Paul Beckett

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. 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. 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. 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.

Introduction In 2014, the contract to deliver the National Lung Cancer Audit (NLCA) was awarded to the Royal College of Physicians. Data were previously submitted using a bespoke dataset (LUCADA), but will now be submitted via the nationally mandated Cancer Outcome and Services Dataset (COSD) and linked to additional cancer registry datasets. For patients diagnosed in 2014, NLCA data were submitted using LUCADA for 132 of 151 English trusts. Trusts also submitted data via COSD and registry data were produced by the National Cancer Registration Analysis Service (NCRAS), providing the opportunity to compare both datasets for data completeness and reliability. Methods We have linked the LUCADA and cancer registration datasets at patient level and assessed completeness of key patient variables including age, sex, stage, performance status and pathological confirmation, as well as recording/dates of treatment received. We assessed the inter-rater/data agreement of these variables using Cohen’s kappa statistics (k). Finally, we carried out a qualitative assessment on a subset of cases to explore reasons why patients were represented in one dataset but not the other. Results There were 26,001 patients in both datasets (94% of LUCADA data) with more in the registry dataset and not LUCADA than vice versa. Recorded sex and age were highly congruent, as was trust first seen which was the same in 96%. 56% of the patients had the same date of diagnosis, 74% were ± 7 days and 86% were ± 14 days of each other. The cancer registry data had a larger proportion of patients with missing PS (27% vs 11%) with agreement on PS (where available) being 97% (k = 0.91). Agreement on stage was 94% (k = 0.81). Agreement for surgery, chemotherapy and radiotherapy was 0.86, 0.88 and 0.77 respectively. Details of the qualitative work and trust first seen algorithms will be provided in the presentation. Conclusion Results suggest that cancer registry data accurately describe key patient features. Compared with LUCADA, the national cancer registry: identified more patients has a higher proportion pathological confirmation identified more patients with surgery, chemotherapy and radiotherapy has a higher proportion of missing data for PS which could be due to data entry transition

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.

Background The National Lung Cancer Audit records outcomes in lung cancer and mesothelioma on a population scale, in order to explain the wide variations seen within the UK and between the UK and other countries and ultimately improving outcomes. Methods All cases of mesothelioma submitted to the audit by English Trusts 2006–2011 were analysed. A hierarchy of diagnosis from surgical histology to non-surgical histology to clinical diagnosis was used to exclude patients with potentially conflicting diagnoses. These records were further analysed to extract data on age/sex distribution, referral source, histological subtype, treatment regime and survival rates. Results There were 8,503 patients with mean age 72yrs (83% male), representing around 65% of expected incident cases (a substantial number diagnosed at autopsy and not included in the audit). 45% have right-sided disease, 28% left-sided, and 1% bilateral (data missing in 26%). The majority of patients (47%) were referred by their primary care physician, but at least 20% present to secondary care as emergencies. Overall, 89% were histo-cytologically confirmed with that figure appearing to rise slowly over the audit period from 81% (2006) to 92% (2011). Survival data is shown in the table. 37% of patients received no anti-cancer treatment, but 28%, 26% and 30% of patients received “surgery”, chemotherapy or radiotherapy at any time. Most surgical operations (60%) were pleurodesis. Median survival varied by first treatment modality: surgery 378 days, chemotherapy 399 days, radiotherapy 308 days, no anti-cancer treatment 140 days. Survival was highest in patients having “surgery” and chemotherapy (491 days). Use of chemotherapy varied across cancer networks from 14% to 41% of patients, but overall increased over the audit period from 13% to 34%. Conclusion Mesothelioma is predominantly a cancer of elderly males, with a striking tendency for right-sided disease. Only 11% have no histological confirmation, but where this is obtained, the epithelioid subtype has best prognosis. Low rates of anti-cancer treatment may reflect therapeutic nihilism as well as patient fitness, but there is an encouraging trend towards wider use of chemotherapy which was associated with a greater than doubling in survival compared with no treatment.

Background Surgery for lung cancer patients with mediastinal lymph node involvement (N2 disease) remains controversial. In one study (Albain 2009), progression-free (but not overall) survival was higher for patients who received induction chemo- radiotherapy followed by lobectomy but post operative mortality was high in pneumonectomy patients. We describe treatment and outcomes for patients with pre-treatment IIIA disease using data submitted from England to the National Lung Cancer Audit (NLCA) 2008–2011. Methods Patients with pre-treatment staging of T1–3, N2, M0 were included. Small cell cancer, mesothelioma and carcinoid were excluded. The extent and histological nature of pre-treatment N2 disease is not recorded in the NLCA. Survival analyses were performed according to treatment received. Results 6,775 of 98,403 (6.9%) patients met the inclusion criteria. 2,669 (39%) patients had either chemotherapy or radiotherapy recorded and 2,250 (33%) patients had no treatment recorded. 948 (14%) patients received chemotherapy and radiotherapy however radiotherapy treatment intent was recorded as curative in only 12%. 907 (13%) patients had surgery recorded as part of their treatment plan. Of these, 70% had post operative pathological nodal status recorded (25% N0, 14% N1, 30% N2). Median survival following surgery for the 271 patients with pathological N2 disease was 806 days, with 30 day survival of 99% and 1 year survival 76%. Conclusions Lung cancer patients with stage IIIA disease make up a very small proportion of the overall lung cancer population. Only a small proportion of these patients receive surgery and there is significant discrepancy between the recorded pre and post operative nodal status. In patients with pathological confirmed N2 disease survival is similar to the 713 days reported in the Albain study. The automated collection of detailed radiotherapy/chemotherapy treatment data in future will allow a more reliable comparison between surgical and non-surgical treatments.

Introduction The National Lung Cancer Audit, now in its 8^th year, is run jointly by the Royal College of Physicians and The Information Centre for health and social care, and is commissioned by the Healthcare Quality Improvement Partnership (HQIP). Over this period, the audit has collected rich data of increasing quality and has charted improving standards of care for patients, as well as persistent variation across organisations which in most cases is independent of case-mix. Methods Although several other countries also submit data to the audit, this abstract presents provisional results for England only for patients first seen in 2012. Results 31,003 patient records were submitted with the improvement in recording of stage being the most noteworthy change in data quality. Full details are given in Table 1. Spirometry data is available for 63% of Stage I-II/PS 0–1 NSCLC patients. The histological confirmation rate has risen slightly after a dip in the previous year, and the proportion of patients with non-subtyped NSCLC continues to fall. There have been small but incremental rises in the anti-cancer treatment rate, the resection rate in histologically-confirmed NSCLC, and the proportions of patients having the input of specialist nurses and having the nurse present at the time of diagnosis. Increases are also noted in the proportion having CT scan before bronchoscopy (90%) and having chemotherapy for locally advanced NSCLC with good PS (57%). Variation in practice still exists–for example, the resection rate in Stage I-II NSCLC varies from 35% to 62% across the cancer networks. Our final presentation will contain further analyses of survival across the audit lifespan. Conclusions The lung cancer community should be very proud of the quality of data that they provide to the audit, data which provides clear evidence of gradually improving standards of care. Demonstrating that these improved diagnostic pathways and increased treatment rates translate into longer survival has so far proven elusive since short-term survival is heavily influenced by the large numbers of patients presenting with advanced incurable disease, but as the data matures it is hoped that longer-term survival will indeed increase.