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Patterns of Lung Cancer Treatment in the Mount Vernon Cancer Network

Matt Williams Nov 2010 Matt.Williams@nhs.net. Patterns of Lung Cancer Treatment in the Mount Vernon Cancer Network. Lung Cancer. Common cancer with a poor outcome 38 000 cases/ yr, ~35 000 deaths Leading cause of cancer related death in UK Many present late Surgery/ RT/ ChemoTx/ BSC

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Patterns of Lung Cancer Treatment in the Mount Vernon Cancer Network

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  1. Matt Williams Nov 2010 Matt.Williams@nhs.net Patterns of Lung Cancer Treatmentin the Mount Vernon Cancer Network

  2. Lung Cancer • Common cancer with a poor outcome • 38 000 cases/ yr, ~35 000 deaths • Leading cause of cancer related death in UK • Many present late • Surgery/ RT/ ChemoTx/ BSC • Patterns of care may relate to this • UK has low surgical resection rates

  3. Background • Epidemiology of cancer incidence well described • Epidemiology of care less well described • Previous work has focussed on patterns of initial care • Often quite old • Variable relevance

  4. Patterns of care in Lung Cancer • Scotland, 1999 – 2003 (Erridge, 2008) • Small increase in the use of radical RT • More CT scanning leads to more met. Dx diagnosis • Geographical inequalities in rates of radical treatment in SE England (Jack, 2003) • Time to hospital and deprivation both reduce access to care (Yorkshire) (Crawford, 2009)

  5. Transnational Comparisons • Teeside/ Italy • British patients older, poorer PS, higher stage, more comorbid, more likely to have smoked, • Brit. Columbia/ Scotland • Survival lower in Scotland, irres. of treatment intent. Scottish patients older, less path, more small cell or squamous • Treatment rates only part of the difference.

  6. Why are there differences ? Low volumes reduce treatment likelihood (Shalini, 08) For Met Dx in VA Hosp, non-black, high SES, Teaching hosp. more likey to get chemoTx (Earle 00) More co-morbidities (as a count) in older, more pack years, more alcohol, lower SES and female patients. Only explains part of the difference in outcome. (Tammemagi 04) Prim. care less likely to refer met. lung than met. breast, and less aware of impact of chemotherapy (Wassenaar 07) Sec. care knowledge patchy (Raby 95) Poor, older more likely to be diagnosed late (Groome 08) Even in trials poor do worse (Cella 91)

  7. Substantial Variations in UK Care • LUCADA • National audit of lung cancer • Data reported and collected via MDTs • PS, FEV1, Smoking, treatment, reasons • Patchy data • Some evidence of ascertainment bias

  8. Open Questions • What are current patterns of care ? • How much treatment do people get ? • Are there systematic patterns of variation ? • In what order do they get it ? • Where do they have their care ? • When do they die ? • Where do they die ? • What do they die of ?

  9. Data • Incident population from ECRIC • Treatment Data from MVH and 3 DGHs • Treatment Data from ECRIC • Diagnostic/ Referral data from LUCADA • Survival Data from ECRIC Integrating this data is hard, due to different assumptions, coding and levels of granularity

  10. Results • 659 patients diagnosed in the MVCN in 2007 • Median Age 72 • 59% male • 13% Small cell lung cancer • 60% had staging • 48% Stage IV • 281 (43%) had active treatment

  11. Survival • 608/ 659 deaths (1st March 2010) • Median OS: 89 days • 41 days in those without treatment • 236 days in those who were treated • Better survival for non-metastatic patients • 175 vs. 53 days • Better survival in younger pts • 112 vs. 81 days • No difference based on sex

  12. Patterns of care • 1st Treatment: • Chemo 82 (29%) 279 days • Radiotherapy 148 (53%) 188 • Surgery 51 (18%) 360 • 2nd Treatment: • Chemo 31 (%) • Radiotherapy 69 • Surgery 2

  13. Amount of Care • No active treatment 378 • 1 treatment 179 • 2 treatments 63 • 3 treatments 32 • 4 treatments 4 • 5 + 3

  14. Place of Deaths • 608/ 659 died • 301 died in hospital • 155 died at home • 89 in a hospice • 21 Nursing home • 16 Other • 77 Unknown • More likely to die in a hospital (and less in a hospice) if you had no treatment chisq =0.005

  15. Causes of Death • 608 deaths • 461 Cancer • 62 missing • 85 non-cancer • Slightly less likely to die of cancer-related causes if you had treatment (chisq = 0.02)

  16. Conclusions • Incident population of lung cancer patients in the MVCN in 2007 • Compiled data on demographics, treatment, survival and deaths • Survival is poor • 57% had no treatment • Surgical rate 7.7%

  17. Conclusions • If you are treated, you do better • Median OS 236 vs. 42 days • Most people only get one treatment (course) • Most people die in hospital • Treatment is likely a proxy for fitness • What can we do for the untreated ? • Urgent hospice/ etc.

  18. Caveats & The future • Incidence and Outcome robust • Treatment is an underestimate • Integrating data from Registries and local sources is hard • Describing patterns of care is difficult • Not yet added LUCADA or deprivation data • HES Data

  19. Thanks • Jeanette Dickson & Pete Ostler (MVH) • David Greenberg & Karen Wright (ECRIC) • MSc Tutors

  20. Questions ?

  21. Weaknesses of current work • Often focus on initial treatment, or “Access” • LUCADA relies on self-notification • We should use incident populations • Based on cancer networks • Patterns of care perhaps more important than access for palliative treatments

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