Factors influencing treatment selection and thirty-day mortality following chemotherapy for people with small cell lung cancer: an analysis of national audit data

Background Thirty-day mortality after treatment for lung cancer is a measure of unsuccessful outcome and where treatment should have been avoided. Guidelines recommend offering chemotherapy to individuals with small cell lung cancer (SCLC) who have poorer performance status (PS) because of its high initial response rate. However, this comes with an increased risk of toxicity and early death. We quantified real-world 30-day mortality in SCLC following chemotherapy, established the factors associated with this and compared these to the factors that influence receipt of chemotherapy. Methods We used linked national English datasets to define the factors associated with both receiving chemotherapy and 30-day mortality following chemotherapy. Results We identified 3,715 people diagnosed with SCLC, of which 2,235 (60.2%) received chemotherapy. There were 174 (7.8%) deaths within 30 days of chemotherapy. The adjusted odds of receiving chemotherapy decreased with older age, worsening PS and increasing comorbidities. Thirty-day mortality was independently associated with poor PS (PS 2 vs PS 0 adjusted OR 3.75 95% CI 1.71-8.25) and stage (extensive vs limited adjusted OR 1.68 95% CI 1.03-2.74) but in contrast was not associated with increasing age. Both chemotherapy administration and 30-day mortality varied by hospital network.Conclusions To reduce variation in chemotherapy administration predictors of 30-day mortality could be used as an adjunct to improve sub-optimal patient selection. We have quantified 30-day mortality risk by the two independently associated factors, PS and stage, so that patients and clinicians can make better informed decisions about the potential risk of early death following chemotherapy

Post-treatment survival difference between lobectomy and stereotactic ablative radiotherapy in stage I non-small cell lung cancer in England.

BACKGROUND: Approximately 15%-20% of all non-small cell lung cancer (NSCLC) cases present with stage I disease. Surgical resection traditionally offers the best chance of a cure but some patients will not have this treatment due to older age, comorbidities or personal choice. Stereotactic ablative radiotherapy (SABR) has become an established curative intent treatment option for patients who are not selected for or do not choose surgery. The aim of this study is to compare survival at 90 days, 6 months, 1 year and 2 years for patients who received either lobectomy or SABR. METHODS: We used data from the 2015 National Lung Cancer Audit database and linked with Hospital Episode Statistics and the radiotherapy dataset to identify patients with NSCLC stage IA-IB and performance status (PS) 0-2 who underwent surgery or SABR treatment. We assessed the likelihood of death at 90 days, 6 months, 1 year and 2 year after diagnosis and procedure date to observe survival between two patient groups. RESULTS: We identified 2373 patients in our cohort, 476 of whom had SABR. The median difference between date of diagnosis and date of treatment for surgery patients was 17 days while for SABR patients it was 73 days. Increasing age and worsening PS were associated with having SABR rather than surgery. Survival between the two treatment modalities was similar early on but by 1-year people who had surgery did better than those who had SABR (adjusted ORs 2.12, 95% CI 1.35 to 2.31). This difference persisted at 2 years and when the analysis was restricted to patients aged <80 years and with PS 0 or 1 and stage IA only. CONCLUSION: Our analysis suggests that patients who have lobectomy have a better survival compared with SABR patients; however, we found considerable delays in patients receiving SABR which may contribute to poorer long-term outcomes with this treatment option. Reducing these delays should be a key focus in development and reorganisation of services

Apples and pears? A comparison of two sources of national lung cancer audit data in England

In 2014, the method of data collection from NHS trusts in England for the National Lung Cancer Audit (NLCA) was changed from a bespoke dataset called LUCADA (Lung Cancer Data). Under the new contract, data are submitted via the Cancer Outcome and Service Dataset (COSD) system and linked additional cancer registry datasets. In 2014, trusts were given opportunity to submit LUCADA data as well as registry data. 132 NHS trusts submitted LUCADA data, and all 151 trusts submitted COSD data. This transitional year therefore provided the opportunity to compare both datasets for data completeness and reliability. We linked the two datasets at the patient level to assess the completeness of key patient and treatment variables. We also assessed the interdata agreement of these variables using Cohen’s kappa statistic, κ. We identified 26 001 patients in both datasets. Overall, the recording of sex, age, performance status and stage had more than 90% agreement between datasets, but there were more patients with missing performance status in the registry dataset. Although levels of agreement for surgery, chemotherapy and external-beam radiotherapy were high between datasets, the new COSD system identified more instances of active treatment. There seems to be a high agreement of data between the datasets, and the findings suggest that the registry dataset coupled with COSD provides a richer dataset than LUCADA. However, it lagged behind LUCADA in performance status recording, which needs to improve over time

