Sharma P. Riaz

High Procedure Volume Is Strongly Associated With Improved Survival After Lung Cancer Surgery

PURPOSE Studies have reported an association between hospital volume and survival for non-small-cell lung cancer (NSCLC). We explored this association in England, accounting for case mix and propensity to resect. METHODS We analyzed data on 134,293 patients with NSCLC diagnosed in England between 2004 and 2008, of whom 12,862 (9.6%) underwent surgical resection. Hospital volume was defined according to number of patients with resected lung cancer in each hospital in each year of diagnosis. We calculated hazard ratios (HRs) for death in three predefined periods according to hospital volume, sex, age, socioeconomic deprivation, comorbidity, and propensity to resect. RESULTS There was increased survival in hospitals performing > 150 surgical resections compared with those carrying out < 70 (HR, 0.78; 95% CI, 0.67 to 0.90; Ptrend < .01). The association between hospital volume and survival was present in all three periods of follow-up, but the magnitude of association was greatest in the early postoperative period. CONCLUSION High-volume hospitals have higher resection rates and perform surgery among patients who are older, have lower socioeconomic status, and have more comorbidities; despite this, they achieve better survival, most notably in the early postoperative period.

Variation in surgical resection for lung cancer in relation to survival: population-based study in England 2004-2006.

BACKGROUND Compared with some European countries, England has low lung cancer survival and low use of surgical resection for lung cancer. The use of surgical resection varies within England. We assessed the relationship between surgical resection rate and the survival of lung cancer patients in England. METHODS We extracted data on 77,349 non-small cell lung cancer (NSCLC) patients diagnosed between 2004 and 2006 from the English National Cancer Repository Dataset. We calculated the frequency of surgical resection by age, socio-economic deprivation and geographical area. We used Cox regression to compute mortality hazard ratios according to quintiles of frequency of surgical resection amongst all 77,349 lung cancer patients, and separately for the 6900 patients who underwent surgical resection. RESULTS We found large geographical variation in the surgical resection rate for NSCLC in PCT areas (3-18%). A high frequency of resection was strongly inversely associated with overall mortality (HR 0.88, 95% CI 0.86-0.91 for the highest compared to the lowest resection quintile) and only moderately associated with mortality amongst the resected patients (HR 1.15, 95% CI 0.98-1.36). Compared to the highest resection quintile, 5420 deaths could be delayed in the overall NSCLC group, whereas about 146 more deaths could be expected amongst the resected patients. CONCLUSION The differences in the magnitudes of both the hazard ratios and the absolute excess deaths within resected patients and all NSCLC patients suggests that lung cancer survival in England could plausibly increase if a larger proportion of patients underwent surgical resection. Carefully designed research into the possible benefit of increasing resection rates is indicated.

Completeness of case ascertainment and survival time error in English cancer registries : impact on 1-year survival estimates

Background:It has been suggested that cancer registries in England are too dependent on processing of information from death certificates, and consequently that cancer survival statistics reported for England are systematically biased and too low.Methods:We have linked routine cancer registration records for colorectal, lung, and breast cancer patients with information from the Hospital Episode Statistics (HES) database for the period 2001–2007. Based on record linkage with the HES database, records missing in the cancer register were identified, and dates of diagnosis were revised. The effects of those revisions on the estimated survival time and proportion of patients surviving for 1 year or more were studied. Cases that were absent in the cancer register and present in the HES data with a relevant diagnosis code and a relevant surgery code were used to estimate (a) the completeness of the cancer register. Differences in survival times calculated from the two data sources were used to estimate (b) the possible extent of error in the recorded survival time in the cancer register. Finally, we combined (a) and (b) to estimate (c) the resulting differences in 1-year cumulative survival estimates.Results:Completeness of case ascertainment in English cancer registries is high, around 98–99%. Using HES data added 1.9%, 0.4% and 2.0% to the number of colorectal, lung, and breast cancer registrations, respectively. Around 5–6% of rapidly fatal cancer registrations had survival time extended by more than a month, and almost 3% of rapidly fatal breast cancer records were extended by more than a year. The resulting impact on estimates of 1-year survival was small, amounting to 1.0, 0.8, and 0.4 percentage points for colorectal, lung, and breast cancer, respectively.Interpretation:English cancer registration data cannot be dismissed as unfit for the purpose of cancer survival analysis. However, investigators should retain a critical attitude to data quality and sources of error in international cancer survival studies.

