European Respiratory Society guideline on various aspects of quality in lung cancer care.

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

ERS statement on harmonised standards for lung cancer registration and lung cancer services in Europe.

The European Respiratory Society (ERS) task force for harmonised standards for lung cancer registration and lung cancer services in Europe recognised the need to create a single dataset for use in pan-European data collection and a manual of standards for European lung cancer services.The multidisciplinary task force considered evidence from two different sources, reviewing existing national and international datasets alongside the results of a survey of clinical data collection on lung cancer in 35 European countries. A similar process was followed for the manual of lung cancer services, with the task force using existing guidelines and national or international recommendations for lung cancer services to develop a manual of standards for services in Europe.The task force developed essential and minimum datasets for lung cancer registration to enable all countries to collect the same essential data and some to collect data with greater detail. The task force also developed a manual specifying standards for lung cancer services in Europe.Despite the wide variation in the sociopolitical landscape across Europe, the ERS is determined to encourage the delivery of high-quality lung cancer care. Both the manual of lung cancer services and the minimum dataset for lung cancer registration will support this aspiration.

Achieving Thoracic Oncology data collection in Europe: a precursor study in 35 Countries.

BACKGROUND: A minority of European countries have participated in international comparisons with high level data on lung cancer. However, the nature and extent of data collection across the continent is simply unknown, and without accurate data collection it is not possible to compare practice and set benchmarks to which lung cancer services can aspire. METHODS: Using an established network of lung cancer specialists in 37 European countries, a survey was distributed in December 2014. The results relate to current practice in each country at the time, early 2015. The results were compiled and then verified with co-authors over the following months. RESULTS: Thirty-five completed surveys were received which describe a range of current practice for lung cancer data collection. Thirty countries have data collection at the national level, but this is not so in Albania, Bosnia-Herzegovina, Italy, Spain and Switzerland. Data collection varied from paper records with no survival analysis, to well-established electronic databases with links to census data and survival analyses. CONCLUSION: Using a network of committed clinicians, we have gathered validated comparative data reporting an observed difference in data collection mechanisms across Europe. We have identified the need to develop a well-designed dataset, whilst acknowledging what is feasible within each country, and aspiring to collect high quality data for clinical research.

The European initiative for quality management in lung cancer care.

Lung cancer is the commonest cause of cancer-related death worldwide and poses a significant respiratory disease burden. Little is known about the provision of lung cancer care across Europe. The overall aim of the Task Force was to investigate current practice in lung cancer care across Europe. The Task Force undertook four projects: 1) a narrative literature search on quality management of lung cancer; 2) a survey of national and local infrastructure for lung cancer care in Europe; 3) a benchmarking project on the quality of (inter)national lung cancer guidelines in Europe; and 4) a feasibility study of prospective data collection in a pan-European setting. There is little peer-reviewed literature on quality management in lung cancer care. The survey revealed important differences in the infrastructure of lung cancer care in Europe. The European guidelines that were assessed displayed wide variation in content and scope, as well as methodological quality but at the same time there was relevant duplication. The feasibility study demonstrated that it is, in principle, feasible to collect prospective demographic and clinical data on patients with lung cancer. Legal obligations vary among countries. The European Initiative for Quality Management in Lung Cancer Care has provided the first comprehensive snapshot of lung cancer care in Europe.

Comorbidities in lung cancer: prevalence, severity and links with socioeconomic status and treatment.

BACKGROUND: Survival from lung cancer remains poor in Scotland, UK. Although the presence of comorbidities is known to influence outcomes, detailed quantification of comorbidities is not available in routinely collected audit or cancer registry data. The aim of the present study was to assess the prevalence and severity of comorbidities in patients with newly diagnosed lung cancer across four centres throughout Scotland using validated criteria. METHODS: Between 2005 and 2008, all patients with newly diagnosed lung cancer coming through the multidisciplinary teams in four Scottish centres were included in the study. Patient demographics, WHO/Eastern Cooperative Oncology Group performance status, clinicopathological features and primary treatment modality were recorded. RESULTS: Details of 882 patients were collected prospectively. The majority of patients (87.3%) had at least one comorbidity, the most common being weight loss (53%), chronic obstructive pulmonary disease (43%), renal impairment (28%) and ischaemic heart disease (27%). A composite score was produced that included both number and severity of comorbidities. One in seven patients (15.3%) had severe comorbidity scores. There were statistically significant variations in comorbidity scores between treatment centres and between non-small cell lung carcinoma treatment groups. Disease stage was not associated with comorbidity score. CONCLUSIONS: There is a high prevalence of multiple, severe comorbidities in Scottish patients with lung cancer, and these vary by site and treatment group. Further research is needed to determine the relationship between comorbidity scores and survival in these patients.

