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Abstract:
Lung cancer remains the number one cause of cancer-related death worldwide. Cancer immunotherapy nowadays has become not only a growing field but also a fascinating area as recent clinical trials have improved both PFS and OS in first line and second line treatment for patients with advanced NSCLC. The idea of immunotherapy in cancer is to modify the host immune system, so cytotoxic T-cells (CTCs) can recognize tumor-associated antigens (TAAs) as abnormal and be destroyed by an immune response. For many decades, we have tried unsuccessfully many vaccines against different lung cancer antigens. It was thought at one point that lung cancer was a non immunogenic tumor very different from melanoma and kidney cancers. Whole-cell vaccines (e.g. belagenpumatucel-L) and antigen-specific vaccines (e.g., CIMAvax, MAGE-A3, L-BPL25) showed just promising results in clinical trials, but failed to significantly improve clinical outcomes [1-4]. The major reason why vaccines failed in lung cancer was due to tumor escape mechanisms from host immune surveillance [5, 6]. One of this mechanisms was recently elucidated, checkpoint pathway. Lung cancer has been found to have high levels of CTLA-4 expression, programmed death-1 (PD-1), PD ligand 1 (PD-L1), B7-H3 and B7-H4 expression on tumor-infiltrating lymphocytes (TILs), and regulatory CD4+ T-cells (Tregs) suggesting that lung cancer is immunogenic. For many years, cancer immunology was centered on the adaptive immune system and T-cell activation. Stimulation of the T-cell response involves antigen presenting cells (APCs), or dendritic cells (DCs), expressing tumor antigens from the tumor microenvironment, which then bind to the T-cell receptor (TCR) on CD4+ or CD8+ T-cells. Meanwhile, B7-1/CD80, or B7-2/CD86 on the APC, bind to CD28 on the T-cell in a costimulatory fashion to stimulate tumor-antigen specific T-cells to proliferate. However, cross talk between APCs and T-cells at the immunological synapse is regulated very closely and can be attenuated. One of this attenuation signal is mediated by CTLA-4, which is also stimulated by CD80 and CD86. Although CTLA-4 and CD28 have the same ligands, CTLA-4 has a much higher affinity for them; hence, T-cell proliferation occurs despite the effects of CTLA-4 because of the intracellular location, short half-life and quick degradation of CTLA-4 [7, 8]. Another example of a tumor immune checkpoint is PD-1 which binds B7-H1/PD-L1 and B7-DC/PD-L2 [9]. By using PD-1 inhibitors, we are able to remove the interaction between PD-1 receptor located in the T-cells and its ligand expressed in the tumor cells which causes inhibitory signaling over the T-cells. Hence, an immune response cannot be mounted. CTLA-4 has been studied in lung cancer in combination with platinum-based doublet (carboplatin/paclitaxel). Outcomes from that study were not enough to grant approval from regulatory entities. However, investigators found better response to CTLA-4 inhibition in patients with squamous cell histology; this population has higher percentage of TILs than their non-squamous counterparts. Why the combined therapy (chemotherapy plus ipilimumab) had limited effect remains unclear. Conversely, studies using PD-1 inhibitors pembrolizumab and nivolumab have shown OS advantage over docetaxel in second line therapy, and more recently, OS and PFS advantage in first line against chemotherapy when tumor cells expressed > 50% of PD-L1 [10]. We also understand that PD-L1 is not the perfect predictive biomarkers so efforts are directed to discover more specific markers which can help us to tailor checkpoint inhibitors in lung cancer. The approval of nivolumab in NSCLC came from two phase III trials CheckMate 017 and CheckMate 057 which studied nivolumab vs docetaxel in second-line for squamous and non-squamous advanced NSCLC, respectively. The CheckMate 017 reached the “trifecta” proving that nivolumab was statistically superior to docetaxel for OS, PFS and response rate (RR). Interestingly, OS benefit was independent of PD-L1 expression. The CheckMate 057 showed OS and RR in favor of nivolumab. There was no difference in PFS between