Invitation strategies and participation in a community-based lung cancer screening programme located in areas of high socioeconomic deprivation.

INTRODUCTION: Although lung cancer screening is being implemented in the UK, there is uncertainty about the optimal invitation strategy. Here, we report participation in a community screening programme following a population-based invitation approach, examine factors associated with participation, and compare outcomes with hypothetical targeted invitations. METHODS: Letters were sent to all individuals (age 55-80) registered with a general practice (n=35 practices) in North and East Manchester, inviting ever-smokers to attend a Lung Health Check (LHC). Attendees at higher risk (PLCOm2012NoRace score≥1.5%) were offered two rounds of annual low-dose CT screening. Primary care recorded smoking codes (live and historical) were used to model hypothetical targeted invitation approaches for comparison. RESULTS: Letters were sent to 35 899 individuals, 71% from the most socioeconomically deprived quintile. Estimated response rate in ever-smokers was 49%; a lower response rate was associated with younger age, male sex, and primary care recorded current smoking status (adjOR 0.55 (95% CI 0.52 to 0.58), p<0.001). 83% of eligible respondents attended an LHC (n=8887/10 708). 51% were eligible for screening (n=4540/8887) of whom 98% had a baseline scan (n=4468/4540). Screening adherence was 83% (n=3488/4199) and lung cancer detection 3.2% (n=144) over 2 rounds. Modelled targeted approaches required 32%-48% fewer invitations, identified 94.6%-99.3% individuals eligible for screening, and included 97.1%-98.6% of screen-detected lung cancers. DISCUSSION: Using a population-based invitation strategy, in an area of high socioeconomic deprivation, is effective and may increase screening accessibility. Due to limitations in primary care records, targeted approaches should incorporate historical smoking codes and individuals with absent smoking records.

The diagnostic pathway in lung cancer patients with best supportive care decisions: are there lessons to be learnt?

INTRODUCTION: A proportion of patients with lung cancer will not be suitable for anti-cancer treatment and are managed with best supportive care (BSC). The aim of this retrospective case series analysis was to critically review the use of diagnostic and staging investigations in patients who were ultimately managed with BSC. METHODS: A retrospective review of all lung cancer patients with a multidisciplinary team outcome of BSC from 01 June 2018 to 01 June 2019 was performed. Patients were categorised into those with an early BSC decision and those that underwent further investigations prior to a BSC decision (investigations beyond initial computed tomography (CT)). Patient demographics, clinical characteristics and outcomes were collated and analysed. RESULTS: Seventy-seven lung cancer patients managed with BSC were identified. Patients were elderly (average age 79 years), functionally limited (80% World Health Organization performance status ≥3), frail (70% clinical frailty score ≥6) and had advanced stage disease (90% stage III/IV). Thirty-one (40%) underwent further investigations beyond the initial CT prior to the BSC decision. The most common types of further investigations were endobronchial ultrasound-guided transbronchial needle aspiration (27/31; 74%), positron emission tomography - CT (18/31; 45%) and CT-guided lung biopsy (7/31; 23%). This is despite high levels of consultant chest physician review at first assessment (71%), cancer nurse specialist involvement (97%), specialist palliative care involvement (65%), a high pathological confirmation rate of sampling procedures (89%) and adequacy of molecular testing. The most common reason for a BSC recommendation was a lack of fitness for systemic therapy (17/31; 55%). Six out of thirty-one (19%) patients deteriorated rapidly and died on the cancer pathway and 5/31 (16%) patients had inadequate renal function for systemic anti-cancer treatment. There was low utilisation of serum epidermal growth factor receptor mutation testing across the study cohort (2/77; 3%). DISCUSSION: In an older, functionally limited and frail patient with lung cancer, there is a risk of over-investigation. Impaired renal function is an important clinical factor to identify early to support discussions in this cohort. There will always be an unavoidable proportion of patients that undergo further investigations (often in search of rare targetable mutations) and are then ultimately recommended for best supportive care; such cases could form the basis of specific review and learning for lung cancer services.

Risk perception and disease knowledge in attendees of a community-based lung cancer screening programme.

OBJECTIVES: In England, a risk-based approach is used to determine eligibility for lung cancer screening. Ensuring effective communication and counselling of risk is therefore increasingly important. In this study, we explore the perception of lung cancer risk in attendees of a community-based screening service, located in socio-economically deprived areas of Manchester. We analyse responses based on demographic variables, calculated risk score and screening eligibility. MATERIALS AND METHODS: The Manchester Lung Health Check (LHC) programme invited ever smokers, age 55-80, to a lung cancer risk assessment in which their 6-year risk was calculated (using the PLCOM2012 model). Those at high risk (PLCOM2012 score ≥ 1.51%) were eligible for low dose CT (LDCT) screening. Prior to their assessment, attendees were invited to complete the study questionnaire, which assessed absolute and comparative risk perception, disease knowledge (incidence, survival, and risk factors), lung cancer specific worry, and mental health. RESULTS: 371 participants completed the questionnaire; 66% (n = 243) had linked clinical data. Perceived absolute risk was markedly higher than calculated risk (median: 20% vs. 1%; p < 0.001) and higher in women than men (25% vs. 15%; p = 0.001). There was no correlation between perceived absolute and calculated risk. Overall, 30% classified themselves at higher, and 21% at lower, lung cancer risk compared to others their age. Median PLCOM2012 score increased with perceived comparative risk (p = 0.004). Those eligible for screening were more likely to: classify themselves at higher comparative risk (41% vs. 21%; p < 0.0001), report lung cancer-specific worry (27% vs. 10%; p = 0.001) and have indications of depression (20% vs. 10%; p = 0.05). Family history of lung cancer was significantly associated with higher comparative risk (adjOR 4.03, 95%CI 1.74-9.3; p = 0.001). CONCLUSION: Employing comparative rather than absolute risk may assist risk counselling. Further research is required to determine the optimal approach to risk communication in this setting.

