1. Curative treatment rates for patients diagnosed with
early-stage non-small-cell
lung cancer (NSCLC) in England
A Khakwani,1 SV Harden,2 D Baldwin,1 K Foweraker,1 N Navani,2 R Dickinson,2 D West, P Beckett,2 R Hubbard1
1University of Nottingham; 2Royal College of Physicians; 3Society for Cardiothoracic Surgery

2. Background
Overall survival for lung cancer in England has previously been shown to be improving year on year and to correlate with surgical resection rates (National Lung Cancer Audit (NLCA) 2016 report). Recently, the NLCA switched to using anonymised data that were collected and processed by the National Cancer Registration and Analysis Service (NCRAS), which has allowed linkage of the dataset to other national datasets including the radiotherapy dataset (RTDS). The main aim of this study was to identify a national curative treatment rate for early-stage NSCLC and to identify factors influencing whether a patient receives surgery, radical radiotherapy (RT) or no active treatment.

3. Methods
A cross-sectional analysis was conducted on all English patients diagnosed with stage I– II lung cancer between 1 January and 31 December Types of surgery and radical radiotherapy were identified from NCRAS databases including the Cancer Outcomes and Services Dataset (COSD), Hospital Episode Statistics (HES) and RTDS databases. Survival was defined from time from treatment until death, and Cox regression analysis was used to determine factors associated with survival.

4. Results
36,025 cases of lung cancer were identified in 2015, with 8,841 (24.5%) cases of stage IA–IIB proven or presumed NSCLC. 4,560 (51.6%) patients received surgery and 1,419 (16.1%) received radical RT, creating a combined total of 5,979 (67.6%) patients receiving treatment with curative intent. Rates of curative intent treatment varied across cancer networks from 61.6% to 74.4%.
The majority (3,427/4,560, 75.2%) of surgical patients had a lobectomy or bilobectomy, with just 153/4,560 (3.4%) undergoing pneumonectomy. Stereotactic ablative radiotherapy (SABR) was delivered in 718/1,419 (50.6%) radical RT cases, generally for stage I disease; 60/1,419 (4.2%) patients received continuous hyperfractionated accelerated RT (CHART) and 486/1,419 (34.2%) patients received 55 Gy/20 fractions, a commonly prescribed hypofractionated radical RT regime in England.

5. Results continued
Notably, 2,862 (32.4%) patients, the majority of whom had performance status (PS) 3 or 4, did not receive treatment with curative intent, receiving either palliative therapy or supportive care only, and this proportion varied across networks (25.6–38.4%). There was a higher proportion of patients with poor performance status (PS=3–4) in this group compared with those receiving treatment with curative intent. Where performance status was documented, 98.9% of patients receiving surgery had PS=0–2, 89.9% of patients receiving any form of radical RT had PS=0–2, and 61.3% of patients not receiving curative intent treatment had PS=0–2.

7. Conclusion
In England for 2015, the curative treatment rate for stage I and II NSCLC was 67.6%. This means that almost one-third of patients did not receive treatment with curative intent for their early-stage lung cancer, ranging from 25.6% to 38.4% across networks. An NLCA deep-dive spotlight audit to identify more details about why these patients did not receive definitive treatment is planned for later this year.

8. Acknowledgements
Data for this study are based on patient-level information collected by the NHS, as part of the care and support of cancer patients. The data are collated, maintained and quality assured by the NCRAS, which is part of Public Health England. The authors would like to acknowledge Natasha Wood (audit project manager, NCRAS) and Eleanor Fitzgerald (cancer intelligence analyst) at Public Health England for providing the data.
Reference
Royal College of Physicians. National Lung Cancer Audit annual report 2016 (for the audit period 2015). London: Royal College of Physicians, [Accessed 14 September 2017].