R Stanley

Early mortality after surgical resection for lung cancer: an analysis of the English National Lung cancer audit

Introduction For appropriately staged non-small cell lung cancer (NSCLC) surgical resection can dramatically improve survival, but some may not be offered this treatment because of concerns about perioperative mortality. Methods We used data from the National Lung Cancer Audit (NLCA) to determine the proportions of English patients who died within 30 and 90 days after surgery for NSCLC. We quantified the predictors of early postoperative death and using these results devised a score to predict risk of death within 90 days of surgery. Results We analysed data on 10 991 patients operated on between 2004 and 2010. Three per cent (334) of patients died within 30 days of their procedure and 5.9% (647) within 90 days. Age was strongly associated with early postoperative death (adjusted OR within 90 days for 80–84 years vs 70–74 years: 1.46, 95% CI 1.07 to 1.98); significant associations were also observed with performance status (PS) (adjusted OR within 90 days for PS 2 vs PS 0: 2.40, 95% CI 1.68 to 3.41), as well as lung function, stage and procedure type. Conclusions Our results show that age is the most important predictor of death within both of these early postoperative periods. We used the data in the NLCA to develop a predictive score, based on an English population and specific to lung cancer surgery, which estimates risk of death within 90 days; this score should be tested in future cohorts.

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.

Lung cancer survival in England: trends in non-small-cell lung cancer survival over the duration of the National Lung Cancer Audit.

Background:In comparison with other European and North American countries, England has poor survival figures for lung cancer. Our aim was to evaluate the changes in survival since the introduction of the National Lung Cancer Audit (NLCA).Methods:We used data from the NLCA to identify people with non-small-cell lung cancer (NSCLC) and stratified people according to their performance status (PS) and clinical stage. Using Cox regression, we calculated hazard ratios (HRs) for death according to the year of diagnosis from 2004/2005 to 2010; adjusted for patient features including age, sex and co-morbidity. We also assessed whether any changes in survival were explained by the changes in surgical resection rates or histological subtype.Results:In this cohort of 120 745 patients, the overall median survival did not change; but there was a 1% annual improvement in survival over the study period (adjusted HR 0.99, 95% confidence interval (CI) 0.98–0.99). Survival improvement was only seen in patients with good PS and early stage (adjusted HR 0.97, 95% CI 0.95–0.99) and this was partly accounted for by changes in resection rates.Conclusion:Survival has only improved for a limited group of people with NSCLC and increasing surgical resection rates appeared to explain some of this improvement.

The impact of the ‘hub and spoke’ model of care for lung cancer and equitable access to surgery

Objectives To determine the influence of where a patient is first seen (either surgical or non-surgical centre) and patient features on having surgery for non-small cell lung cancer (NSCLC). Design Cross-sectional study from individual patients, between 1January 2008 and 31March 2012. Setting Linked National Lung Cancer Audit and Hospital Episode Statistics datasets. Participants 95 818 English patients with a diagnosis of NSCLC, of whom 12 759 (13%) underwent surgical resection. Main outcome measure Odds of having surgery based on the empirical catchment population of the 30 thoracic surgical centres in England and whether the patient is first seen in a surgical centre or a non-surgical centre. Results Patients were more likely to be operated on if they were first seen at a surgical centre (OR 1.37; 95% CI 1.29 to 1.45). This was most marked for surgical centres with the largest catchment populations. In these surgical centres with large catchment populations, the resection rate for local patients was 18% and for patients first seen in a non-surgical centre within catchment was 12%. Conclusions Surgical centres that serve the largest catchment populations have high resection rates for patients first seen in their own centre but, in contrast, low resection rates for patients first seen at the surrounding centres they serve. Our findings demonstrate the importance of going further than relating resection rates to hospital volume or surgeon number, and show that there is a pressing need to design lung cancer services which enable all patients, including those first seen at non-surgical centres, to have equal access to lung cancer surgery.

Small-Cell Lung Cancer in England: Trends in Survival and Chemotherapy Using the National Lung Cancer Audit

Background The purpose of this study was to identify trends in survival and chemotherapy use for individuals with small-cell lung cancer (SCLC) in England using the National Lung Cancer Audit (NLCA). Methods We used data from the NLCA database to identify people with histologically proven SCLC from 2004–2011. We calculated the median survival by stage and assessed whether patient characteristics changed over time. We also assessed whether the proportion of patients with records of chemotherapy and/or radiotherapy changed over time. Results 18,513 patients were diagnosed with SCLC in our cohort. The median survival was 6 months for all patients, 1 year for those with limited stage and 4 months for extensive stage. 69% received chemotherapy and this proportion changed very slightly over time (test for trends p = 0.055). Age and performance status of patients remained stable over the study period, but the proportion of patients staged increased (p-value<0.001), mainly because of improved data completeness. There has been an increase in the proportion of patients that had a record of receiving both chemotherapy and radiotherapy each year (from 19% to 40% in limited and from 9% to 21% in extensive stage from 2004 to 2011). Patients who received chemotherapy with radiotherapy had better survival compared with any other treatment (HR 0.24, 95% CI 0.23–0.25). Conclusion Since 2004, when the NLCA was established, the proportion of patients with SCLC having chemotherapy has remained static. We have found an upward trend in the proportion of patients receiving both chemotherapy and radiotherapy which corresponded to a better survival in this group, but as it only applied for a small proportion of patients, it was not enough to change the overall survival.

