Guidelines and Standards in Lung Cancer David Baldwin Consultant Respiratory Physician NUH Hon Senior Lecturer Nottingham University Clinical lead NICE lung cancer GL Chair NICE QS Topic Expert Group

Matthew Callister, Leeds

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Improving outcomes: level of ambition “Our aspiration is that England should achieve cancer outcomes which are comparable with the best in the world” We believe that by 2014/15, 5000 additional lives can be saved each year. It is now for the NHS, working with PHE to deliver this ambition. Note: The “additional 5000 lives” will require England to match the European average. Approximately 10,000 additional lives would be saved if England was to match survival achieved in Sweden (and Australia and Canada) 4

Adjusted surgery rates 2009

Lancet 2011; 377: 127–38 LUNG CANCER 5 YR R.S. AUS CAN SWE NOR DEN UK COLORECTAL CANCER 5 YR R.S. OVARIAN CANCER 5 YR R.S. BREAST CANCER 5 YR R.S. Lancet 2011; 377: 127–38

Possible explanations for ‘poor’ UK cancer survival outcomes Late diagnosis lack of public awareness of symptoms ‘cultural’ attitudes primary care as ‘gatekeeper’ less good access to diagnostics Inferior specialist services availability of specialist clinicians access to treatment (e.g. high-cost, drugs; advanced radiotherapy techniques, etc.) Statistical artefacts Patient characteristics high rate of co-morbidities different disease biology (population genetic differences)

Holmberg et al. Thorax, 2010;65:436-441

Source: R Hubbard; unpublished Symptoms significantly associated with diagnosis of lung cancer (..so far) Symptom Cases (%) Controls (%) Odds ratio 95% CI P-value Cough 2yrs before lung ca index 1yr before lung ca index 39.5 33.3 16.1 10.1 3.70 4.77 3.50-3.90 4.49-5.07 <0.001 Haemoptysis 11.2 10.45 0.4 0.2 32.7 54.7 27.0-39.6 42.5-70.4 Chest/shoulder pain 25.2 20.35 6.6 2.75 3.67 2.58-2.92 3.42-3.93 Voice hoarseness 2.8 2.3 0.65 0.35 4.32 6.7 3.59-5.20 5.34-8.4 Difficulty in breathing 26.65 23 7.75 5 4.79 6.4 4.48-5.12 5.93-6.91 Weight loss 6.65 6 1.2 0.7 6.17 9.86 5.41-7.04 8.39-11.6 Symptoms based on NICE guidelines recommendations Source: R Hubbard; unpublished 9

Record of symptoms among cases 5 years before lung cancer index date Source: R Hubbard; unpublished

What are the outcomes? And what’s in the guideline? Improved mortality Improved survival Improved quality of life Improved palliation of symptoms Improved patient satisfaction Curative treatments Earlier diagnosis; More active treatment incl palliative care; HNA Fast efficient service; good communication; caring HCP; easy access to urgent care

How can we improve outcomes? Diagnose earlier by other methods Public awareness Prompt recognition and referral More CXRs Improve the accuracy of assessment

Quality Standards http://guidance. nice. org Based largely on NICE GL Supposed to be aspirational Need to be easily measurable Limited to 15

Quality Statements 1. People are made aware of the symptoms and signs of lung cancer through local coordinated public awareness campaigns that result in early presentation. 2. People reporting one or more symptoms suggesting lung cancer are referred within 1 week of presentation for a chest X-ray or directly to a chest physician who is a core member of the lung cancer multidisciplinary team.

Quality Statements 3. People with a chest X-ray result suggesting lung cancer have a copy of the radiologist's report sent to and followed up by the lung cancer multidisciplinary team.

Quality Statements 4. People with known or suspected lung cancer have access to a named lung cancer clinical nurse specialist who they can contact between scheduled hospital visits. 5. People with lung cancer are offered a holistic needs assessment at each key stage of care that informs their care plan and the need for referral to specialist services.

Quality Statements 6. People with lung cancer following initial assessment and CT scan are offered investigations that give the most information about diagnosis and staging with the least risk of harm 7. People with lung cancer have adequate tissue samples taken in a suitable form to provide a complete pathological diagnosis including tumour typing and sub-typing, and analysis of predictive markers.

Quality Statements 8. People with resectable lung cancer who are of borderline fitness and not initially accepted for surgery are offered the choice of a second surgical opinion, and a multidisciplinary team opinion on non-surgical treatment with curative intent. 9. People with lung cancer are offered assessment for multimodality treatment by a multidisciplinary team comprising all specialist core members.

Quality Statements 10. People with lung cancer stage I-III and good performance status who are unable to undergo surgery are assessed for radiotherapy with curative intent by a clinical oncologist specialising in thoracic oncology 11. People with lung cancer stage I-III and good performance status who are offered radiotherapy with curative intent receive planned treatment techniques that optimise the dose to the tumour while minimising the risks of normal tissue damage.

Quality Statements 12. People with stage IIIB or IV non-small-cell lung cancer and eligible performance status are offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors. 13. People with small-cell lung cancer have treatment  initiated within 2 weeks  of the pathological diagnosis

Quality Statements 14. People with lung cancer are offered a specialist follow-up appointment within 6 weeks of completing initial treatment and regular specialist follow-up thereafter, which can include protocol-led clinical nurse specialist follow-up. 15. People with lung cancer have access to all appropriate palliative interventions delivered by expert clinicians and teams.

Quality Statements – what’s missing? Specific Palliative Care recommendations Covered by generic QS Palliative Care Patient experience Specific recommendations on communication

Lung cancer mortality - NLST Arm Lung cancer deaths Lung cancer mortality per 100,000 py Reduction in lung cancer mortality (%) CT 346 247 20.0 (6.8-26.7) CXR 425 309 p = 0.004 NNT = 320 24

Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer. Figure 1. Cumulative Numbers of Lung Cancers and of Deaths from Lung Cancer. The number of lung cancers (Panel A) includes lung cancers that were diagnosed from the date of randomization through December 31, 2009. The number of deaths from lung cancer (Panel B) includes deaths that occurred from the date of randomization through January 15, 2009. The National Lung Screening Trial Research Team . N Engl J Med 2011;365:395-409.

Summary Quality Service Value for money Awareness and prompt action Accurately assessing patients for treatment Curative surgery where possible Alternative curative treatments Targeted systemic therapy Small cell treatment rapidly Holistic needs assessment Palliative interventions by expert teams Offering regular follow-up Reduced emergency admissions; longer survival; more active treatment. Longer survival; reduced mortality; less futile surgery; Longer survival; Better quality of life; better choices