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D. Gunawardana
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O19 - Support and Palliation I (ID 138)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Nurses
- Presentations: 1
- Moderators:Y. Chen, J. Ingham
- Coordinates: 10/29/2013, 10:30 - 12:00, Bayside 104, Level 1
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O19.03 - Perceptions and attitudes to early integration of palliative care for patients with incurable lung cancer (ID 2588)
10:50 - 11:00 | Author(s): D. Gunawardana
- Abstract
- Presentation
Background
Lung cancer is the leading cause of death from cancer in Australia with the majority of patients diagnosed with late stage incurable disease. Although there is evidence of patient benefit from early involvement with specialist palliative care, this may not translate into clinical practice. The aim of this study was to explore clinicians’ perceptions and attitudes to Palliative Care referral.Methods
A modified validated self-report palliative care referral questionnaire (Johnson, 2008) was given to doctors and nurses working in the multi-disciplinary lung cancer teams at three teaching hospitals in metropolitan Melbourne. Participants were asked whether listed items had contributed to referral (9 triggers) or non referral (15 barriers) of their patients. Level of agreement with 22 attitudinal and perception items explored clinicians’ views about palliative care.Results
55 questionnaires were distributed and 42 completed (76% response rate). Respondents had a median of 6 years (interquartile range 3-12) of experience practicing in their specialty. One-third (14/42) were doctors working in Medical Oncology, 26% (11/42) in Respiratory Medicine, 19% (8/42) in Radiation Oncology, and 12%, (5/42) in Surgical Oncology, plus two oncology nurses and one physician trainee.93% of respondents agreed that early referral to Palliative Care is beneficial to patients and 95% agreed that Palliative Care can benefit patients receiving active treatment. The majority (69%) of clinicians believe that their relationship with the patient continues when she/he elects to have specialist palliative care. 71% indicated that it is not difficult to refer a patient they have cared for a long time and have a close relationship with. Almost two-thirds (64%) disagreed that when they first bring up palliative care patients give up hope. However, only 60% of respondents agreed that all advanced cancer patients should be referred to Palliative Care. The most frequently cited reasons for referral were for physical symptoms. The majority reported that Palliative Care is either very important or important for patients with psycho-social issues or foreseeable future psycho-social issues, yet only half of respondents agreed that psycho-social issues would trigger a referral to Palliative Care. When asked for the main reasons for not referring to Palliative Care, 60% agreed they do not refer when the patient has no symptoms and 60% also agreed they do not refer if they can manage the patients’ symptoms themselves. However, only 38% of clinicians reported they were well trained to take care of the symptoms of advanced cancer patients. Issues related to patients not understanding or accepting their prognosis were cited as barriers to referral by more than a third of clinicians.Conclusion
Clinicians involved in the care of patients with incurable lung cancer have positive perceptions and attitudes to Palliative Care but this may not translate into routine referral of all patients with incurable lung cancer. In order to make referral routine, we need education around the perception that only patients with unmanageable symptoms benefit from referral to Palliative Care. Furthermore, additional training of oncologists about symptom management appears desirable since a significant proportion reported a deficiency in this area.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O26 - Support and Palliation II (ID 140)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Nurses
- Presentations: 1
- Moderators:J. White, Y. Lai
- Coordinates: 10/29/2013, 16:15 - 17:45, Bayside 104, Level 1
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O26.03 - Is early integration of palliative care for patients with incurable lung cancer acceptable to Australian healthcare professionals? (ID 2596)
16:35 - 16:45 | Author(s): D. Gunawardana
- Abstract
- Presentation
Background
In a recent landmark US study, metastatic NSCLC patients who received palliative care from the time of diagnosis concurrently with standard oncology management reported improvements in quality-of-life, symptom control, reduction in “aggressive therapies” at end-of-life, and a survival advantage compared to those receiving standard oncology management alone. The aim of this qualitative sub-study was to explore Australian health care professionals’ perceptions of early integration of palliative care for patients with incurable lung cancer.Methods