nivolumab and docetaxel in non-squamous NSCLC patients. In this study, PD-L1 expression levels at different cut-off matter for OS. For those patients who had ≥1%, ≥ 5%, and 10%, the hazard ratio (HR) for OS were 0.59 (p < 0.06), 0.43 (p < 0.001), and 0.40 (p < 0.001), respectively. In both studies, nivolumab was well tolerated and had better treatment-related adverse event profile. In case of pembrolizumab, it was KEYNOTE-010 study which proved OS advantage over docetaxel in second line therapy. Herein, pembrolizumab at a dose of 10 mg/kg and 2 mg/kg shown an OS of 12.7 months (HR 0.61; p < 0.001) and 10.4 months (HR 0.71; p < 0.001); OS for docetaxel was 8.5 months. Noteworthy, OS was better in patients whose tumors expressed PD-L1 ≥50%; these patients had an OS of 17.3 and 14.9 months when received pembrolizumab at 10 mg/kg and 2 mg/kg, respectively. Again, grade 3-5 treatment-related AEs were less common for both pembrolizumab doses than for docetaxel. Recently, press release on KEYNOTE-024 phase III study, reported OS in favor of pembrolizumab over platinum-based doublet in first-line therapy for advanced NSCLC patients with PD-L1 expression. The clinical results from KEYNOTE-024 may change the landscape of lung cancer treatment at first-line for advanced NSCLC. Also in development are the PD-L1 inhibitors which affect the interaction between PD-L1 and B7.1 and PD-1 receptor and PD-L2; the later interactions are not affected by PD-1 inhibitors. Atezolizumab and darvulumab have several phase III trials ongoing in first line for advanced NSCLC. Phase II trials for both compounds have shown promising results. The role of PD-L1 as predictive biomarker is still not well defined. PD-L1 expression is a dynamic process and it also varies as part of an adaptive immune resistance exerted by the tumor. There are other possible predictive biomarkers such as higher nonsynonymous mutation burden, molecular smoking signature, higher neo-antigenic burden, DNA repair pathway mutations, high levels of PD-L1 expression, T-helper type 1 gene expression, and others. There is no question that we must continue looking for a better predictive biomarker which can help us to determine the therapeutic benefit of PD-1/PD-L1 inhibitors. References. 1. Nemunaitis J, Dillman RO, Schwarzenberger PO, et al. Phase II study of belagenpumatucel-L, a transforming growth factor beta-2 antisense gene-modified allogeneic tumor cell vaccine in non-small-cell lung cancer. J Clin Oncol. 24, 4721–30 (2006). 2. González G, Crombet T, Neninger E, Viada C, Lage A. Therapeutic vaccination with epidermal growth factor (EGF) in advanced lung cancer: analysis of pooled data from three clinical trials. Hum Vaccin. 3(1), 8-13 (2007). 3. Vansteenkiste J, Zielinski H, Linder A, et al. Final results of a multi-center, double-blind, randomized, placebo-controlled phase II study to assess the efficacy of MAGE-A3 immunotherapeutic as adjuvant therapy in stage IB/II non-small cell lung cancer (NSCLC). J Clin Oncol. 25(18S), 7554 (2007). 4. Palmer M, Parker J, Modi S, et al. Phase I study of the BLP25 (MUC1 peptide) liposomal vaccine for active specific immunotherapy in stage IIIB/IV non-small-cell lung cancer. Clin Lung Cancer. 3(1), 49-57 (2001). 5. Gross S, Walden P. Immunosuppressive mechanisms in human tumors: why we still cannot cure cancer. Immunology Letters. 116(1), 7–14 (2008). 6. Dunn GP, Bruce AT, Ikeda H, Old LJ, Schreiber RD. Cancer immunoediting: from immunosurveillance to tumor escape. Nat Immunol. 3, 991–8 (2002). 7. Egen JG, Kuhns MS, Allison JP. CTLA-4: new insights into its biological function and use in tumor immunotherapy. Nat immunol 3(7):611-618, 2002. 8. Zang X, Allison JP. The B7 family and cancer therapy: costimulation and coinhibition. Clin Cancer Res 13(18):5271-5279, 2007. 9. Blank C, Mackensen A. Contribution of the PD-L1/PD-1 pathway to T-cell exhaustion: an update on implications for chronic infections and tumor evasion. CancerI Immunol Immunother 56(5):739-745, 2007. 10. http://www.businesswire.com/news/home/20160616005393/en/Merck%E2%80%99s-KEYTRUDA%C2%AE%C2%A0-pembrolizumab-Demonstrates-Superior-Progression-Free-Survival. Access online September 20, 2016.

