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D.R. Baldwin
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MINI 19 - Surgical Topics in Localized NSCLC (ID 138)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:D. Jablons, B. Stiles
- Coordinates: 9/08/2015, 16:45 - 18:15, 605+607
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MINI19.08 - Validation of a Surgical Predictive Score for 90 Day Mortality in Lung Cancer and Comparison with Thoracoscore (ID 2754)
17:25 - 17:30 | Author(s): D.R. Baldwin
- Abstract
- Presentation
Background:
Current British Thoracic Society (BTS) guidelines advocate the use of a global risk prediction score such as Thoracoscore to estimate the risk of death prior to radical surgical management in those with non-small cell lung cancer (NSCLC). A recent publication by Powell et al(1) used the National Lung Cancer Audit (NLCA) linked to Hospital Episode Statistics (HES) to produce a score to predict 90 day mortality. The aim of this study is to validate this score, henceforth called the NLCA score, and compare its performance with Thoracoscore.
Methods:
We identified data on all patients in the NLCA who received curative surgery for NSCLC between 2010 and 2012. We calculated the proportion that died in hospital and within 90 days of surgery. Each person was given a score based on the coefficients and constants in the NLCA score and Thoracoscore. The discriminatory power of both scores was assessed by a receiver operating characteristic (ROC) and an area under the curve (AUC) calculation.
Results:
We identified 2858 patients for whom we had complete data to form our validation cohort. The 90 day mortality was 5%. We generated ROC curves to assess the discrimination of the NLCA score in predicting 90 day mortality and to test the ability of Thoracoscore to predict in-hospital mortality. Area under the ROC curve was 0.68 and 0.60 respectively. We performed a post hoc analysis using data from the NLCA on all 15554 patients who underwent curative surgery for NSCLC between 2004 and 2012 to derive summary tables for 90 day mortality, stratified by procedure type, age and performance status (table 1).
Conclusion:
These results suggest that although the NLCA score performs slightly better than Thoracoscore neither performs well enough to be advocated for routine use to risk stratify patients prior to lung cancer surgery. It may be that the addition of physiological parameters to demographic and procedural data or use of physiological measurements alone would better predict mortality; however this would form the basis of a further project. In the interim we advocate the use of our summary tables that serve to provide clinicians and patients the real-life range of mortality according to performance status and age for both lobectomy and pneumonectomy. 1. Powell HA, Tata LJ, Baldwin DR, Stanley RA, Khakwani A, Hubbard RB. Early mortality after surgical resection for lung cancer: an analysis of the English National Lung cancer audit. Thorax. 2013;68(9):826-34. Figure 1
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MS 15 - Current Screening Trials, Current Evidence and Screening Algorithms (ID 33)
- Event: WCLC 2015
- Type: Mini Symposium
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:P. Mazzone, T. Vidaurre-Rojas
- Coordinates: 9/08/2015, 14:15 - 15:45, Four Seasons Ballroom F3+F4
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MS15.03 - UKLS Impact of Utilization of Risk Assessment in Trial Selection (ID 1914)
15:00 - 15:20 | Author(s): D.R. Baldwin
- Abstract
- Presentation
Abstract:
Future implementation of lung cancer screening programmes will require accurate identification of the population who will benefit the most, to ensure that the benefits outweigh the harms [1]. In the USA, the current criteria for Medicare reimbursement [2], for screening are: age 55 to 77, a smoking history of 30 pack-years or more and smoking within 14 years of entry [3]. However, an in-depth analysis of the NLST showed that there was marked variation in individual risk of lung cancer death, with some screened that had only a low chance of benefit: 20% of participants at lowest risk accounted for only 1% of prevented lung-cancer deaths). [4]Conversely, 88% of the prevented deaths were in the 60% of participants that were at highest risk. The only risk prediction model so far utilised in the recruitment of participants into a CT Lung Cancer Screening RCT, is the LLP~v2~ risk model in the pilot UK lung cancer screening trial (UKLS) [5]. The Liverpool Lung Project (LLP) risk model was based on a case-control study [6]. The LLP~v1~ model utilised conditional logistic regression to develop a model based on factors