Members of the lung cancer multi-disciplinary teams of three large metropolitan teaching hospitals in Melbourne were invited to attend a focus group discussion. Data from focus groups were supplemented with interviews from a purposive sample of individual health care providers who were unable to attend the groups. Participants were asked to describe barriers and facilitators to implementation of a model of early integration of palliative care.Results
Three focus groups and six individual interviews were conducted with 28 health care professionals. Key facilitators and barriers to referral (see table) were grouped into 4 themes: 1. Trust; 2. Care Coordination; 3. Ease of Referral; and 4. Perceived patient/family reaction.Key themes Issues discussed as facilitators / or barriers Trust 1. Confidence in the quality of the palliative care service 2. Palliative care poses a threat to the referrer 3. Past experience with community palliative care Care Coordination 1. Integration of concurrent palliative care and "active treatment" 2. Concern about adding to fragmented care and lack of co-ordination 3. Effective Communication between care providers Ease of Referral 1. The value of a physical presence of the palliative care provider in the clinic 2. Perception of limited resources Perceived patient/family reaction 1. Cultural perceptions about what referral to palliative care means 2. Concern about patient and/or family reaction to referral leading to distress and loss of hope Conclusion
Early involvement of palliative care in patients with incurable lung cancer is acceptable to the majority of treating clinicians. Palliative care services must be embedded into the system, sufficiently resourced and of high quality. For early referral to occur the model ideally involves a physical presence of a palliative care clinician in clinic who is easily accessible for referrals and considered a core team member.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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P2.12 - Poster Session 2 - NSCLC Early Stage (ID 205)
- Event: WCLC 2013
- Type: Poster Session
- Track: Medical Oncology
- Presentations: 2
- Moderators:
- Coordinates: 10/29/2013, 09:30 - 16:30, Exhibit Hall, Ground Level
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P2.12-013 - Patterns of recurrence following surgical resection of stage I-III non-small cell lung cancer (NSCLC) (ID 1968)
09:30 - 09:30 | Author(s): D. Gunawardana
- Abstract
Background
Despite receiving curative treatment, a significant proportion of patients with locoregional non-small cell lung cancer (NSCLC) will develop recurrent disease. The role of routine surveillance imaging following curative treatment remains controversial, as there is no definitive evidence that early detection and treatment of asymptomatic metastases improves survival. The aim of this study was to explore the patterns of recurrence in stage I-III NSCLC patients treated in routine clinical care.Methods
Retrospective analysis of 218 patients across two tertiary centres in Melbourne, Australia, who underwent surgical resection of stage I-III NSCLC over a 5-year period. Patients who died within 30 days of surgery or with no follow-up data were excluded. Clinicopathologic, treatment and outcome data were collected.Results
Between July 2006 and June 2012, 206 patients underwent surgical resection, with a median follow-up of 30 months. Median age was 69 years (range 46–84), with a male:female ratio of 65 vs 35%. There were 113 (55%), 52 (25%) and 39 (19%) stage I, II and III tumours respectively. One patient had a pathologic complete response to neoadjuvant chemoradiotherapy. Adjuvant chemotherapy was delivered to three (3%), 20 (39%) and 28 (72%) patients with stage I, II and III disease respectively. Nine of 39 (23%) stage III patients received adjuvant radiotherapy. 73 of 206 (35%) patients relapsed at a median of 10.5 months from surgery (range 0.7–46.4). A further 15 (7%) patients were diagnosed with new primary lung cancers and four (2%) with second, non-pulmonary malignancies. Relapses were more frequent in patients with higher stage tumours (Table 1). Of the patients receiving adjuvant or neoadjuvant chemotherapy, 55% developed recurrent disease. Among patients who recurred, 46 (63%) were symptomatic, with 32 of these (70%) requiring emergency or early clinical reviews. In contrast, new primary tumours were significantly more likely to be detected on routine surveillance imaging (87% vs 29% of recurrences, p=0.0001). One-year post-relapse survival was 40% for disease recurrences vs 53% for new primary lung cancers.Table 1 – Clinicopathologic features and patterns of relapse in 206 patients with resected stage I-III NSCLC[1]