Factors influencing treatment selection and thirty-day mortality following chemotherapy for people with small cell lung cancer: an analysis of national audit data

Background Thirty-day mortality after treatment for lung cancer is a measure of unsuccessful outcome and where treatment should have been avoided. Guidelines recommend offering chemotherapy to individuals with small cell lung cancer (SCLC) who have poorer performance status (PS) because of its high initial response rate. However, this comes with an increased risk of toxicity and early death. We quantified real-world 30-day mortality in SCLC following chemotherapy, established the factors associated with this and compared these to the factors that influence receipt of chemotherapy. Methods We used linked national English datasets to define the factors associated with both receiving chemotherapy and 30-day mortality following chemotherapy. Results We identified 3,715 people diagnosed with SCLC, of which 2,235 (60.2%) received chemotherapy. There were 174 (7.8%) deaths within 30 days of chemotherapy. The adjusted odds of receiving chemotherapy decreased with older age, worsening PS and increasing comorbidities. Thirty-day mortality was independently associated with poor PS (PS 2 vs PS 0 adjusted OR 3.75 95% CI 1.71-8.25) and stage (extensive vs limited adjusted OR 1.68 95% CI 1.03-2.74) but in contrast was not associated with increasing age. Both chemotherapy administration and 30-day mortality varied by hospital network. Conclusions To reduce variation in chemotherapy administration predictors of 30-day mortality could be used as an adjunct to improve sub-optimal patient selection. We have quantified 30-day mortality risk by the two independently associated factors, PS and stage, so that patients and clinicians can make better informed decisions about the potential risk of early death following chemotherapy

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

Factors influencing treatment selection and thirty-day mortality following chemotherapy for people with small cell lung cancer: an analysis of national audit data

Background Thirty-day mortality after treatment for lung cancer is a measure of unsuccessful outcome and where treatment should have been avoided. Guidelines recommend offering chemotherapy to individuals with small cell lung cancer (SCLC) who have poorer performance status (PS) because of its high initial response rate. However, this comes with an increased risk of toxicity and early death. We quantified real-world 30-day mortality in SCLC following chemotherapy, established the factors associated with this and compared these to the factors that influence receipt of chemotherapy. Methods We used linked national English datasets to define the factors associated with both receiving chemotherapy and 30-day mortality following chemotherapy. Results We identified 3,715 people diagnosed with SCLC, of which 2,235 (60.2%) received chemotherapy. There were 174 (7.8%) deaths within 30 days of chemotherapy. The adjusted odds of receiving chemotherapy decreased with older age, worsening PS and increasing comorbidities. Thirty-day mortality was independently associated with poor PS (PS 2 vs PS 0 adjusted OR 3.75 95% CI 1.71-8.25) and stage (extensive vs limited adjusted OR 1.68 95% CI 1.03-2.74) but in contrast was not associated with increasing age. Both chemotherapy administration and 30-day mortality varied by hospital network. Conclusions To reduce variation in chemotherapy administration predictors of 30-day mortality could be used as an adjunct to improve sub-optimal patient selection. We have quantified 30-day mortality risk by the two independently associated factors, PS and stage, so that patients and clinicians can make better informed decisions about the potential risk of early death following chemotherapy

Barriers to delivering advanced cancer nursing: a workload analysis of specialist nurse practice linked to the English National Lung Cancer Audit

