of strategic reform in cancer control, however, survival remains lower than in comparable developed countries and continued investment is needed to close the international survival gap.

The European initiative for quality management in lung cancer care

Lung cancer is the commonest cause of cancer-related death worldwide and poses a significant respiratory disease burden. Little is known about the provision of lung cancer care across Europe. The overall aim of the Task Force was to investigate current practice in lung cancer care across Europe. The Task Force undertook four projects: 1) a narrative literature search on quality management of lung cancer; 2) a survey of national and local infrastructure for lung cancer care in Europe; 3) a benchmarking project on the quality of (inter)national lung cancer guidelines in Europe; and 4) a feasibility study of prospective data collection in a pan-European setting. There is little peer-reviewed literature on quality management in lung cancer care. The survey revealed important differences in the infrastructure of lung cancer care in Europe. The European guidelines that were assessed displayed wide variation in content and scope, as well as methodological quality but at the same time there was relevant duplication. The feasibility study demonstrated that it is, in principle, feasible to collect prospective demographic and clinical data on patients with lung cancer. Legal obligations vary among countries. The European Initiative for Quality Management in Lung Cancer Care has provided the first comprehensive snapshot of lung cancer care in Europe. European initiative on quality management in lung cancer: first systematic snapshot on lung cancer care in Europe http://ow.ly/tHfIF

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.

Improving care for patients with lung cancer in the UK

The care of patients with lung cancer in the UK today has improved over the last 10 years, primarily because we are now able to measure and quantify the differences in patient care pathways and outcomes. The National Lung Cancer Audit started in 2004 with 40% case ascertainment and today it is inconceivable that any NHS hospital that manages patients with lung cancer would not contribute. With 100% case ascertainment since 2010,1 active treatment rates increased from 45% in 2005 to 61% in 2012 and the overall surgical resection rates rose from 9% to 16% in the same period. Measurements of performance and outcome data can drive improved survival in patients with lung cancer, and the establishment of national data collection is an important step towards improving the quality of patient care.2 However, even with these improvements, survival from lung cancer in the UK lags behind that of comparable countries.3 ,4 The reasons for this in part are due to late diagnosis and huge variations in the delivery of care across the country. A round table meeting assembled experts with the remit to explore what changes were needed in the current management of patients with lung cancer in the UK to improve their survival. To provide a snapshot of how respiratory physicians view the current state of lung cancer management in the UK, Thorax sent out an online survey in August 2013 to 6000 hospital physicians identified as having an interest in respiratory medicine. This group was chosen as respiratory physicians are the ‘gatekeepers’ who determine entry into lung cancer diagnostic and care pathways: their attitudes have great influence on lung cancer patients. Responses were received from 3–4% of the survey group, who are likely to represent a particularly motivated group of respiratory physicians with an interest …

Endoscopic (oesophageal) ultrasound guided fine needle aspiration (EUS-FNA)

A new tool in lung cancer staging The management of lung cancer depends to a great extent on its histological type and the stage of disease. Although most patients with non-small cell lung cancer (NSCLC) have advanced disease at presentation, approximately 30% have tumour confined to the lung and locoregional lymph nodes. For these patients surgery offers the best hope of a cure. Despite apparent complete resection, 5 year survival rates after surgery are approximately 40–50%.1 This highlights the importance of accurately staging lung cancer to determine resectability and provide prognostic information. In clinical practice a presumptive diagnosis and stage are based on presentation, risk factors, and radiological appearances—particularly CT scans. Obtaining a histological diagnosis and confirming the stage of the disease often take place at the same time. One of the most difficult tasks is accurate staging of nodal involvement in the mediastinum. It is reported that mediastinal lymph nodes contain metastatic disease in 28–38% of patients with NSCLC at the time of diagnosis.2 Traditionally, CT scanning has been used to assess mediastinal lymph node involvement. Lymph nodes greater than 1 cm in short axis diameter are considered abnormal and suggest involvement. However, CT detection of lymph node spread has sensitivity and specificity rates of 61% and 79%, respectively.3 Positron emission tomography with 18-fluorodeoxyglucose (FDG-PET) is more accurate in identifying mediastinal lymph node involvement. FDG-PET in combination with CT scanning has been shown to further improve sensitivity and specificity rates in detecting lymph node involvement,3 but in much of …

Lung cancer resection rate is related to survival

Treasure and colleagues1 provided a welcomed counterpoint to the belief that resection rate should go up in England. However, we feel the editorial is intentionally controversial and biased against the role of surgery. In particular, the authors question the relationship between resection rate and outcome but fail to cite the recent evidence that relates resection rate to survival in the UK: that the small excess mortality from operating in higher-risk groups was more than justified by the increase in overall survival from lung cancer.2 In terms of treatment, …

ERS Statement on harmonised standards for lung cancer registration and lung cancer services in Europe

The European Respiratory Society (ERS) task force for harmonised standards for lung cancer registration and lung cancer services in Europe recognised the need to create a single dataset for use in pan-European data collection and a manual of standards for European lung cancer services. The multidisciplinary task force considered evidence from two different sources, reviewing existing national and international datasets alongside the results of a survey of clinical data collection on lung cancer in 35 European countries. A similar process was followed for the manual of lung cancer services, with the task force using existing guidelines and national or international recommendations for lung cancer services to develop a manual of standards for services in Europe. The task force developed essential and minimum datasets for lung cancer registration to enable all countries to collect the same essential data and some to collect data with greater detail. The task force also developed a manual specifying standards for lung cancer services in Europe. Despite the wide variation in the sociopolitical landscape across Europe, the ERS is determined to encourage the delivery of high-quality lung cancer care. Both the manual of lung cancer services and the minimum dataset for lung cancer registration will support this aspiration. Written by Europeans for Europeans, this minimum dataset and manual for lung cancer services will help to improve standards for our patients http://ow.ly/6qa630mm5bz