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.

Epidemiology of thymoma.

Thymic tumours are a heterogeneous group of malignancies with a range of clinical presentations. The most common types are thymoma and thymic carcinoma, but overall it remains a rare cancer, and one without a clear aetiology. In this review of the epidemiology of the disease, the relationship between sex, age, and ethnicity is reviewed, along with limited evidence on the genetics of the condition. In terms of risk factors and potential causative factors, environmental exposures such as tobacco, radiation, alcohol, or diet, seem to be irrelevant, but there is some evidence linking the development of thymoma and thymic carcinoma with viral conditions, including Epstein Barr Virus. But data is not conclusive, and in the absence of large patient numbers, it is difficult to prove causation. There has been good research looking at the link between thymoma and other malignancies, either before or after the diagnosis. There does not appear to be a significant increased likelihood of thymoma following other malignancies. But, there is a suggestion, in several papers, that there is an increased risk of other malignancies following the diagnosis of thymoma, although the magnitude of this risk is disputed. There does appear to be an increased risk of non-Hodgkins Lymphoma after a diagnosis of thymoma, and this could be related to a disruption in T-cell function caused by either the disease process or the treatment directed at the thymoma. In summary though, it is a rare malignant process with a variety of presentations, often limited to the anterior mediastinum, and without an aggressive disease profile.

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.

The impact of the 'hub and spoke' model of care for lung cancer and equitable access to surgery.

OBJECTIVES: To determine the influence of where a patient is first seen (either surgical or non-surgical centre) and patient features on having surgery for non-small cell lung cancer (NSCLC). DESIGN: Cross-sectional study from individual patients, between 1January 2008 and 31March 2012. SETTING: Linked National Lung Cancer Audit and Hospital Episode Statistics datasets. PARTICIPANTS: 95,818 English patients with a diagnosis of NSCLC, of whom 12,759 (13%) underwent surgical resection. MAIN OUTCOME MEASURE: Odds of having surgery based on the empirical catchment population of the 30 thoracic surgical centres in England and whether the patient is first seen in a surgical centre or a non-surgical centre. RESULTS: Patients were more likely to be operated on if they were first seen at a surgical centre (OR 1.37; 95% CI 1.29 to 1.45). This was most marked for surgical centres with the largest catchment populations. In these surgical centres with large catchment populations, the resection rate for local patients was 18% and for patients first seen in a non-surgical centre within catchment was 12%. CONCLUSIONS: Surgical centres that serve the largest catchment populations have high resection rates for patients first seen in their own centre but, in contrast, low resection rates for patients first seen at the surrounding centres they serve. Our findings demonstrate the importance of going further than relating resection rates to hospital volume or surgeon number, and show that there is a pressing need to design lung cancer services which enable all patients, including those first seen at non-surgical centres, to have equal access to lung cancer surgery.

Small-cell lung cancer in England: trends in survival and chemotherapy using the National Lung Cancer Audit.

BACKGROUND: The purpose of this study was to identify trends in survival and chemotherapy use for individuals with small-cell lung cancer (SCLC) in England using the National Lung Cancer Audit (NLCA). METHODS: We used data from the NLCA database to identify people with histologically proven SCLC from 2004-2011. We calculated the median survival by stage and assessed whether patient characteristics changed over time. We also assessed whether the proportion of patients with records of chemotherapy and/or radiotherapy changed over time. RESULTS: 18,513 patients were diagnosed with SCLC in our cohort. The median survival was 6 months for all patients, 1 year for those with limited stage and 4 months for extensive stage. 69% received chemotherapy and this proportion changed very slightly over time (test for trends p = 0.055). Age and performance status of patients remained stable over the study period, but the proportion of patients staged increased (p-value<0.001), mainly because of improved data completeness. There has been an increase in the proportion of patients that had a record of receiving both chemotherapy and radiotherapy each year (from 19% to 40% in limited and from 9% to 21% in extensive stage from 2004 to 2011). Patients who received chemotherapy with radiotherapy had better survival compared with any other treatment (HR 0.24, 95% CI 0.23-0.25). CONCLUSION: Since 2004, when the NLCA was established, the proportion of patients with SCLC having chemotherapy has remained static. We have found an upward trend in the proportion of patients receiving both chemotherapy and radiotherapy which corresponded to a better survival in this group, but as it only applied for a small proportion of patients, it was not enough to change the overall survival.

The pathological confirmation rate of lung cancer in England using the NLCA database.