Purpose: Health services across the world utilise advanced practice in cancer care. In the UK, lung cancer nurse specialists (LCNS) are recognised as key components of quality care in national guidelines, yet access to LCNS contact is unequal and some responsibilities are reportedly left undone. We assess whether any variation in working practices of LCNS is attributable to factors of the lung cancer service at the hospital trust. Method: Nationwide workload analysis of LCNS working practices in England, linked at trust level to patient data from the National Lung Cancer Audit. Chi-squared tests were performed to assess whether patient contact, workload, involvement in multidisciplinary teams (MDT), and provision of key interventions were related to 1) the trust's lung cancer service size, 2) LCNS caseload, 3) anti-cancer treatment facilities and 4) lung cancer patient survival. Results: Unpaid overtime was substantial for over 60% of nurses and not associated with particular service factors assessed; lack of administrative support was associated with large caseloads and chemotherapy facilities. LCNS at trusts with no specialty were more likely to challenge all MDT members (80%) compared with those at surgical (53%) or chemotherapy (58%) trusts. The most frequent specialist nursing intervention to not be routinely offered was proactive case management. Conclusion: Working practices of LCNS vary according to service factors, most frequently associated with trust anti-cancer treatment facilities. High workload pressures and limited ability to provide key interventions should be addressed across all services to ensure patients have access to recommended standards of care

Barriers to delivering advanced cancer nursing: a workload analysis of specialist nurse practice linked to the English National Lung Cancer Audit

Purpose: Health services across the world utilise advanced practice in cancer care. In the UK, lung cancer nurse specialists (LCNS) are recognised as key components of quality care in national guidelines, yet access to LCNS contact is unequal and some responsibilities are reportedly left undone. We assess whether any variation in working practices of LCNS is attributable to factors of the lung cancer service at the hospital trust. Method: Nationwide workload analysis of LCNS working practices in England, linked at trust level to patient data from the National Lung Cancer Audit. Chi-squared tests were performed to assess whether patient contact, workload, involvement in multidisciplinary teams (MDT), and provision of key interventions were related to 1) the trust's lung cancer service size, 2) LCNS caseload, 3) anti-cancer treatment facilities and 4) lung cancer patient survival. Results: Unpaid overtime was substantial for over 60% of nurses and not associated with particular service factors assessed; lack of administrative support was associated with large caseloads and chemotherapy facilities. LCNS at trusts with no specialty were more likely to challenge all MDT members (80%) compared with those at surgical (53%) or chemotherapy (58%) trusts. The most frequent specialist nursing intervention to not be routinely offered was proactive case management. Conclusion: Working practices of LCNS vary according to service factors, most frequently associated with trust anti-cancer treatment facilities. High workload pressures and limited ability to provide key interventions should be addressed across all services to ensure patients have access to recommended standards of care

Factors associated with survival in small cell lung cancer: an analysis of real-world national audit, chemotherapy and radiotherapy data

Background: The mainstay of treatment for small cell lung cancer (SCLC) involves platinum doublet chemotherapy but the optimal duration, 4 vs. 6 cycles, is not known. Concurrent thoracic radiotherapy followed by prophylactic cranial irradiation (PCI) is recommended for fit individuals with limited stage. However, outside of clinical trials, the efficacy of sequential thoracic radiotherapy and PCI for extensive stage is uncertain.Methods: This retrospective, observational, cohort study used English national lung cancer data to determine the factors associated with survival for all people diagnosed with SCLC. More precisely, for individuals who received chemotherapy, we examined survival by the chemotherapy duration, thoracic radiotherapy dose and the use of PCI.Results: In total 6,438 people were diagnosed with SCLC. We identified that male sex (OR 0.7; 95% CI: 0.62–0.80), increasing age (P=0.01) greater comorbidity (P≤0.01), extensive stage (OR 0.21; 95% CI: 0.19–0.25) and worse performance status (PS2 vs. PS0 adjusted OR 0.38 95% CI: 0.31–0.48) were associated with reduced 1-year survival. Receipt of chemotherapy augmented survival. We analysed data for 1,761 people who had received chemotherapy. Thoracic radiotherapy (≥30 Gy for extensive stage and ≥40 Gy for limited stage) and PCI were independently associated with better survival (P≤0.01 for each), but 6 cycles of chemotherapy instead of 4 was not (limited stage adjusted OR 0.97; 95% CI: 0.48–1.97) extensive stage adjusted OR 1.34; 95% CI: 0.81–2.21).Conclusions: Extending chemotherapy beyond 4 cycles to 6 does not augment survival. Appropriately prescribed thoracic radiotherapy and PCI can prolong survival in both limited and extensive stage SCLC

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 smallcell 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