ADVANCE-1: An adapted collaborative benchmarking approach in centre-based lung cancer care.

The majority of research within lung cancer is focused on prevention, diagnosis and treatment rather than examining infrastructure or processes of lung cancer centres. Benchmarking is a systematic method for documenting and comparing processes, functions or performance of organisations against the best in the world. ADVANCE-1 is a European Respiratory Society funded pilot study with the main aim of creating a benchmarking tool that can easily document and reflect the structure and process within a lung cancer centre and its associated registry. By doing this we can then compare centres and generate best practice learning points from each centre in order to learn from each other. The ADVANCE-1 study group was constituted by two ERS fellowship-holders and senior lung cancer specialists from the two participating lung cancer services in Glasgow, Scotland, and Berlin, Germany. The study design and benchmarking tools were reviewed externally. Once the benchmarking tools were created, prospective testing was undertaken in the two participating centres in order to allow comparison to ascertain best practice in a so called 'collaborative benchmarking approach'. We were then able to create personalised learning points for each centre. The next phase of the project will be to expand the benchmarking across several European centres in the ADANCE-2 project.

Fighting lung cancer in the developed world--a model of care in a UK hospital.

OBJECTIVES: To highlight the initial management approach for Lung Cancer in a UK Hospital with the aim of translating the principles of such methodology to a developing country, such as Pakistan. METHODS: A descriptive observational study was carried out at Stobhill Hospital, Glasgow, UK. The investigator (IMB) observed the Lung Cancer Service, attending the weekly 'New patients Clinic', 'Results Clinic', and 'Multidisciplinary team (MDT) meetings'. The process observations and the factual data describing the details of the service were recorded on a pre-designed pro-forma. Observations relating to two aspects of this service (Results Clinic and MDT) are included in this report. RESULTS: The methodology of communicating results of lung cancer investigations to patients in a pre-planned and staged manner at a dedicated 'Results Clinic' was identified as a useful approach. A format of communication was consistently followed. CONCLUSION: The MDT consisted of a Respiratory Physician, Clinical Oncologist, Thoracic Surgeon, Radiologist, Pathologist and Palliative Care Specialist. Each patient's case was discussed on an individual basis and the team developed a consensus regarding diagnosis, staging of the disease, further need for diagnostic procedures and treatment options, bearing in mind the patient's performance status, co-morbidity and their wishes. This approach has improved the initial part of the lung cancer patient journey and components of this approach could easily be transferred to a developing country.

Lung cancer stigma: A concept with consequences for patients.

BACKGROUND: Patients with lung cancer (LC) report lower quality of life (QoL) and higher levels of psychological distress compared with other cancer populations. Lung cancer stigma (LCS) may in part explain these findings. AIM: We investigated the prevalence of patient-perceived lung cancer stigma (LCS) and its relationships to symptom burden/severity, depression, and deficits in health-related quality of life (HR-QoL). METHODS: In this descriptive, observational, and cross-sectional study, 201 participants were sent questionnaires. These included the Cataldo Lung Cancer Stigma Scale (CLCSS), the Lung Cancer Symptom Scale, the Centre for Epidemiologic Studies-Depression Scale, and the Quality of Life Inventory. RESULTS: Participants were on average 69 years old, 52% women, 95% ever smokers, and 18.5% current smokers. The mean total CLCSS score was 53.1 (SD = 14.1; range = 31-94). LCS was significantly correlated with younger age (P < .001), greater social deprivation (P < .05), being unemployed (P < .001), depression (P < .001), symptom burden (P < .001), and HR-QoL deficits (P < .001). Symptom burden explained 18% of variance in LCS (P < .001). LCS explained 8.5% and 14.3% of the variance in depression (P < .001) and HR-QoL (P < .001), respectively. CONCLUSION: Patients with lung cancer are vulnerable to LCS. Symptom burden can directly contribute to greater perceived LCS. Greater perceived LCS can be directly related to greater levels of depression and lower HR-QoL. A tailored approach is required to screen for LCS and implement interventions to enhance the psychosocial well-being of patients with perceived LCS.

Obtaining tissue diagnosis in lung cancer patients with poor performance status and its influence on treatment and survival.

