Recent evidence regarding resection rate, specialism and survival in lung cancer in the UK Dr Mick Peake Glenfield Hospital, Leicester Clinical Lead, National Cancer Intelligence Network & National Lung Cancer Audit National Clinical Lead, NHS Cancer Improvement
New data Link between resection rate & survival (Riaz S et al. Eur J Cancer 2012;48:54-60) Rising, but variable resection rate (National Lung Cancer Audit, SCTS audit, Riaz et al., in press) Evidence of a strong link between specialisation (and MDT attendance by surgeons) and resection rate (Rich et al, Thorax 2011;66:1078-1084; Lau et al, WCLC Amsterdam & paper in preparation) Increase in resection rate after introduction of thoracic surgeon (Martin-Ucar et al. Lung Cancer. 2004; 46:227-232) Improved quality of surgical practice (SCTS audit) Increase in total number of thoracic surgeons Emerging evidence of stage-for-stage lower survival rates in UK (International cancer Benchmarking Partnership)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 % of patients undergoing surgical resection Proportion of lung cases having a pneumonectomy (%) Resection rate by PCT 2004-6* 18 16 14 12 10 8 Q1 Q2 Q3 Q4 Q5 6 4 2 0 PCT of residence Source: Riaz S et al. Eur J Cancer 2012;48:54-60
Mortality Hazard Ratios for Lung Cancer Patients in England 2004-6 related to resection rate by government office region 1.05 SE N = 77,349 1.00 EE SW NE NW Y&H EM 0.95 WM 0.90 L 0.85 5 6 7 8 9 10 11 Radical surgery (%) Hazard ratio 95% CI Radical surgery 95% CI Source: Riaz S et al. Eur J Cancer 2012;48:54-60
N39 N03 N35 N11 N20 N22 N32 N08 Nir N06 N31 N36 N33 N28 N26 N02 SCAN NWW N37 N01 N07 WSCAN N21 N30 N12 SWCN N29 N34 N23 N38 N25 N24 N27 NSCAN % 25.0 20.0 Surgery in confirmed NSCLC (%) England Scotland Wales N Ireland 15.0 10.0 5.0 0.0
N20 N22 N32 N35 N39 N03 N33 N31 N23 N12 N08 N37 N06 N36 N34 N11 N26 N30 N28 N07 N02 N29 N27 NWW N21 N38 N24 N25 N01 SWCN Odds Ratio 2.50 Surgery in confirmed NSCLC (%, England & Wales only) 2.00 1.50 1.00 0.50 0.00
N07 N35 N30 N28 N39 N31 N29 N38 N08 N32 N11 N22 Nir N03 N12 N37 N23 N20 N21 N25 N26 N33 N36 N01 NWW N02 N24 N06 N34 N27 SWCN % 70.0 60.0 Surgery in Stage I/II NSCLC (%) England Wales N Ireland 50.0 40.0 30.0 20.0 10.0 0.0
Case ascertainment (%) National Lung Cancer Audit (England) Headline indicators over time 2005 2006 2007 2008 2009 2010 40 66 75 92 >97 ~100 % discussed at MDT 79 84.3 86.8 88.6 93.8 96.1 Tissue confirmation rate (%) Overall surgical resection rate (%) Resection rate: confirmed NSCLC (%) Active treatment rate (%) Small Cell chemotherapy rate (%) 68 66 65 66.7 75.9 76.5 9 9.4 10.3 11.2 13.9 13.9 13.8 14.3 15.2 16.0 18.4 18.3 45 50 52 54 59.2 58 57.7 61.7 64.5 63.0 65.4 65
Resection Rate % 20 18 16 14 12 10 8 6 4 2 0 Resection rate (England & Wales): National Lung Cancer Audit Confirmed NSCLC All patients 2005 2006 2007 2008 2009 2010
Resection rate: trend by year Source: Riaz et al, Thorax; in press
Resection rate: trend by age Source: Riaz et al, Thorax; in press
% Change in consultant numbers between 2000 and 2010 140 120 100 80 60 40 20 0
Resection rate for patients with tissue confirmation of NSCLC (2004-2008:England) First seen in centre with thoracic surgery? Number With a tissue diagnosis of NSCLC Number who had surgical resection % having surgery Adjusted Odds Ratio for surgery* No 25,248 2,947 12% 1.00 Yes 9,265 (27%) 1,538 17% 1.51 (1.16-1.97) P value <0.001 *adjusted for sex, age, PS, stage, deprivation index and Charlson co-morbidity index Rich et al; Thorax 2011;66:1078-1084
