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T. Newsom-Davis



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    ISS12 - Immuno–Oncology: A Renaissance in the Treatment of Lung Cancer – MSD Oncology (ID 448)

    • Event: WCLC 2016
    • Type: Industry Supported Symposium
    • Track:
    • Presentations: 1
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      ISS12.04 - Patient Management (ID 6905)

      13:20 - 13:35  |  Author(s): T. Newsom-Davis

      • Abstract

      Abstract not provided

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    P1.03 - Poster Session with Presenters Present (ID 455)

    • Event: WCLC 2016
    • Type: Poster Presenters Present
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      P1.03-010 - Characteristics of Lung Cancer Patients Diagnosed Following Emergency Admission (ID 5091)

      14:30 - 14:30  |  Author(s): T. Newsom-Davis

      • Abstract

      Background:
      The proportion of patients with cancers diagnosed via the emergency route and their demographic characteristics vary according to tumour type[1]. Patients with lung cancers diagnosed as emergency presentations suffer worse outcomes[2]. The aim of this observational study was to determine the characteristics of a sample of patients with new lung cancers presenting through the emergency route.

      Methods:
      Clinical and demographic patient data were extracted from the London Cancer Registry. Data relating to emergency presentations of lung cancer were collected prospectively between January and August 2013 from nine acute trusts across northeast and central London and west Essex. Clinical and demographic characteristics were collated. The total number of emergency presentations were compared to the total numbers of lung cancers diagnosed within the same region over the corresponding time frame from the National Lung Cancer Audit data (NLCA).

      Results:
      Figure 1From the NLCA, there were an estimated 964 lung cancers recorded within the London cancer region during the study period. Of these, 310 (32%) lung cancers were recorded in the London Cancer registry as having presented via the emergency route. The median age of these patients was 73. The majority of patients were white and from areas of increased social deprivation. The proportion of patients presenting with stage IV disease was 67%, while 58% had a performance status of 0-2. The most common presenting symptoms were respiratory. 95% of patients were treated with palliative rather than curative intent.



      Conclusion:
      Approximately one third of new lung cancers within London Cancer are diagnosed following emergency admission. The next phase of work includes incorporating results from the London Cancer Alliance to provide pan-London data and to develop tools in primary care to identify these patients prior to emergency admission.

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    PA01 - Lung Cancer Diagnosis and Care: Identifying and Improving Community Standards (ID 356)

    • Event: WCLC 2016
    • Type: Patient & Advocacy Session
    • Track: Patient Support and Advocacy Groups
    • Presentations: 1
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      PA01.02 - The Route to Diagnosis: Impacting Survival by Changing the System (ID 6745)