INTRODUCTION: 25% of patients with lung cancer have performance status 3 or 4. A pragmatic approach to investigative procedures is often adopted based on the risks and benefits in these patients and whether tissue diagnosis is necessary for anticipated future treatment. This cohort study investigated factors influencing a clinician's decision to pursue a tissue diagnosis in patients with lung cancer and performance status 3 and 4 and to examine the association of tissue diagnosis with subsequent management and survival. METHODS: All patients with lung cancer diagnosed in North Glasgow from 2009 to 2012 were prospectively recorded in a registry. We investigated the relationships between achieving a tissue diagnosis, treatment and survival. RESULTS: Of 2493 patients diagnosed with lung cancer, 490 patients (20%) were PS 3 and 122 patients (5%) were PS 4. Tissue diagnosis was attempted in 60% and 35% patients with PS 3 and PS 4 respectively. Younger age, better performance status and having stage 4 disease were independently associated with a diagnostic procedure being performed. Only 5% of patients with poor performance status received treatment conventionally requiring a tissue diagnosis. Age, stage and performance status were independent predictors of mortality. Achieving a tissue diagnosis was not associated with mortality. Receiving treatment requiring tissue diagnosis is associated with survival benefit. CONCLUSIONS: The majority of patients with poor fitness undergo a diagnostic procedure which does not influence further treatment or affect survival. However, the cohort of patients who do undergo therapy determined by tissue diagnosis have improved survival.

A randomised comparison of radical radiotherapy with or without chemotherapy for patients with non-small lung cancer: results from the Big Lung Trial.

BACKGROUND: A meta-analysis of trials comparing primary treatment with or without chemotherapy for patients with non-small cell lung cancer published in 1995 suggested a survival benefit for cisplatin-based chemotherapy in each of the primary treatment settings studied, but it included many small trials, and trials with differing eligibility criteria and chemotherapy regimens. METHODS: The Big Lung Trial was a large pragmatic trial designed to confirm the survival benefits seen in the meta-analysis, and this paper reports the findings in the radical radiotherapy setting. The trial closed before the required sample size was achieved due to slow accrual, with a total of 288 patients randomised to receive radical radiotherapy alone (146 patients) or sequential radical radiotherapy and cisplatin-based chemotherapy (142 patients). RESULTS: There was no evidence that patients allocated sequential chemotherapy and radical radiotherapy had a better survival than those allocated radical radiotherapy alone, HR 1.07 (95% CI 0.84-1.38, P=0.57), median survival 13.0 months for the sequential group and 13.2 for the radical radiotherapy alone group. In addition, exploratory analyses could not identify any subgroup that might benefit more or less from chemotherapy. CONCLUSIONS: Despite not suggesting a survival benefit for the sequential addition of chemotherapy to radical radiotherapy, possibly because of the relatively small sample size and consequently wide confidence intervals, the results can still be regarded as consistent with the meta-analysis, and other similarly designed recently published large trials. Combining all these results suggests there may be a small median survival benefit with chemotherapy of between 2 and 8 weeks.

The impact of comorbidity upon determinants of outcome in patients with lung cancer.

BACKGROUND: Survival from lung cancer remains poor in Scotland, UK. It is believed that comorbidity may play an important role in this. The goal of this study was to determine the value of a novel comorbidity scoring system (SCSS) and to compare it with the already established Charlson Comorbidity Index and the modified Glasgow Prognostic Score (mGPS). We also wished to explore the relationship between comorbidity, mGPS and Performance Status (PS). In addition we investigated a number of standard prognostic markers and demographics. This study aimed to determine which of these factors most accurately predicted survival. METHODS: Between 2005 and 2008 all newly diagnosed lung cancer patients coming through the Multi-Disciplinary Teams (MDTs) in four Scottish Centres were included in the study. Patient demographics, World Health Organization/Eastern Cooperative Oncology Group performance status, clinico-pathological features, mGPS, comorbidity and proposed primary treatment modality were recorded. Univariate survival analysis was carried out using Kaplan-Meier method and the log rank test. RESULTS: This large unselected population based cohort study of lung cancer patients has demonstrated that a number of important factors have significant impact in terms of survival. It has gone further by showing that the factors which influence survival are different, depending upon the stage of cancer at diagnosis and the potential treatment strategy. The novel comorbidity scoring system, the SCSS, has compared very favourably with the more established CCI. CONCLUSION: This study has identified that a variety of factors are independent prognostic determinants of outcome in lung cancer. There appear to be clear differences between the early and late stage groups.

A prospective study of the impact of weight loss and the systemic inflammatory response on quality of life in patients with inoperable non-small cell lung cancer.