Patient survey examining the experience of care of a hospital-based opt-out tobacco dependency treatment service (the CURE Project).

INTRODUCTION: Treating tobacco dependency in patients admitted to hospital is a key priority in the National Health Service long-term plan. This service evaluation assessed the perception, needs and experience of care within an opt-out hospital-based tobacco dependency treatment service (the Conversation, Understand, Replace, Experts and Evidence Base (CURE) team) in North-West England. METHODS: A survey was offered to all eligible patients between 1 July 2020 and 30 September 2020. Eligibility criteria were adult patients identified as an active smoker being approached by the CURE team as part of the standard opt-out service model, on a non-covid ward without a high suspicion of COVID-19 infection and able to read and write in English. RESULTS: 106 completed surveys were evaluated. Participants demonstrated high levels of tobacco dependency with an average of 37 years smoking history and 66% describing the onset of cravings within 30 min of hospital admission. The average number quit attempts in the previous 12 months was 1.3 but only 9% had used the most effective National Institute for Health and Care Excellence (NICE) recommended treatments. 100% felt the opt-out service model was appropriate and 96% stated the treatment and support they had received had prompted them to consider a further quit attempt. 82% of participants rated their experience of care as 9/10 or 10/10. Participants wanted a broad range of support post discharge with the most popular option being with their general practitioner. 66% and 65% of participants would have been interested in a vaping kit as stop smoking intervention and support vaping-friendly hospital grounds respectively. CONCLUSION: These results suggest this hospital-based, opt-out tobacco dependency treatment service delivers high-quality experience of care and meets the needs of the patients it serves. It also highlights the opportunity to enhance outcomes by providing access to NICE recommended most-effective interventions (varenicline, vaping and combination nicotine replacement therapy) and providing flexible, individualised discharge pathways.

Implementation and outcomes of the RAPID programme: Addressing the front end of the lung cancer pathway in Manchester.

INTRODUCTION: Patients with suspected lung cancer require computed tomography (CT), specialist interpretation of the CT and a consultation with a specialist. Significant time savings could be made with rapid access to these components in the front end of the lung cancer pathway. METHODS: The RAPID programme was launched at Manchester's Wythenshawe Hospital in April 2016. This pathway offers next working day CT for patients with suspected lung cancer, immediate 'hot' reporting of CT images and a same day consultation with a diagnostic specialist. RESULTS: From April 2016 to January 2019, 1,027 patients were referred to the RAPID programme. The median time from referral to CT was 3 days. The CT was hot reported in 94% of patients. The median time from CT to triage and consultation with a diagnostic specialist was 0 days. Overall 56% and 90% of patients had completed a CT and consultation within 3 and 7 days of referral, respectively (0% and 24% prior to implementation). CONCLUSION: Through simple reorganisation of workload, we have significantly reduced the pathway for patients with suspected lung cancer to meet a specialist with a reported CT, something we firmly believe is replicable across all hospitals.

Is there a role for the high-risk multidisciplinary team meeting in thoracic surgery?

OBJECTIVES: There is little information on the impact of a high-risk multidisciplinary team (HRMDT) for thoracic surgery. In our unit, patients considered high risk for thoracic surgery have been discussed at this meeting since its inception in June 2013. The aim of this study was to audit our selection of patients discussed at the HRMDT and its effect on patient outcomes. METHODS: Data were prospectively collected on all patients (n = 820) who underwent lung resection for lung cancer between July 2013 and September 2014. Patients were analysed as two groups HRMDT versus non-HRMDT. Referral to the HRMDT was at the operating surgeons' discretion. Referred patients usually had a higher-than-expected mortality or morbidity risk for the indicated procedure. The median time from HRMDT to surgery was 27 days (IQR 27.75). The median follow-up for all patients was 415 days (IQR 240). RESULTS: There were 102 patients in the HRMDT group and 718 in the non-HRMDT group (males 54 vs 46%; P = 0.12). The median duration from HRMDT to surgery was 27 days (IQR 27.75). Mean age (P = 0.0001), cardiac risk score (P = 0.001) and Thoracoscore (P = 0.0001) were significantly higher in the HRMDT group. There was also a significantly higher proportion of pneumonectomies in the HRMDT group (12 vs 4%; P = 0.001). There were no significant differences between the groups in cardiac, cerebrovascular, GI, pulmonary, renal or composite complications. There was no significant difference in 30-day (3 vs 1%; P = 0.24) or 90-day (5 vs 3%; P = 0.48) mortality between the groups. Operated HRMDT patients had better survival at 200 days (P = 0.002), but there was no difference in long-term survival compared with patients turned down for surgery. CONCLUSIONS: Despite a higher predicted mortality rate by Thoracoscore, HRMDT patients had the same outcome as lower risk non-HRMDT patients. Within the HRMDT cohort, survival in the operated patients was significantly better than that in non-operated patients in the short term. The HRMDT has managed to offer patients a radical treatment option who might have been refused surgery prior to this due to their higher risk profile. We would recommend this forum as a means to further assess and discuss high-risk patients.