Total N Disease-free n (%) Relapsed NSCLC n (%) New primary lung cancer n (%) TOTAL 206 104 (51%) 73 (35%) 15 (7%) Stage 0 I II III 1 113 52 39 1 (100%) 70 (62%) 21 (40%) 10 (26%) 0 25 (22%) 21 (40%) 25 (64%) 0 10 (9%) 2 (4%) 3 (8%) Chemotherapy receipt Yes No 53 145 17 (32%) 84 (58%) 29 (55%) 42 (29%) 3 (6%) 12 (8%) Histology Adenocarcinoma Squamous cell Large cell Other 112 57 15 21 53 (47%) 32 (56%) 6 (40%) 13 (62%) 41 (37%) 18 (32%) 8 (53%) 6 (29%) 9 (8%) 5 (9%) 1 (7%) 0 Method of relapse detection[2] Routine imaging Symptomatic 34 51 N/A N/A 21 (62%) 46 (90%) 13 (38%) 2 (4%) [1]Data for second non-pulmonary malignancies not shown [2]Method of relapse detection not documented in six patients Conclusion
The goals of routine surveillance imaging following curative treatment of NSCLC are two-fold; early detection of: 1) asymptomatic disease recurrence and, 2) new primary lung cancers. Our data demonstrate that the majority of disease recurrences are symptomatic at the time of diagnosis, thus negating the value of routine imaging. In contrast, the high proportion of asymptomatic new primary cancers detected on surveillance imaging supports this approach for patients fit for curative-intent treatment. -
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P2.12-014 - Brain metastases following surgical resection of stage I-III non-small cell lung cancer (NSCLC) (ID 1974)
09:30 - 09:30 | Author(s): D. Gunawardana
- Abstract
Background
The brain is a common site of relapse following curative treatment of stage I-III non-small cell lung cancer (NSCLC). Retrospective series estimate actuarial risk of brain recurrence at ~10% for stage I-II and ~30% for stage III tumours. Possible risk factors are young age, non-squamous histology and higher tumour/nodal stage, with survival typically dictated by the presence of extracranial disease. The aim of this study was to review patterns and treatment of brain metastases in patients with relapsed stage I-III NSCLC.Methods
Retrospective analysis of 218 patients with surgically resected stage I-III NSCLC at two tertiary centres in Melbourne, Australia over a 5-year period. Patients who died within 30 days of surgery or with no follow-up data were excluded. Treatment and outcome data for patients who subsequently developed brain metastases are reported.Results
206 eligible patients underwent surgical resection between July 2006 and June 2012. None received prophylactic cranial irradiation. At a median follow-up of 30 months, 73 (35%) patients had relapsed. Twenty-two (30%) had intracranial metastases, ten with brain-only metastases at the time of relapse. The other 12 had concurrent extracranial disease. Median time to brain relapse was 7.7 months (range 0.7-38.6). The incidence of brain relapse increased with higher stage: 6%, 13% and 21% of patients with stage I, II and III disease respectively (Table 1). Relapses occurred at a median of 10.9 (stage I), 8.8 (stage II) and 6.4 (stage III) months from surgery. Brain metastases were noted more frequently in patients with adenocarcinoma. Although 18/57 patients with squamous cell histology relapsed, none were noted to have intracranial metastases. In five patients, asymptomatic brain metastases were detected on routine surveillance imaging and treated with palliative whole-brain radiotherapy. Three of the five had coexistent extracranial disease and died within four months of relapse. The other two had brain-only metastases and remain alive at nine and 16 months from relapse. For all patients, one-year survival following diagnosis of brain metastasis was higher in those with brain-only disease (50%) compared to those with concurrent extracranial metastases (9%).Table 1 – Clinicopathologic features in total and brain relapse populations
Total population N Brain relapse n (%) TOTAL 206 22 (11%) Median age (yrs) 69 (46-84) 69 (50-84) Sex M F 134 72 15 (11%) 7 (10%) Stage 0 I II III 1 113 52 39 0 7 (6%) 7 (13%) 8 (21%) Histology Adenocarcinoma Squamous cell Large cell Other 112 57 15 21 16 (14%) 0 3 (20%) 3 (14%) Chemotherapy Adjuvant Neoadjuvant None 50 3 145 6 (12%) 1 (33%) 14 (10%) Radiotherapy Adjuvant Neoadjuvant None 12 2 185 5 (42%) 0 16 (9%) Conclusion
In this small retrospective series, the majority of patients who developed brain metastases after curative treatment for NSCLC were symptomatic at the time of relapse. Post-relapse survival was worse in patients with coexistent extracranial disease. None of the incidentally detected asymptomatic brain metastases could be treated curatively, suggesting a limited role for including brain imaging in routine surveillance for resected NSCLC.