Recent trends in resection rates among non-small cell lung cancer patients in England

Background Lung cancer resection rates are low in England, but reports have indicated an increase in recent years. We analysed the recent trends in surgical resection by age, sex, socioeconomic deprivation and surgical procedure in England. Methods Data on 286 217 patients with non-small cell lung cancer diagnosed between 1998 and 2008 were extracted from the English Cancer Repository Dataset and information on surgical resection for these patients was retrieved from linked Hospital Episode Statistics records. We calculated the OR of undergoing surgery per 1-year increment by age, sex, socioeconomic deprivation and surgical procedure. A multinomial logistic regression model was used to assess the association between age and type of surgery. Results The proportion of patients with non-small cell lung cancer undergoing surgery increased from 8.8% in 1998 to 10.6% in 2008. The increase was similar between levels of socioeconomic deprivation, slightly more pronounced among women (OR=1.023 per 1-year calendar increment, 95% CI 1.016 to 1.029) than men (OR=1.010, 95% CI 1.005 to 1.015) and most prominent with increasing age (75–79 age group: OR 1.051, 95% CI 1.041 to 1.062; 80–84 age group: OR 1.102, 95% CI 1.080 to 1.124; and 85+ age group: OR 1.130, 95% CI 1.069 to 1.193). Increasing age was associated with a decreased likelihood of undergoing pneumonectomy (OR 0.88, 95% CI 0.87 to 0.89 per 5-year age increment) or sleeve resection (OR 0.75, 95% CI 0.71 to 0.79) compared with lobectomy, and a slightly increased likelihood of undergoing a wedge resection (OR 1.08, 95% CI 1.06 to 1.10). Conclusion Resection rates have increased in England in recent years and most markedly so in the older age groups.

Lung cancer incidence and survival in England: an analysis by socioeconomic deprivation and urbanization.

Introduction: Most previous studies have investigated either socioeconomic deprivation or urbanization in relationship to lung cancer incidence or survival. We investigated the association between socioeconomic deprivation, urbanization, and lung cancer incidence and survival in England. Methods: We extracted data on patients diagnosed with lung cancer (ICD-10 C33-C34) between 2003 and 2007 and who were resident in England. We assigned each patient to an urbanization score and to a socioeconomic quintile based on their postcode of residence. We calculated age-specific and age-standardized incidence rates (per 100,000 European standard population) by urbanization, sex, and socioeconomic deprivation group. We used Kaplan-Meier survival analysis to compare the survival of patients from urban and rural areas by socioeconomic deprivation. Results: A high proportion of urban areas in England were classified as deprived and rural areas were mostly affluent. The incidence of lung cancer was higher in urban areas than in rural areas. In the more affluent areas, the incidence of lung cancer in urban and rural areas was very similar. Survival from lung cancer was slightly higher in affluent areas than in deprived areas. Survival from lung cancer in urban and rural areas was similar across all socioeconomic deprivation quintiles. Conclusions: The difference in incidence between urban and rural areas can be explained by the differences in the distribution of socioeconomic deprivation quintiles in the two urbanization categories. When socioeconomic deprivation is taken into account, little difference is seen between both the incidence and survival of lung cancer in urban and rural areas.

Survival of patients with small cell lung cancer undergoing lung resection in England, 1998–2009

Introduction Chemotherapy or chemoradiotherapy is the recommended treatment for small cell lung cancer (SCLC), except in stage I disease where clinical guidelines state there may be a role for surgery based on favourable outcomes in case series. Evidence supporting adjuvant chemotherapy in resected SCLC is limited but this is widely offered. Methods Data on 359 873 patients who were diagnosed with a first primary lung cancer in England between 1998 and 2009 were grouped according to histology (SCLC or non-SCLC (NSCLC)) and whether they underwent a surgical resection. We explored their survival using Kaplan–Meier analysis and Cox regression, adjusting for age, sex, comorbidity and socioeconomic status. Results The survival of 465 patients with resected SCLC was lower than patients with resected NSCLC (5-year survival 31% and 45%, respectively), but much higher than patients of either group who were not resected (3%). The difference between resected SCLC and NSCLC diminished with time after surgery. Survival was superior for the subgroup of 198 ‘elective’ SCLC cases where the diagnosis was most likely known before resection than for the subgroup of 267 ‘incidental’ cases where the SCLC diagnosis was likely to have been made after resection. Conclusions These data serve as a natural experiment testing the survival after surgical management of SCLC according to NSCLC principles. Patients with SCLC treated surgically for early stage disease may have survival outcomes that approach those of NSCLC, supporting the emerging clinical practice of offering surgical resection to selected patients with SCLC.

