1. 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

2. Matthew Callister, Leeds

3. 3

4. 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

5. Adjusted surgery rates 2009

6. 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

7. 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)

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

9. Source: R Hubbard; unpublished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
<0.001
Haemoptysis
11.2
10.45
0.4
0.2
32.7
54.7
Chest/shoulder pain
25.2
20.35
6.6
2.75
3.67
Voice hoarseness
2.8
2.3
0.65
0.35
4.32
6.7
Difficulty in breathing
26.65 23
7.75 5
4.79
6.4
Weight loss
6.65 6
1.2
0.7
6.17
9.86
Symptoms based on NICE guidelines recommendations
Source: R Hubbard; unpublished 9

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Source: R Hubbard; unpublished

12. 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

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

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

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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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

22. 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.

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

24. 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 ( )
CXR
425
309
p = NNT = 320 24

25. 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, 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:

26. 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