Staging Issues: Lung Cancer & Mesothelioma. Mick Peake Clinical Lead, NCIN Chair, Lung SSCRG

Transcription

1 Staging Issues: Lung Cancer & Mesothelioma Mick Peake Clinical Lead, NCIN Chair, Lung SSCRG

2 Staging systems Non-Small Cell Lung Cancer (>85%): UICC TNM v6 used until transition since then to v7

3 UICC TNM v6 vs v7 - Lung Version 6 based on a surgical series of <5000 cases in one US institution ( Mountain ) going back to 1973, last updated 1997 Version 7 developed by the IASLC (International Association for the Study of Lung Cancer) based on multi-national, multiprofessional database of >100,000 cases

4 Staging systems Non-Small Cell Lung Cancer (>85%): UICC TNM v6 used until transition since then to v7 Small Cell Lung Cancer: Veterans Association (Limited vs Extensive disease) used widely (some variability in interpretation). UICC proposed use of TNM v7 for SCLC Mesothelioma: Two (3) systems in use, UICC TNM v6 & IMIG (International Mesothelioma Interest Group) - IMIG most accepted.

5 Staging systems Non-Small Cell Lung Cancer (>85%): UICC TNM v6 used until transition since then to v7 Small Cell Lung Cancer: Veterans Association (Limited vs Extensive disease) used widely (some variability in interpretation). UICC proposed use of TNM v7 for SCLC Mesothelioma: Historically poorly Two collected: (3) systems in use, UICC TNM Prior to v6 2005, & IMIG most (International Cancer Registries Mesothelioma Interest had stage Group) on <10% - IMIG of lung most cancer accepted. cases

6 National Lung Cancer Audit (England) Case ascertainment and data completeness % of trusts submitting data Number of cases 10,920 16,922 20,639 27,818 30,155 Case ascertainment (%) Data completeness (%) Stage Performance status Treatment

7 International Cancer Benchmarking Partnership: Availability of Lung Cancer TNM Stage

8 International Cancer Benchmarking Partnership: Availability of Lung Cancer TNM Stage % missing

9 Mapping of T,N & M to SEER summary stage 2000

10 A: Clinical stage IASLC Survival Curves Underpinning v7 Survival (years) B: Pathological stage Survival (years)

11

12

13 TNM v7 CT staging map

14 TNM v7 Revised Mediastinal Node map

15 What are the more complex clinical issues in staging? Size of tumour: prognosis and suitability of adjuvant chemotherapy Extent of N2 disease: Surgery vs chemo-radiotherapy Reliability of PET-CT stage for nodes (& some metastases): Suitability for radical therapy Number (and site) of metastases: metastatectomy

16 How is staging collected? Clinical stage Clinically verified largely collected at & by MDTs Data entry variable: MDT co-ordinators, audit staff, specialist nurses, clinicians, etc. Some collected as T,N & M, some as summary stage Part of the National Lung Cancer Audit programme since 2005 Pathological stage Resection specimens (then via registries) Sampling of nodes & metastases mostly recorded by MDT

17 Potential variation in recording of TNM versions Recommendation to switch to collection of TNM v7 (from v6) on Central National Lung Cancer Audit database modified to allow collection of v6 or v7 in 2010 Some local collection software not changed until mid NLCA data analysis imminent so regional and local variations in usage can be analysed

18 Potential errors in recording of stage Variable expertise in radiology (and other MDT members): Tendency to overstage; especially mediastinal nodes and local invasion Failure to sample PET +ve nodes (~20% false positive) Variable access to mediastinal node staging could result in a systematic variation in nodal staging Failure to sample PET positive metastases

19 Stage migration during diagnostic pathway CXR

20 Stage migration during diagnostic pathway CXR CT

21 Stage migration during diagnostic pathway CXR CT Biopsy of primary

22 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling

23 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT

24 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

25 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

26 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

27 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

28 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

29 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

30 Stage migration during diagnostic pathway CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

31 Stage migration during diagnostic pathway MDT Treatment Decision CXR CT Biopsy of primary Nodal Sampling PET-CT Resection

32 Summary Historically poor recording of lung cancer stage Impact of National Lung Cancer Audit TNM v7 well accepted clinically Transition between v6 complicates analyses Variation and inaccuracies in quality Vital need to collect stage at time of MDT treatment decision