The pathological confirmation rate of lung cancer in England using the NLCA database

BACKGROUND The National Lung Cancer Audit (NLCA) recommends that trusts obtain pathology (histology or cytology) for 75% of their lung cancer patients, however this figure was arbitrarily chosen and the optimal pathological confirmation rate is unknown, and many countries report somewhat higher rates. The aims of this study were to provide a simple means of benchmarking appropriate pathological confirmation rates by stratifying patients into groups, and whether obtaining pathology based on those groups is associated with a survival benefit. METHODS We calculated the proportion of patients with non-small cell or small cell lung cancer in the NLCA database, first seen between 1st January 2004 and 31st December 2010, who had pathological confirmation of their diagnosis. Using logistic we assessed the independent influence of patient factors on the likelihood of having histology or cytology, and the overall effect on survival. We also used bivariate analysis to identify the features which were most strongly associated with having pathology and performed Cox regression to identify any survival advantage. FINDINGS We analysed data on 136,993 individuals. Age and performance status (PS) were the strongest predictors of pathological confirmation: age ≥ 85 odds ratio (OR) 0.20 (95% confidence interval (CI) 0.19-0.22) compared with age<55; PS 4 OR 0.11 (95%CI 0.10-0.12) compared with PS 0. Pathological confirmation of diagnosis was associated with a small early survival advantage for groups 1 & 2 which represented younger patients with good PS, even after adjusting for other patient features: hazard ratio (HR) 0.93 & 0.89 respectively. CONCLUSION Stratifying patients by age and performance status is useful and appropriate when benchmarking standards for pathological confirmation of the diagnosis of lung cancer. We have shown better survival at six months and one year for younger patients with better PS, even after adjusting for confounders. Much of the survival advantage was accounted for by adjusting for the use of chemotherapy.

P13 Identifying patients who had surgical resection for non-small cell lung cancer using large datasets

Introduction Surgical resection rates have become an important indicator of NHS Trust performance and efforts to increase them are on-going with the aim of improving overall survival. The National Lung Cancer Audit (NLCA) has collected data on primary lung cancer since 2004 and has now been linked with Hospital Episode Statistics (HES) for research into inequalities in access to treatment. How well these two large datasets capture surgical data is not known. Methods We used the NLCA to identify all cases of NSCLC, excluding stage IIIB or IV, diagnosed between January 2004 and March 2010. We calculated the proportion of cases with a procedure date in the NLCA, and the proportion with a code in HES, for potentially curative surgery less than 6 months after or 3 months before diagnosis. We looked at the age, lung function, performance status, stage and survival according to where surgery was recorded. Given the increase in NLCA case ascertainment from approximately 19% in 2004 to 98% in 2009 we also looked for changes in our results over time. Abstract P13 Table 1. Features and survival of people according to the database in which records of surgery were present N= 60,196 Record of surgical procedure Both HES only NLCA only Neither n = 8,53514% n = 2,5684% n = 7951% n = 48,29880% Mean age (years) 67.4 66.8 67.8 72.6 Mean % predicted FEV1 77.1 74.7 74.2 63.8 Missing FEV1 (% of total) 54.6 77.8 68.7 81.8 Stage (% of non-missing) 1a or 1b 67.2 56.4 58.4 36.2 2a or 2b 21.9 23.0 21.7 19.6 3a 10.9 20.6 19.9 44.2 Missing stage (% of total) 14.5 60.6 52.0 72.9 Performance status (% of non-missing) 0–1 92.3 86.2 85.5 47.9 2 6.4 10.2 9.0 24.1 3–4 1.2 3.6 5.5 27.9 Missing performance status (% of total) 28.2 58.9 38.2 50.4 Median survival (months)* 62 41 18 7 **Died within 30-days of surgery (%) 2.6 4.4 5.8 N/A Died within 90-days of surgery (%) 5.3 8.6 16.7 N/A * Survival is calculated from date of diagnosis not date of procedure; FEV1 Forced expiratory Volume in 1 second; ** HES date of procedure unless NLCA only Results There were 60,196 people in the NLCA who met the inclusion criteria; 8,535 (14%) had a record of surgery in both databases. An additional 2,568 (4%) had a record of surgery in HES and 795 (1%) in the NLCA. The features of people who had surgery in HES only or the NLCA only were similar, however median survival was shorter, and the proportion that died soon after surgery was higher, in the NLCA only group compared with those with surgery records in both databases (table 1). The proportion with HES only records of surgery decreased from 6% (n = 215) in 2004 to 3% (n = 367) in 2009; the patterns of survival each year were similar to the overall results. Conclusion The proportion of people who had potentially curative surgery differed according to the database used to identify surgical procedures. There are many possible explanations for our results; however use of either database alone is likely to under-estimate the proportion of people who had surgery and this should be taken into account in studies investigating access to surgery.

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)