that were significantly associated with lung cancer (smoking duration, prior diagnosis of pneumonia, occupational exposure to asbestos, prior diagnosis of cancer family history of lung cancer (early onset <60 years) and exposure to asbestosis [6]. The multivariable model was combined with age-standardised incidence data to estimate the absolute risk of developing lung cancer. The discrimination of the LLP was evaluated and demonstrated its predicted benefit for stratifying patients for CT screening by using data from three independent studies from Europe and North America [7]. The LLP~v2~ was used to select subjects with ≥5% risk of developing lung cancer in the next five years for UKLS [8]. This method may improve cost-effectiveness by limiting screening to high-risk individuals. The UKLS approached 247,354 individuals in the two pilot sites, 75,958 people (30.7%) responded positively to the screening invitation. Demographic factors associated with positive response were: higher socioeconomic status, age 56-70 years, and ex-smokers. Those from lower socioeconomic groups and current smokers were less likely to respond. 8,729 (11.5%) positive responders were calculated as high risk of lung cancer. The high risk individuals were more often elderly, current smokers, of lower socioeconomic status and males (2.4x females). 4,055 were randomised into the UKLS. Forty two UKLS participants have been diagnosed with confirmed lung cancer, 34 of these were detected at baseline or three months, giving a baseline prevalence of 1.7% which is significantly higher than that reported by the NLST[9]or NELSON [10]trials. To date, 2.1% of all individuals screened have been diagnosed with lung cancer. 36/42 (85.7%) of the screen-detected cancers were identified at stage 1 or 2. Of those with a confirmed cancer, 17/42 (40.5%) were from the most deprived Index of Multiple Deprivation (IMD) quintile. Figure 1 Figure 1: Percentage of UKLS positive responders (n=75,958) with an LLP risk of >5%, by individual year of age. The positive response rate increased steadily with higher socioeconomic status: 21.7% of individuals in the lowest (most deprived) IMD quintile gave a positive response compared with 39.7% in the highest quintile (p<0.001;) (Figure 2). The proportion of individuals with a high LLP risk score decreased with higher socioeconomic status; ranging from 18.2% in the most deprived quintile to 8.3% in the least deprived quintile (p<0.001;). LLP risk were offset by, the socio-demographic spectrum of the individuals attending the clinic, which was in proportion to that of the original approached sample. People recruited into the UKLS trial therefore spanned all IMD quintiles in roughly equal numbers, including a representative proportion from more deprived postcodes. However, in the high risk sub group of individuals invited for screening, there was a trend towards individuals of higher socioeconomic status being more likely to consent to participate in the trial. Figure 2 Figure 2: Impact of socioeconomic status upon initial response rate (lower line), LLP risk (bars) and trial consent rate (upper line). The demographic and response data from the UKLS pilot trial enable specific recommendations to be made regarding the implementation of any future UK-wide lung LDCT screening programme. Such a programme would need to target those most at risk who may be least likely to take up offers of screening (i.e. the most deprived, current smokers, and the over 70s), and women.
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P1.06 - Poster Session/ Screening and Early Detection (ID 218)
- Event: WCLC 2015
- Type: Poster
- Track: Screening and Early Detection
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.06-022 - The British Thoracic Society Guideline on the Investigation and Management of Pulmonary Nodules (2015) (ID 2328)
09:30 - 09:30 | Author(s): D.R. Baldwin
- Abstract
Background:
British Thoracic Society (BTS) Guidelines are aimed primarily at practitioners within the UK. They are National Health Service Evidence accredited which means they must adhere to robust guideline development methodology. The evidence base for this guideline comes mostly from countries outside the UK so the recommendations will have relevance to other countries healthcare systems.
Methods:
The recommendations are based on a comprehensive review of the literature on pulmonary nodules and expert opinion. A third of the 360 references cited were from 2012 onwards, reflecting the rapid expansion of the evidence base. The new evidence has resulted in important differences from guidelines previously published by the American College of Chest Physicians and the Fleischner Society.