Mesothelioma incidence projections in South East England

We estimated the past and future age-standardised incidence rates of mesothelioma by birth cohort and by period of diagnosis in South East England. We extracted data on patients diagnosed with mesothelioma (International Classification of Diseases-10 C45) between 1960 and 2009 from the Thames Cancer Registry. We calculated the age-standardised incidence rates using the European standard population. We used age-cohort and age-period modelling to estimate the age-specific incidence rates for the 1900 to 1950 birth cohorts and the 1935 to 2034 calendar periods. A much more pronounced increase in mesothelioma incidence between 1972 and 2007 was observed in males than in females. In both sexes, the incidence rates increased in successive generations up to the 1945 birth cohort. Projection of rates in the future showed an increase in incidence in males until 2022 and a decrease thereafter. Among females, the incidence rate was predicted to increase gradually until reaching its maximum around 2027, and to remain stable thereafter. The occurrence of mesothelioma is closely linked to occupational exposure to asbestos in the 1960s and 1970s and, due to the long latency period, the incidence of mesothelioma is projected to increase until the 2020s.

Resection rate, hospital procedure volume and survival in pancreatic cancer patients in England: Population-based study, 2005-2009.

OBJECTIVE We assessed the association between population resection rates, hospital procedure volume and death rates in pancreatic cancer patients in England. DESIGN Patients diagnosed with pancreatic cancer were identified from a linked cancer registration and Hospital Episode Statistics dataset. Cox regression analyses were used to assess all-cause mortality according to resection quintile and hospital volume, adjusting for sex, age, deprivation and comorbidity. RESULTS There were 31,973 pancreatic cancer patients studied, 2580 had surgery. Increasing resection rates were associated with lower mortality among all patients (χ(2)(1df) = 176.18, ptrend < 0.001), with an unadjusted hazard ratio (HR) of 0.78 95%CI [0.75 to 0.81] in the highest versus the lowest resection quintile. Adjustment changed the estimate slightly (HR 0.82, 95%CI [0.79 to 0.85], (χ(2)(1df) = 99.44, ptrend < 0.001)). Among patients that underwent surgery, higher procedure volume was associated with lower mortality (HR = 0.88 95%CI [0.75-1.03] in hospitals carrying out 30+ versus <15 operations a year, shared frailty model, χ(2)(1df) = 1.82, ptrend = 0.177). CONCLUSION Higher population resection rates were associated with lower mortality. The association with hospital procedure volume was less clear possibly due to small number of patients who underwent surgery. Nevertheless these results suggest survival is higher in hospitals that carry out a greater number of operations a year, particularly those doing 30+ operations, supporting the benefit of centralising perioperative expertise in specialist centres. Ensuring people are increasingly diagnosed when they are suitable candidates for surgery, and have access to these specialist centres may lead to an increase in the proportion of patients that undergo surgical resection which could plausibly increase survival of pancreatic cancer patients.

187 Survival of small cell lung cancer patients undergoing lung resection in England 1998-2009

187 Survival of small cell lung cancer patients undergoing lung resection in England 1998 2009 M. Luchtenborg1,2 *, S.P. Riaz2, E. Lim3, R. Page4, D.R. Baldwin5, E. Jakobsen6, P. Vedsted7, M.J. Lind8, M.D. Peake9, A. Mellemgaard10, J. Spicer11, L. Lang-Lazdunski12, H. Moller1,7. 1King’s College London, Cancer Epidemiology and Population Health, 3rd Floor, Bermondsey Wing, Guy’s Hospital, Great Maze Pond, London SE1 9RT, United Kingdom, 2Public Health England, Knowledge & Intelligence Team, 2nd Floor, Skipton House, 80 London Road, London SE1 6HL, United Kingdom, 3The Academic Division of Thoracic Surgery, The Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom, 4Department of Thoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, United Kingdom, 5Nottingham University Hospitals and University of Nottingham, Respiratory Medicine Unit, David Evans Centre, Nottingham City Hospital Campus, UK, 6The Danish Lung Cancer Registry, Department of Thoracic Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark, 7Department of Public Health and Research Centre for Cancer Diagnosis in Primary Care, Aarhus University, Aarhus, Denmark, 8Queens Centre for Oncology and Haematology, Hull and East Yorkshire NHS Trust, Hull HU16 5JQ, United Kingdom, 9Department of Respiratory Medicine, Glenfield Hospital, Groby Road, Leicester LE3 9QP, United Kingdom, 10Department of Oncology, Herlev University Hospital, Copenhagen, Denmark, 11Research Oncology, Division of Cancer Studies, King’s College London, London, United Kingdom, 12Department of Thoracic Surgery, Guy’s & St Thomas’ NHS Foundation Trust, London, UK