ARTICLE IN PRESS doi:10.1510/icvts.2007.157289
Interactive CardioVascular and Thoracic Surgery 6 (2007) 712–714 www.icvts.org
Institutional report - Pulmonary
Lung cancer resection rate in south Manchester: is it comparable to international standards? Results of a prospective tracking study夞 Mohan P. Devbhandaria, *, Sing Yang Soona, Pauline Quennellb, Peotr Krysiaka, Rajesh Shaha, Mark T. Jonesa Department of Cardiothoracic Surgery, South Manchester University Hospital, Southmoor Road, Manchester M23 9LT, UK b Department of Clinical Audit, South Manchester University Hospital, Southmoor Road, Manchester M23 9LT, UK
a
Received 6 April 2007; received in revised form 9 July 2007; accepted 11 July 2007
Abstract The UK has been reported to have the lowest resection and survival rates for lung cancer patients. These reports were based largely on retrospective data from the cancer registry and are now outdated. To monitor the present day surgical resection rate at our institution all newly diagnosed cases of lung cancer presenting to us were enrolled into a prospective tracking study. From September 2003 to March 2005 all suspected primary lung cancer referrals to the North West Lung Centre were tracked to identify patients with newly diagnosed lung cancer. The histology of 247 patients confirmed to be new lung cancer cases were small cell (SCLC), non-small cell (NSCLC) and mixed cancers in 33 (16%), 170 (83.5%) and 1 (0.5%) patients, respectively, while 43 patients had no histological confirmation. Overall, 43 patients (17%) underwent surgery while chemotherapy and radiotherapy were used in 91 (38%) and 43 (17%), respectively. Out of 170 confirmed NSCLC patients, 43 (25%), 65 (38%) and 27 (16%) patients underwent surgery, chemotherapy and radiotherapy, respectively. The remaining 35 (20%) did not receive any treatment because of patient wishes or poor condition. The surgical resection rates were 17% for all lung cancers and 25% for NSCLC. Current surgical resection rates at the South Manchester University Hospital are comparable to international standards. Similar data from the rest of the UK are required to determine the national resection rate, which may not be as low as once thought to be. 䊚 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Lung cancer; Surgery; Resection
1. Introduction Lung cancer remains the leading cause of cancer death in the western world. In 2002, in England and Wales, nearly 29,000 deaths were attributed to lung cancer wNational institute for clinical excellence. Lung cancer: the diagnosis and treatment of lung cancer (available http:yy guidance.nice.org.ukyCG24yguidanceypdfyEnglish) accessed 6 July 2007x. Concerns have been raised about the poor quality of treatment for lung cancer patients in the UK wJoint working group of the British Thoracic Society and The Society of Cardiothoracic Surgeons of Great Britain and Ireland. Critical under-provision of thoracic surgery in the UK 2001 (available at www.scts.org) accessed 2 March 2007x evidenced by the lowest curative resection rate of 8–10% of total w1, 2x compared to figures of around 25% in the USA w3, 4x and the rest of Europe w5x. More recent audit data from the National Lung Cancer Audit (LUCADA) continue to show the same trend with an average national resection rate of 8%. The reasons for this are unclear. In order to improve the treatment of lung cancer patients a number of guidelines and waiting time targets wAvailable at 夞 Presented as a poster at the 4th annual meeting of the British Thoracic Oncology Group, Dublin, January 2006. *Corresponding author. Tel.: q44 161 9803100; fax: q44 161 2912685. E-mail address:
[email protected] (M.P. Devbhandari). 䊚 2007 Published by European Association for Cardio-Thoracic Surgery
http://guidance.nice.org.uk/CG24, accessed on 12 October 2007x have recently been introduced. The accuracy of reported resection figure for any given patient population depends on the precision of denominator (the total population of lung cancer patients with NSCLC in the studies) data used for calculation. Previously reported studies suggesting very low resection rates in the UK were not based on prospectively collected data. The determination of a denominator figure is not a simple exercise due to the complexity of referral patterns of patients from secondary care to the tertiary specialist lung surgery centres. The retrospective studies in these situations are hence subject to many flaws. To address this problem we designed a prospective pilot ‘tracking study’ to determine the precise denominator data required to establish the true resection rate for non-small cell lung cancer (NSCLC) in the south Manchester region. Additionally, the study also aimed to monitor the quality of lung cancer services provided to patients by the lung cancer services at the South Manchester University Hospital (SMUHT). 2. Materials and methods From September 2003 to March 2005, all suspected primary lung cancer referrals to the chest clinic were screened to identify patients with newly diagnosed lung cancer.