BACKGROUND: The National Lung Cancer Audit (NLCA) recommends that trusts obtain pathology (histology or cytology) for 75% of their lung cancer patients, however this figure was arbitrarily chosen and the optimal pathological confirmation rate is unknown, and many countries report somewhat higher rates. The aims of this study were to provide a simple means of benchmarking appropriate pathological confirmation rates by stratifying patients into groups, and whether obtaining pathology based on those groups is associated with a survival benefit. METHODS: We calculated the proportion of patients with non-small cell or small cell lung cancer in the NLCA database, first seen between 1st January 2004 and 31st December 2010, who had pathological confirmation of their diagnosis. Using logistic we assessed the independent influence of patient factors on the likelihood of having histology or cytology, and the overall effect on survival. We also used bivariate analysis to identify the features which were most strongly associated with having pathology and performed Cox regression to identify any survival advantage. FINDINGS: We analysed data on 136,993 individuals. Age and performance status (PS) were the strongest predictors of pathological confirmation: age ≥ 85 odds ratio (OR) 0.20 (95% confidence interval (CI) 0.19-0.22) compared with age<55; PS 4 OR 0.11 (95%CI 0.10-0.12) compared with PS 0. Pathological confirmation of diagnosis was associated with a small early survival advantage for groups 1 & 2 which represented younger patients with good PS, even after adjusting for other patient features: hazard ratio (HR) 0.93 & 0.89 respectively. CONCLUSION: Stratifying patients by age and performance status is useful and appropriate when benchmarking standards for pathological confirmation of the diagnosis of lung cancer. We have shown better survival at six months and one year for younger patients with better PS, even after adjusting for confounders. Much of the survival advantage was accounted for by adjusting for the use of chemotherapy.

Inequalities in outcomes for non-small cell lung cancer: the influence of clinical characteristics and features of the local lung cancer service.

BACKGROUND: The treatment given to patients with lung cancer and survival vary between and within countries. The National Lung Cancer Audit (NLCA) linked to Hospital Episode Statistics was used to quantify the extent to which these outcomes are influenced by patient features and/or hospital facilities and performance indicators. METHODS: All patients with a histological diagnosis of non-small cell lung cancer (NSCLC) were included. Logistic regression was used to quantify the independent influence of features of both patients and hospitals on the likelihood of having surgery and Cox regression was used for survival analyses. RESULTS: There were 34,513 patients with NSCLC in our dataset. After adjusting for age, sex, performance status, stage and Charlson Index of comorbidity, patients with NSCLC first seen in thoracic surgical centres (27% of the cohort) were 51% more likely to have surgery than those seen in non-surgical centres (adjusted OR 1.51, 95% CI 1.16 to 1.97). Resection rates varied from 13% to 17% between non-surgical and thoracic surgical centres. Surgery was the most powerful determinant of overall survival (adjusted HR 0.41, 95% CI 0.39 to 0.44). CONCLUSION: A minority of patients with NSCLC first seen in a thoracic surgical centre are more likely to have surgery and to benefit from the survival advantage this confers. This finding suggests that there is an opportunity to improve the outcome for patients with lung cancer in England by optimising access to thoracic surgeons in non-surgical centres.

Lung cancer in England: information from the National Lung Cancer Audit (LUCADA).

AIMS: Our aims were to determine whether the information in the National Lung Cancer Audit database (LUCADA) is influenced by the completeness of reporting and to describe the current socio-demographics and survival of people with lung cancer in England. METHODS: Using national registry data as a gold standard we stratified NHS Trusts into quartiles on the basis of their patient ascertainment. We assessed the distribution of patient features across these quartiles using Cox and logistic regression. We then examined overall survival and access to treatment. RESULTS: We analysed data for 60,059 patients whose data were entered between 2004 and 2008. There was little variation in key patient features, treatment and median survival across quartiles of data completeness. Socio-economic disadvantage did not influence survival or access to surgery but was related to a decreased use of chemotherapy. CONCLUSION: Our findings suggest that LUCADA accurately describes people in England who are diagnosed with lung cancer and can therefore be used to drive health care improvements. Individual patient socio-economic status does not affect survival and has only a limited impact on access to treatment and so NHS Trust level factors should be studied to explain the previously published regional variations in these outcomes.

Cutaneous angiosarcoma presenting as an unusual facial bruise.

Angiosarcoma is a rare vascular tumour accounting for 2% of soft tissue sarcomas, which together represent less than 1% of all cancers. Although well described in specialist literature, it is unusual in general medical practice. We describe a case in which the initial appearance as a bruise gave rise to diagnostic uncertainty and delay.