1. 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* P value No25,2482,94712%1.00 Yes9,265 (27%) 1,53817%1.51 (1.16- 1.97) <0.001 *adjusted for sex, age, PS, stage, deprivation index and Charlson co-morbidity index

2. Resection rate by PCT 2004-6* *Source: National Cancer Data Repository

3. N = 77,349 Mortality Hazard Ratios for Lung Cancer Patients in England 2004-6 related to resection rate by government office region

4. Mortality hazard ratios for resected patients; England 2004-6 by Government Regional Office N = 6,900

5. Mortality hazard ratios for resected patients; England 2004-6 by Government Regional Office N = 6,900 Implications: comparing the top quintile PCT with Lower 4: 5420 deaths ‘postponed’ by surgery 146 deaths related to higher resection rates

6. Kelvin Lau David Waller Sridhar Rathinam Michael Peake Glenfield Hospital, Leicester, UK UK National Lung Cancer Audit Programme The effects of investing in thoracic surgery on lung cancer resection rates

7. Lung cancer in UK is under treated

8. There is a wide variation in lung cancer surgery in England 5.2% – 10.1% 10.9% – 13.2% 13.6% – 14.5% 14.6% – 16.5% 16.9% – 31.8%

9. Hypothesis the variability in Resection Rate is determined by the provision of specialist thoracic surgery Method We correlated results of the NATIONAL LUNG CANCER AUDIT with manpower data for cardiothoracic surgery

11. National Lung Cancer Audit results 33 English Cancer Networks, comprising 174 Hospital Trusts 31 Trusts had Thoracic Surgery in house (Base Hospitals) 18 (58%) Trusts had less than 2 Pure Thoracic Surgeons 13 (42%) Trusts had 2 or more Pure Thoracic Surgeons In 2008, 15,774 cases of histologically confirmed NSCLC –18.4% cStage I and II –14.2% underwent resection

12. Resection rates are higher in centres who treat more cases R = 0.155 p = 0.06

13. Resection rates are higher in base than in referring centres p < 0.001 Resection Rate p < 0.001 Across the UKWithin each Cancer Network

14. Resection rates are higher in centres with 2 or more specialist thoracic surgeons p = 0.02 Resection Rate

15. Resection rates are higher when surgeons attend preoperative MDTs p = 0.012

16. The increase in resection rate was greatest in those units who employed new thoracic surgeons p = 0.04 19% 66% 2008 2009 Growth Resection Rate

17. Conclusion Lung cancer resection rates in UK can be increased by Increasing the number of specialist thoracic surgeons at preoperative MDTs in referring hospitals Increasing the number of specialist thoracic surgeons in operating centres Thereby increasing the individual caseload in any unit Individual Units must invest in more pure Thoracic Surgical appointments The number of specialist thoracic surgeons in training must be increased

18. Resection Rate - Leicester Surgical Numbers Resection Rate for confirmed NSCLC Resection Rate for all Lung Cancers 1994-1996*6512.24.5 1997-1999*17523.412.0 20024519.912.7 20035821.013.8 20046020.813.5 20058930.420.6 20069431.119.3 * A Martin-Ucar et al. Lung Cancer. 2004; 46:227-232 (specialist thoracic surgeon appointed 1997)