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Despite substantial reductions in smoking prevalence, lung cancer is the leading cause of cancer-related mortality for both genders in the United States. In 2016, lung cancer is expected to be responsible for 158,080 deaths. Tobacco smoking is still the number one risk factor for lung cancer and has been linked to 90% of all lung cancer cases. Currently, only 15% of all lung cancer cases are diagnosed at an early stage. Historically, these poor rates were due to the lack of effective routine screening. This changed dramatically in November 2011 when the National Lung Cancer Screening Trial (NLST), released their results that showed low-dose computed tomography (LDCT) could reduce lung cancer mortality by 20%. LDCT is now widely recommended for current and former smokers. Identification of all barriers and facilitators is essential for the successful promotion of lung cancer screening. Denormalization of smoking has been one of the most successful tobacco control measures and is associated with a sharp decrease in the prevalence of smoking. However, smoking is now concentrated in the most vulnerable populations (e.g. lower income groups and the mentally ill) who have the least ability and/or willingness to quit. In addition, denormalization has the effect of sanctioning smoking related stigma. A majority (95 %) of lung cancer patients experience stigma, with 48 % of lung cancer patients specifically reporting feeling stigmatized by their medical providers. Perceived lung cancer stigma is defined as a personal experience characterized by exclusion, rejection, blame or devaluation. Lung cancer conjures up attributions of blame because it is associated with smoking cigarettes and is perceived to be a controllable behavior. Perceived lung cancer stigma is a risk factor for poor psychosocial and medical outcomes in the context of lung cancer diagnosis and treatment. People often associate lung cancer with previous smoking behavior, regardless of whether the person with lung cancer was a smoker or not. There is growing body of evidence that patients, caregivers, healthcare providers, and members of the general public have negative implicit attitudes toward lung cancer. Perceived lung cancer stigma is one barrier that can delay the detection of lung cancer because of fear of health professionals’ censure associated with smoking. In our previous work we found that there were four beliefs associated with whether older (>55) current and former smokers would agree to lung cancer screening (LDCT): Perceives accuracy of the LDCT as an important factor in the decision to have a LDCT scan; Believes that early detection of LC will result in a good prognosis; Believes that they are at high risk for lung cancer; and is not afraid of CT scans. This study showed that older smokers are aware of the risks of smoking, are interested in smoking cessation, and most are interested in and positive about LDCT. There are no studies that have examined the impact of perceived lung cancer stigma on the decision to have an LDCT. To address this gap, we conducted a secondary analysis in which lung cancer stigma was measured by five true or false items: doctors treat smokers badly; doctors have a bias against smokers; cigarette smokers keep their smoking a secret from important people in their lives; cigarette smokers avoid talking about smoking with their doctor; cigarette smokers feel guilty about their smoking; and friends and family are upset that I smoke. Four variables demonstrated a significant association with LDCT agreement: People treat smokers badly; Doctors have a bias against smokers; Smokers feel guilt about smoking; and Friends and family do not approve of my smoking. Only two of the independent variables made a unique statistically significant contribution to the model. A test of the model against a constant only model was statistically significant, indicating that the predictors as a set, reliably distinguished between those who would agree to an LDCT and those who would not agree (chi square = 8.5 p. = <.1 with df = 4). The model as a whole explained between 43% of the variance in agreement to have a CT scan, and correctly classified 83.2% of cases. The strongest predictor for agreeing to a LDCT was “People treat smokers badly”, (OR 3.7, 95% CI .143-.971). Participants with this belief were almost 4 times less likely to agree to a CT scan than those who did not have the belief. The odds ratios for the remaining predictor, Doctors have bias against smokers, was OR 1.7, 95% CI 1.47- 4.90); Believes that they are at high risk for LC (OR 2.1, 95% CI 1.8 – 3.12). DISCUSSION The decision to agree to a LDCT is negatively associated with two indicators of perceived stigma, “people treat smokers badly” and “doctors have a bias against smokers.” These findings suggest that stigma is a barrier to preventative care utilization much like it is for patients with HIV, STDs, TB and mental health problems. Smokers from deprived communities are an important group to engage with lung cancer screening but thus far participation in trials has been skewed towards former smokers and better educated smokers. With the current demographic profile of smokers, the effectiveness of a lung cancer screening program depends in part on whether there are inequalities in participation which has the potential to exacerbate disparities in lung cancer survival. Given the impact of lung cancer stigma on satisfaction with care and patient outcomes it is imperative that further research explore the association of perceived lung cancer stigma and the decision to have LDCT.