The relationship between weight loss, the systemic inflammatory response and quality of life in patients with inoperable non-small cell lung cancer (NSCLC) was studied. The extent of weight loss, the systemic inflammatory response (C-reactive protein) and quality of life (EORTC-QLQ-C30) was measured in 106 patients with inoperable NSCLC (stage III and IV). Approximately 40% had more than 5% weight loss and almost 80% had elevated circulating C-reactive protein concentrations (>10 mg/l). The functional scale scores of the EORTC-QLQ-C30 were poor (50 or less) and the fatigue symptom score was also poor (50 or more). When patients were grouped according to whether or not they had experienced more than 5% weight loss, Karnofsky performance status and global quality of life were lower (P<0.05) and symptom scores fatigue (P<0.05) and pain (P<0.01) were greater in the weight-losing group. When the weight-stable cancer patients were grouped according to whether or not they had evidence of a systemic inflammatory response, the symptom fatigue was higher in the inflammatory group (P<0.05). In the weight-stable cancer patients C-reactive protein concentration was correlated with fatigue r=0.31 (P<0.05). The results of the present study indicate that both weight loss and the systemic inflammatory response impact on different aspects of quality of life. In particular, fatigue is associated with the presence of a systemic inflammatory response independent of weight loss.

Does knowledge of cancer diagnosis affect quality of life? A methodological challenge.

BACKGROUND: As part of an assessment of quality of life in lung cancer patients an investigation was carried out to examine whether the knowledge of their diagnosis affected their quality of life. METHODS: Every patient in a defined geographical area with a potential diagnosis of lung cancer was interviewed at first consultation and after a definitive treatment has been given. Quality of life was assessed using three standard measures: the Nottingham Health Profile (NHP), the EORTC quality of life questionnaire (QLQ-C30) and its lung cancer supplementary questionnaire (QLQ-LC13). Comparison was made in quality of life scores between patients who knew their cancer diagnosis and those who did not. RESULTS: In all, 129 lung cancer patients were interviewed. Of these, 30 patients (23%) knew and 99 (78%) did not know their cancer diagnosis at the time of baseline assessment. The patient groups were similar in their characteristics except for age (P = 0.04) and cell type (P < 0.0001). Overall, there were no significant differences between these two groups with regard to their scores on the three instruments used. A major finding was that both group scored almost the same on emotional reactions (P = 0.8) and social isolation (P = 1.0) as measured by the NHP, and emotional (P = 0.7) and social functioning (P = 1.0) as measured by the EORTC QLQ-C30. In addition there were no significant differences in patients' symptom scores between those who knew their diagnosis and those who did not, nor did any consistent pattern emerge. The only significant difference was for sleep difficulties (P = 0.02). CONCLUSION: The findings suggest that the knowledge of cancer diagnosis does not affect the way in which patients respond to quality of life questionnaires.

Quality of life in lung cancer patients: does socioeconomic status matter?

BACKGROUND: As part of a prospective study on quality of life in newly diagnosed lung cancer patients an investigation was carried out to examine whether there were differences among patients' quality of life scores and their socioeconomic status. METHODS: Quality of life was measured at two points in time (baseline and three months after initial treatment) using three standard instruments; the Nottingham Health Profile (NHP), the European Organization for Research and Cancer Treatment Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer supplement (QLQ-LC13). Socioeconomic status for each individual patient was derived using Carstairs and Morris Deprivation Category ranging from 1 (least deprived) to 7 (most deprived) on the basis of the postcode sector of their address. RESULTS: In all, 129 lung cancer patients entered into the study. Of these data for 82 patients were complete (at baseline and follow-up). 57% of patients were of lower socioeconomic status and they had more health problems, less functioning, and more symptoms as compared to affluent patients. Of these, physical mobility (P = 0.05), energy (P = 0.01), role functioning (P = 0.04), physical functioning (P = 0.03), and breathlessness (P = 0.02) were significant at baseline. However, at follow-up assessment there was no significant difference between patient groups nor did any consistent pattern emerge. CONCLUSION: At baseline assessment patients of lower socioeconomic status showed lower health related quality of life. Since there was no clear trend at follow-up assessment this suggests that patients from different socioeconomic status responded to treatment similarly. In general, the findings suggest that quality of life is not only the outcome of the disease and its treatment, but is also highly dependent on each patients' socioeconomic characteristics.

Simple and Objective Prediction of Survival in Patients with Lung Cancer: Staging the Host Systemic Inflammatory Response.