Resection Rate Resection rates are higher in base than in referring centres Across the UK Within each Cancer Network 25% 20% 20% p < 0.001 15% p < 0.001 15% 10% 10% 5% 5% 0% Base Peripheral 0% Base Peripheral Source: Lau et al; J Thor Onc, 2011:(abstract)
Resection Rate Resection rates are higher in centres with 2 or more specialist thoracic surgeons 25% p = 0.02 20% 15% 10% 5% 0% Less than 2 2 or More Source: Lau et al; J Thor Onc, 2011:(abstract)
Resection rates are higher when surgeons attend preoperative MDTs 16 p = 0.012 14 12 10 8 6 4 2 0 Less than two-thirds More than two-thirds Source: Lau et al; J Thor Onc, 2011:(abstract)
Resection Rate The increase in resection rate was greatest in those units who employed new thoracic surgeons 20 p = 0.04 15 10 19% 66% 2009 Growth 5 2008 0 Static Expanded (5 Units) Source: Lau et al; J Thor Onc, 2011:(abstract)
Surgical Resection Rate - Leicester Surgical Numbers Resection Rate for confirmed NSCLC 1994-1996* 65 12.2 4.5 1997-1999* 175 23.4 12.0 2002 45 19.9 12.7 2003 58 21.0 13.8 2004 60 20.8 13.5 2005 89 30.4 20.6 2006 94 31.1 19.3 2007 23.5 17.4 2008 33.3 22.2 2009 22.7 15.8 2010 23.7 16.3 Resection Rate for all Lung Cancers * A Martin-Ucar et al. Lung Cancer. 2004; 46:227-232
Leicester: Median survival by year of diagnosis MS (months) P <0.001 7 6 5 4 3 2 1 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
1yr survival in lung cancer patients diagnosed 2000-2007 by stage 100 90 80 70 60 50 40 30 20 10 0 Canada Sweden Denmark UK All stages TNM1 TNM2 TNM3 TM4 Missing Source: International Cancer Benchmarking Partnership: Walters, Maringe, Rachet, Coleman et al (in preparation)
1yr survival in lung cancer patients diagnosed 2000-2007 by stage 100 90 80 70 60 50 40 30 20 10 0 Over 35% of UK patients unstaged (<10% in others except Australia - ~20%) Canada Sweden Denmark UK All stages TNM1 TNM2 TNM3 TM4 Missing Source: International Cancer Benchmarking Partnership: Walters, Maringe, Rachet, Coleman et al (in preparation)
Source: R Page, Society of Cardiothoracic Surgeons Audit 2011
Source: R Page, Society of Cardiothoracic Surgeons Audit 2011
Source: R Page, Society of Cardiothoracic Surgeons Audit 2011
Source: R Page, Society of Cardiothoracic Surgeons Audit 2011
Source: R Page, Society of Cardiothoracic Surgeons Audit 2011
Source: R Page, Society of Cardiothoracic Surgeons Audit 2011
New data Link between resection rate & survival (Riaz S et al. Eur J Cancer 2012;48:54-60) Rising, but variable resection rate (National Lung Cancer Audit, SCTS audit, Riaz et al., in press) Evidence of a strong link between specialisation (and MDT attendance by surgeons) and resection rate (Rich et al, Thorax 2011;66:1078-1084; Lau et al, WCLC Amsterdam & paper in preparation) Increase in resection rate after introduction of thoracic surgeon (Martin-Ucar et al. Lung Cancer. 2004; 46:227-232) Improved quality of surgical practice (SCTS audit) Increase in total number of thoracic surgeons Emerging evidence of stage-for-stage lower survival rates in UK (International cancer Benchmarking Partnership)
Conclusions Rapid recent increase in availability of data on surgical practice and outcomes More work needed on relationship of treatment rates and survival (not only surgery) There remains a need for more specialist thoracic surgeons Increasing resection rates in older patients prompt questions about patient-reported outcome measures We need to use these data in discussions with local service providers and commissioners