Abstract:
Background As the most common cancer and the leading cause of cancer deaths worldwide, lung cancer has garnered increasing attention and efforts to reduce its toll. In contrast to the wealth of information on lung cancer burden for the general population, a rapid review of the academic literature (published in the past 10 years) to identify articles about lung cancer in Indigenous populations of four comparable OECD countries, found a paucity of information. The reasons for the paucity of articles are multi-faceted and most likely related to the lack of indigenous identification in health and cancer administrative datasets, among other issues. The search identified 62 articles which documented disparities in lung cancer outcomes for Indigenous peoples, identified likely reasons and made recommendations for better targeted prevention and management strategies. Indigenous people in all four countries, namely Aboriginal and/or Torres Strait Islanders in Australia; Māori in New Zealand; First Nations, Métis or Inuit in Canada; American Indians and/or Alaskan Natives (AIs/ANs) in the United States (US), have significantly lower life expectancy than their non-Indigenous counterparts, to which their lung cancer burden must surely contribute. The burden of lung cancer for Indigenous populations Lung cancer is one of the most commonly occurring cancers for indigenous people across all four countries. It has recently been reported that lung cancer incidence is higher in Indigenous men in Australia, Canada’s Métis and in Alaskan Natives than in their non-indigenous counterparts, and in Māori women, Alaskan Native women and Indigenous women in some Australian States [1]. Lung cancer is the leading cause of cancer deaths in Indigenous Australians (1 in 4 cancer deaths) and Māori where mortality rates were three times those of non-Māori (nearly 1 in 3 cancer deaths) [1, 2]. Lung cancer mortality among the Alaskan Native population is higher than the US white population, and among the highest of any racial/ethnic group in the US [3]. Survival following a diagnosis of lung cancer was lower for indigenous people in all four countries compared to their non-indigenous counterparts [4, 5, 6]. For example for Indigenous Australians five year survival following a diagnosis of lung cancer was 7% compared with 11%. Indigenous Australians are 1.7 times more likely to die from lung cancer than non-Indigenous Australians. In Australia, lung cancer accounted for 25% of all Indigenous deaths from cancer [2]. In the USA and Canada lung cancer survival rates improved over time for non-indigenous populations but remained unchanged or declined for the AI/AN and First Nations cohorts [6, 8], increasing disparities. Explaining the disparities The greater burden of lung cancer in indigenous populations is largely attributable to the higher prevalence of tobacco smoking. In both Australia and New Zealand, 39% of the Indigenous populations aged 15 and over were daily smokers – almost 3 times the rate of the non-Indigenous populations [4, 9]. AI/AN populations had the highest tobacco use (29%) of any population group in the USA [10]. Smoking rates among Canada’s Aboriginal populations are on average twice as high as those of non-Aboriginal Canadians, with nearly half of Inuit adults smoking daily or regularly [11]. While smoking rates in all four countries have decreased, the decline in indigenous smoking prevalence has occurred at the same or slower rate than for non-indigenous people, meaning the gap in smoking rates has remained. Although higher lung cancer incidence and mortality rates for indigenous peoples is related to patterns of tobacco use, they also reflect the significant disparities in terms of socio-economic disadvantage, social dislocation, geographic/remoteness and related stressors indigenous people face [1]. Poorer survival of indigenous people with lung cancer is attributed to a greater likelihood of advanced disease at diagnosis [12], lower rates of treatment, not receiving optimal lung cancer care concordant with clinical guidelines care [1, 7, 13, 14], and higher prevalence of comorbidities [2]. But these factors do not explain all the survival disparities. Recent research has shifted focus from patient and community-level factors to examining system-level and societal factors that affect lung cancer care and outcomes for indigenous patients including difficulty accessing health services and the cultural appropriateness of healthcare services [6]; lack of coordination and follow-up processes [15, 16]; health professional behaviours including knowledge about lung cancer, relationships with patients and carers, communication and responsiveness to needs [15, 16]; and the impact of stigma and shame on delays in medical help-seeking and lung cancer