Background. Prediction of survival in patients diagnosed with lung cancer remains problematical. The aim of the present study was to examine the clinical utility of an established objective marker of the systemic inflammatory response, the Glasgow Prognostic Score, as the basis of risk stratification in patients with lung cancer. Methods. Between 2005 and 2008 all newly diagnosed lung cancer patients coming through the multidisciplinary meetings (MDTs) of four Scottish centres were included in the study. The details of 882 patients with a confirmed new diagnosis of any subtype or stage of lung cancer were collected prospectively. Results. The median survival was 5.6 months (IQR 4.8-6.5). Survival analysis was undertaken in three separate groups based on mGPS score. In the mGPS 0 group the most highly predictive factors were performance status, weight loss, stage of NSCLC, and palliative treatment offered. In the mGPS 1 group performance status, stage of NSCLC, and radical treatment offered were significant. In the mGPS 2 group only performance status and weight loss were statistically significant. Discussion. This present study confirms previous work supporting the use of mGPS in predicting cancer survival; however, it goes further by showing how it might be used to provide more objective risk stratification in patients diagnosed with lung cancer.

Chronic obstructive pulmonary disease: a complex comorbidity of lung cancer.

Chronic obstructive pulmonary disease (COPD) is a major burden throughout the world. It is associated with a significantly increased incidence of lung cancer and may influence treatment options and outcome. Impaired lung function confirming COPD is an independent risk factor for lung cancer. Oxidative stress and inflammation may be a key link between COPD and lung cancer, with numerous molecular markers being analysed to attempt to understand the pathway of lung cancer development. COPD negatively influences the ability to deliver radical treatment options, so attempts must be made to look for alternative methods of treating lung cancer, while aiming to manage the underlying COPD. Detailed assessment and management plans utilising the multidisciplinary team must be made for all lung cancer patients with COPD to provide the best care possible. Journal of Comorbidity 2011;1:45-50.

Variation in comorbidity and clinical management in patients newly diagnosed with lung cancer in four Scottish centers.

BACKGROUND: Treatment and survival rates within Scotland for patients with lung cancer seem lower than in many other European countries. No study of lung cancer has attempted to specifically investigate the association between variation in investigation, comorbidity, and treatment and outcome between different centers. METHODS: Patient demographics, World Health Organization/Eastern Cooperative Oncology Group performance status, and primary treatment modality were recorded. In addition to recording the comorbidities present in each patient, the severity of each comorbidity was graded on a 4-point scale (0-3) using validated severity scales. Data were collected as the patient was investigated and entered in an anonymized format into a database designed for the study. RESULTS: Prospectively collected data from 882 patients diagnosed with lung cancer in four Scottish centers. A number of statistically significant differences were identified between centers. These included investigation, treatment between centers (i.e., surgical rates), age, tumor histology, smoking history, socioeconomic profile, ventilatory function, and performance status. Predictors of declining performance status included increasing severity of a number of comorbidities, age, lower socioeconomic status, and specific centers. CONCLUSIONS: This study has identified many significant intercenter differences within Scotland. We believe this to be the first study to identify nontumor factors independent of performance status that together limit the ability to deliver radical, possibly curative, therapy to our lung cancer population. It is only by identifying such factors that we can hope to improve on the relatively poor outlook for the majority of Scottish patients with lung cancer.

Elevated preoperative C-reactive protein predicts poor cancer specific survival in patients undergoing resection for non-small cell lung cancer.

BACKGROUND: Although only the minority of patients with non-small cell lung cancer (NSCLC) are suitable for surgical resection, it offers the best possibility of cure. The aim of this study was to examine the relationship between the clinicopathological status, the preoperative systemic inflammatory response, and survival in patients undergoing potentially curative resection for NSCLC. METHODS: Data from 96 patients who underwent resection of NSCLC between 2000 and 2003 were collected retrospectively and that for 2004-2006 prospectively. RESULTS: All patients had Eastern cooperative oncology group performance status 0 or 1. No patient had T4, unresectable nodal or metastatic disease, and all macroscopic tumors were removed, with subsequent negative surgical margins. The majority of patients were older than 60 years (71%), men (57%), underwent a lobectomy (65%), and had tumor, node, metastasis stage I disease (66%). Of the markers of the systemic inflammatory response, white cell count, C-reactive protein, and albumin, only an elevated C-reactive protein (>10 mg/L) was associated with cancer-specific survival. On multivariate analysis, only tumor, node, metastasis stage (hazard ratio 1.88, 95% confidence interval 1.34-2.63, p < 0.001) and preoperative C-reactive protein (hazard ratio 1.67, 95% confidence interval 1.01-2.83, p < 0.05) retained independent significance. Those patients with a preoperative C-reactive protein concentration >10 mg/L had a median survival of 26.2 months compared with 75.9 months in those patients with a C-reactive protein < or =10 mg/L (p < 0.05). CONCLUSION: The results of this study indicate that the presence of a systemic inflammatory response predicts poor outcome in patients who have undergone potentially curative resection for lung cancer.