Results:
There are four algorithms: initial approach to solid nodules; surveillance of solid nodules; management of sub-sold nodules; and pulmonary nodule treatment. Two malignancy prediction calculators are recommended to assess the risk of malignancy; one (the Brock University model) that performs best for smaller nodules and one that has the better accuracy for larger nodules following PET-CT (the Herder model). There are recommendations based on recent evidence from screening studies, for a higher nodule size threshold for follow up (≥5mm or ≥80mm[3]). This will reduce the number of follow up CTs which, in the UK at least, are not cost effective. Surveillance recommendations are also different from previous guidelines: people can be discharged after 1 year of stability if measured by semi-automated volumetry. Management is also dependent on the volume doubling time (VDT) with immediate further assessment for nodules that show a VDT of ≤400 days and either biopsy or further observation for nodules with VDTs of >400 to ≤600 days. People with nodules with a VDT >600 days have the option of discharge, if VDT is measured by volumetry. As in previous guidelines, a 3 month repaet CT is recommended for sub-solid nodules.After that, management is governed by risk assessment by the Brock tool (with the proviso that it may underestimate risk after the initial CT) and according to specific features that predict malignancy. Acknowledging the good prognosis of sub-solid nodules, there are recommendations for less aggressive options in their management. The guidelines provide more clarity in the use of further imaging, with ordinal scale reporting for PET-CT recommended to facilitate incorporation into the Herder risk model and more clarity about the place of biopsy and its influence on pre-test probability. Segmentectomy can be considered for primary diagnosis and treatment for nodules smaller than 2cm, and sub-lobar resection is recommended for pure ground glass nodules. Where fitness levels preclude surgery, non-surgical treatment with stereotactic ablative radiotherapy or radiofrequency ablation is recommended, even where biopsy is not possible, provided the probability of malignancy is high. Finally, there are evidence based recommendations about the information that people need that should be provided for them.
Conclusion:
The BTS guideline is intended to be used both as a summary in the day to day management of the person with a pulmonary nodule as well as a comprehensive reference text.
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P1.11 - Poster Session/ Palliative and Supportive Care (ID 229)
- Event: WCLC 2015
- Type: Poster
- Track: Palliative and Supportive Care
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.11-013 - Place and Cause of Death in Patients with Lung Cancer in the United Kingdom (ID 2735)
09:30 - 09:30 | Author(s): D.R. Baldwin
- Abstract
Background:
Many patients with cancer die in an acute hospital bed, which has been frequently identified as the least preferred location, with psychological and financial implications. This study aims to look at place and cause of death in patients with lung cancer to identify which factors are associated with dying in an acute hospital bed versus at home.
Methods:
We used data from the National Lung Cancer Audit (NLCA) linked to Hospital Episode Statistics (HES) and Office of National Statistics (ONS) records to determine cause and place of death in those with lung cancer overall. England was divided into 28 cancer Networks at the time these data were collected so we used these to assess geographical variation in place of death. We used multivariate logistic regression to compare demographic, co-morbid and tumour-related factors between those who died in an acute hospital versus those who died at home.
Results:
Of 143627 patients identified 40% (57678) died in an acute hospital, 29% (41957) died at home and 17% (24108) died in a hospice. Individual factors strongly associated with death in an acute hospital bed compared to home were male sex, increasing age, poor performance status, social deprivation and diagnosis via an emergency route (table 1). There was marked variation between cancer Networks in place of death. The proportion of patients dying in an acute hospital ranged from 28% to 48%, with variation most notable in provision of hospice care (9% versus 33%). Cause of death in the majority was lung cancer (86%), with other malignancies, chronic obstructive pulmonary disease (COPD) and ischaemic heart disease (IHD) comprising 9% collectively.
Conclusion:
A substantial proportion of patients with lung cancer die in acute hospital beds and this is more likely with increasing age, male sex, social deprivation and in those with poor performance status. There is marked variation between Networks, suggesting a need to improve end-of-life planning in those at greatest risk, and to review the allocation of resources to provide more hospice beds, enhanced community support and ensure equal access. Figure 1