      11:20 - 11:40  |  Author(s): T. Newsom-Davis

      • Abstract
      • Presentation
      • Slides

      Abstract:
      A significant proportion of lung cancer patients are first diagnosed with their disease as part of an emergency presentation (EP) to acute medical services. EP includes patients attending the emergency department (ED), primary care referrals to acute services, and emergency admissions to secondary care. This route to diagnosis is more common in lung cancer than other malignancies[1]. Initial studies focused on the United Kingdom, where 40% of lung cancer patients were found to present in this fashion[1], but it occurs in all European countries, with rates up to 52%[2]. Lung cancer patients presenting via EP tend to be older, have lower socio-economic status and greater social deprivation, display worse overall health, and have a lower performance status[3]. They are more likely to present with advanced stage disease~,~ and are less likely to have surgery or other treatments with curative intent[2]. The emergency route to diagnosis is associated with poorer patient experience and is a significant additional burden on acute medical services[4]. Most importantly, EP lung cancer patients have poorer survival[1]: the risk of dying in the first month post-diagnosis is four times higher for EP compared to non-EP patients[2]. For the majority of lung cancer patients, there are opportunities for earlier diagnosis and prevention of EP[5]. Most have a relatively long history of symptoms, often more than 12 weeks, and three-quarters have been to their general practitioner (GP) with their symptoms, usually on several occasions. There is also a group of patients who delay consulting a doctor, and they are more likely to report barriers to presenting to healthcare services[5]. Novel methods of lung cancer diagnosis, focusing on symptom recognition, early involvement of primary care and prompt assessment in secondary care, have the potential to address this important problem. In the UK, the issue of late diagnosis and EP of cancer is increasingly recognised in cancer strategies. A number of innovative approaches have been brought together by the ACE (Accelerate, Coordinate and Evaluate) program, which aims to improve early diagnosis of cancer across a range of tumour types by learning from current best-practice and trialling new projects, many of which focus on lung cancer[6]. These are now informing health policy. Prominent independent reports have also addressed the EP of lung cancer, and have produced a series of recommendations[7]. At a national level, campaigns to raise public awareness of the signs and symptoms of lung cancer can help promote earlier presentation to primary care, whilst the adoption of lung cancer screening programmes has the potential to reduce the number of lung cancer patients diagnosed late. Lung cancer risk assessment and clinical decision support tools can assist the GP. System-based tools use patients’ current symptoms to provide an indication as to who should be referred for further investigations, whilst lung cancer risk prediction models identify high risk individuals without symptoms for CT screening. These require further testing and validation, but if proven successful, should be available in primary care practices. Improving communication between primary and secondary care is critical. Direct telephone or email access between GPs and secondary care consultants would speed discussion about high risk cases. Meanwhile GPs should be able to make direct referrals for CT scans for patients with suspected lung cancer without the need for specialist authorization. Other innovative schemes have pioneered open-access patient self-referral for chest radiographs. The ED is often used as a safe and quick access point to secondary care, even for those patients who do not require emergency medical care. Developing new outpatient pathways can prevent EP by providing GPs with access to rapid-access clinics for patients with, for example, clinical suspicion of cancer but who are too unwell to wait 2 weeks for an urgent outpatient appointment, or those in whom the likely tumour type is not clear[6]. The Danish pathway for patients with serious but non-specific symptoms and signs of cancer is one of the pioneers in this area[8]. To support the patient through their whole journey and expedite the diagnostic process, a clinical nurse specialist (CNS) should be available to all patients undergoing investigations for suspected lung cancer. Those who present via EP should be seen within 24 hours by a CNS who then acts as their key worker. The patient should be registered on a timed, multi-disciplinary pathway, so that diagnosis is efficient and the patient is afforded the same treatment opportunities as those presenting via elective routes. Although there is not one solution to the problem of EP in lung cancer, and different approaches are needed for different health systems, there are common themes by which survival can be improved by changing the system for this vulnerable patient group. References: 1. Elliss-Brookes L, McPhail S, Ives A, et al. Routes to diagnosis for cancer - determining the patient journey using multiple routine data sets. British journal of cancer 2012;107(8):1220-6. doi: 10.1038/bjc.2012.408 2. Newsom-Davis T, Berardi R, Cassidy N, et al. Emergency diagnosis of lung cancer: an international problem. American Society of Clinical Oncology Annual Meeting. Chicago, 2015. 3. Mitchell ED, Pickwell-Smith B, Macleod U. Risk factors for emergency presentation with lung and colorectal cancers: a systematic review. BMJ Open 2015;5(4):e006965. doi: 10.1136/bmjopen-2014-006965 4. NHS England. High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review End of Phase 1 Report: NHS England Leeds, 2013. 5. Forbes L, Sarafraz-Shekary N, Kaushal A, Ramirez A-J, Hughes C, Newsom-Davis T.[. ]What explains diagnosis of lung or bowel cancer as an emergency? 10th NCRI Annual Conference; 2014; Liverpool. 6. Cancer Research UK: ACE Programme: Cancer Research UK; 2016 [Available from: http://www.cancerresearchuk.org/health-professional/early-diagnosisactivities/ace-programme accessed May 2016. 7. Expert Lung Cancer Working Group. Tackling emergency presentation of lung cancer: An expert working group report and recommendations. London: British Lung Foundation, 2015. 8. Ingeman ML, Christensen MB, Bro F, et al. The Danish cancer pathway for patients with serious non-specific symptoms and signs of cancer-a cross-sectional study of patient characteristics and cancer probability. BMC Cancer 2015;15:421. doi: 10.1186/s12885-015-1424-5

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