ARTICLE IN PRESS M.P. Devbhandari et al. / Interactive CardioVascular and Thoracic Surgery 6 (2007) 712–714
Patients from the area served by SMUHT chest physicians were enrolled into a prospective tracking study. SMUHT is the tertiary referral centre for lung surgery for a much wider area of Greater Manchester. For this study patients coming from areas beyond our primary catchment area were considered to be non-local patients and excluded from the study. Patients presenting with either recurrence of previously diagnosed lung cancer or metastasis from other sites were also excluded from the study. At SMUHT all the referrals are first assessed by respiratory physicians in the outpatient clinic or in the ward. Following the diagnostic work-up including chest X-ray, bronchoscopy, lung function tests, CT scan"needle biopsy, the patients are discussed in the multi-disciplinary team meetings (MDT). An increasing number of patients are having PET scans as a part of their investigation. Following discussion at the MDT a treatment plan is formulated and appropriate specialist referrals are made. Those patients who need further investigations such as exercise test, angiogram, bone scan, echocardiography etc. to assess the suitability for radical treatment are re-discussed in the MDT in the light of the new results and followed by formulation of treatment plan and appropriate specialist referrals. A sizable proportion of patients present through a nongeneral practitioner (GP) route. To ensure that all the qualifying patients are enrolled into the study additional methods were used to identify patients. The methods employed were regular interval screenings of histology results, chest CT scan reports, ICD codes, thoracic surgery database and Macmillan referrals. A dedicated audit officer (PQ) tracked the patients’ journey through their investigations and treatments to make a prospective record of accurate data. Once identified, a proforma was completed for each patient, which was used to record the progression of the patient through various stages of treatment pathway. 3. Results Of all suspected lung cancer referrals tracked from August 2003 to March 2005, a total of 247 were confirmed to be new ‘local’ cases of lung cancer. One hundred and thirtythree (54%) of these cases were GP referrals and 114 (46%) were casualty and internal referrals. The majority of patients were male (65%) and the median age was 71 years (IQR 62–77 years) at presentation. Histologyycytology was available for 204 (82.6%) patients. The cell types were small cell (SCLC), non-small cell (NSCLC) and mixed cancers in 33 (16%), 170 (83.5%) and 1 (0.5%) patients, respectively, while 43 patients had no histological confirmation. TNM staging data were available for 188 clinically NSCLC patients excluding 26 poorly patients and 33 small cell lung cancers who were not staged formally. They were clinically staged I 26 (13.8%), II 15 (7.9%), IIIa 24 (12.7%) and IIIb–IV 123 (65.4%) (Fig. 1). Overall, 43 patients (17%) underwent surgery while chemotherapy and radiotherapy were used in 91 (38%) and 43 (17%), respectively. Out of 170 confirmed NSCLC patients, 43 (25%), 65 (38%) and 27 (16%) patients underwent surgery, chemotherapy and radiotherapy, respectively (Fig. 2). The remaining 35 (20%) did not receive any treatment because of patient
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Fig. 1. Treatment methods and staging in clinically NSCLC patients (ns188). This included 18 patients who did not have histological confirmation.
wishes or poor condition. The overall surgical resection rates were 17% for all lung cancers and 25% for NSCLC. The types of resection carried out were pneumonectomies 21%, lobectomiesybilobectomies 65% and lesser resections 14%. The mean age (years) for pneumonectomy (62) was significantly lower (P-0.01) than lobectomy (69) and lesser resection (71) (Fig. 3). Lobectomy was the commonest operation for all stages as expected (Fig. 4). Two patients died postoperatively at a mean of 16 days. 4. Discussion The UK resection rate for lung cancer has been reported to be below 10%. It is felt that more cases may be potentially suitable for resection. Compared to this a US national survey reported a resection rate of 30.5%. Similarly, Damhuis and Schutte w5x in Rotterdam found a 20% resection rate which is the same resection rate as noted by Moghissi and Connolly w2x. Resection rate for NSCLC in Greater Manchester in the year 1999 and 2000 obtained by comparing total resections and the South Manchester University Hospital and the Manchester Royal Infirmary with North West Cancer Registry data gave a resection rate of 12.08% and 11.55% for the years 1999 and 2000, respectively. The cause of the low resection rate has remained
Fig. 2. Modes of treatment in histologically proven NSCLC patients (ns170).
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Fig. 3. Type of resection vs. mean age of the patients.
reported previously from other centres in the UK w8x. In their analysis the higher resection rates they achieved were possibly due to earlier diagnosis, MDT discussion, high histological confirmation, universal CT scanning and prompt surgical review. They felt it was unlikely to be due to more aggressive surgery or operating on more elderly patients in those centres compared to the rest of the UK. A more recent report from another UK centre ascribed their improved resection rate to an improved specialist thoracic surgical service w9x. We concur with these authors but we would like to emphasise that the major contributory factor may be prompt assessment by respiratory physicians and collection of more accurate denominator data than the aforementioned factors. There is a possibility that the actual UK resection rate may have been under-reported due to the lack of precise denominator data for pathologically proven non-small cell lung cancer. We aim to extend the study to patients from areas in the Northwest of England beyond our local catchment area. 5. Conclusion With precise recording of denominator data; these results show that surgical resection rates for lung cancer in south Manchester local patients are comparable to international standards. Similar data from the rest of the UK are required to determine the national resection rate, which may not be as low as once thought to be. References
Fig. 4. Type of resection vs. stage of NSCLC.
speculative; older age, more aggressive tumours, less aggressive surgical treatment, inadequate provision of thoracic surgery being some of the factors postulated. There are, however, problems in direct comparison of international resection rates due to retrospective collection of data, mostly from registry and variations in the use of denominators, as noted by Connolly et al. w6x and Phillips w7x. Only prospectively collected data can give robust and reliable indication of the true resection rate. These data suggest that the true resection rate in South Manchester is higher than the currently reported UK national resection rates. Though this study covers a relatively short period of time and a small geographical area, the findings have an important implication for the whole of the country. Similar improvements in resection rates have been
w1x Gregor A, Thomson CS, Brewster DH, Stroner PL, Davidson J, Fergusson RJ, Milroy R, on behlf of the Scottish Cancer Trials Lung Group and the Scottish Cancer Therapy Network. Management and survival of patients with lung cancer in Scotland diagnosed in 1995: results of a national population based study. Thorax 2001;56:212–217. w2x Moghissi K, Connolly C. Resection rate in lung cancer patients. Eur Respir J 1996;9:5–6. w3x Fry WA, Menck HR, Winchester DP. The nationl cancer data base report on lung cancer. Cancer 1996;77:1947–1955. w4x Humphrey EW, Smart CR, Winchester DP, Steele GD Jr, Yarbro JW, Chu KC, Triolo HH. National survey of the pattern of care for carcinoma of the lung. J Thorac Cardiovasc Surg 1990;100:837–843. w5x Damhuis RAM, Schutte PR. Resection rates and postoperative mortality in 7,899 patients with lung cancer. Eur Respir J 1996;9:7–10. w6x Connolly CK, Johnston I, Milroy R, Jones R. Surgical resection rates in lung cancer. Thorax 1999;54:374. w7x Phillips A. Resections rates in lung cancer. Thorax 1999;54:374. w8x Laroche CM, Wells FC, Coulden R, Stewart S, Goddard M, Lowry E, Price A, Gilligan D. Improving surgical resection rate in lung cancer. Thorax 1998;53:445–449. w9x Martin-Ucar AE, Waller DA, Atkins JL, Swinson D, O’Byrne KJ, Peake MD. The beneficial effects of specialist thoracic surgery on the resection rate for non-small cell lung cancer. Lung Cancer 2004;46:227–232.