patients’ quality of life [16]. Strategies to reduce the disproportionate burden The current evidence highlights that significant disparities exist in lung cancer outcomes between indigenous and non-indigenous peoples and that multiple strategies are required to reduce the burden of lung cancer for indigenous people. At the systems level, inclusion of an indigenous identifier in administrative data is required to accurately identify and monitor lung cancer outcomes. The provision of and timely access to medically effective and culturally accepted diagnostic, treatment and support services, and personalised care that addresses the social-cultural needs of indigenous patients, is required to improve indigenous patients engagement with cancer care services and, in turn, cancer outcomes [12]. Tobacco control and smoking cessation initiatives are critical – but there is limited evidence about what works in indigenous populations. While public policy initiatives have reduced overall smoking prevalence, they appear to have had less impact on smoking rates among indigenous populations. Well-targeted tobacco control strategies need to consider historical, social, economic and cultural reasons why indigenous people smoke – factors that also can undermine efforts to reduce smoking uptake and encourage indigenous people to quit. The use of both comprehensive and tailored interventions has been recommended, including culturally appropriate health materials and activities, with indigenous peoples’ engagement and control [17]. It is also essential to increase symptom awareness to expedite diagnoses, and there are novel initiatives aimed at improving awareness of lung cancer risk factors and symptoms among indigenous communities and health professionals. Reducing the disproportionate burden of lung cancer on indigenous peoples requires targeted and multifaceted approaches that recognise and address the broad and interconnected web of factors at patient, provider and system levels that impact on optimal care and outcomes. References 1. Moore, S.P., et al., Cancer incidence in indigenous people in Australia, New Zealand, Canada, and the USA: a comparative population-based study. Lancet Oncol, 2015. 2. Australian Institute of Health and Welfare, Cancer in Australia: an overview 2014. Cancer series No 90. Cat. no. CAN 88. 2014, AIHW: Canberra. 3. Lanier, A.P.D., G. E.;Kelly, J. J.;Provost, E., Disparities in cancer mortality among Alaska Native people, 1994-2003. Alaska Med, 2008. 49(4): p. 120-5. 4. Australian Institute of Health and Welfare & Cancer Australia 2013. Cancer in Aboriginal and Torres Strait Islander peoples of Australia: an overview. Cancer series no 78. Cat. No. CAN 75. Canberra:AIHW 5. NZ Ministry of Health (2015) Cancer Patient Survival: 1994 to 2011 Wellington 6. Nishri, E.D.S., A. J.;Withrow, D. R.;Marrett, L. D., Cancer survival among First Nations people of Ontario, Canada (1968-2007). Int J Cancer, 2015. 136(3): p. 639-45. 7. Smith CB, Bonomi M, Packer S, Wisnivesky JP. Disparities in lung cancer stage, treatment and survival among American Indians and Alaskan Natives. Lung Cancer. 2011 May;72(2):160-4. doi: 10.1016/j.lungcan.2010.08.015 8. White, M.C.E., D. K.;Swan, J.;Wiggins, C. L.;Eheman, C.;Kaur, J. S., Disparities in cancer mortality and incidence among American Indians and Alaska Natives in the United States. Am J Public Health, 2014. 104 Suppl 3: p. S377-87. 9. Ministry of Health, Tobacc use 2012/13: New Zealand health survey. 2014, Ministry of Health: Wellington. 10. Centers for Disease Control and Prevention, Current Cigarette Smoking Among Adults—United States, 2005–2014. Morbidity and Mortality Weekly Report, 2015. 64(44): p. 1233-40. 11. Statistics Canada, Select health indicators of First Nations people living off reserve, Métis and Inuit. Catalogue no. 82-6240X. 2013. 12. Moore, S.P.G., Adèle C.;Bray, Freddie;Garvey, Gail;Coory, Michael;Martin, Jennifer;Valery, Patricia C., Survival disparities in Australia: an analysis of patterns of care and comorbidities among indigenous and non-indigenous cancer patients. BMC Cancer, 2014. 14: p. 517-517. 13. Javid, SH, Varghese TK, Morris AM, Porter MP, He H, Buchwald D, Flum DR; Collaborative to Improve Native Cancer Outcomes (CINCO). Guideline-concordant cancer care and survival among American Indian/Alaskan Native patients. Cancer. 2014 Jul 15;120(14):2183-90. 14. Whop, LJ, Bernardes CM, Kondalsamy-Chennakesavan S, Darshan D, Chetty N, Moore SP, Garvey G, Walpole E, Baade P, Valery PC. Indigenous Australians with non-small cell lung cancer or cervical cancer receive suboptimal treatment. Asia Pac J Clin Oncol. 2016 Mar 21. doi: 10.1111/ajco.124632016 15. Dunn, J. , Garvey, G., Valery, P. C., Ball, D., Fong, K.M. , Vinod, S., O’Connell, DL. & Chambers, S.K. Barriers to Lung Cancer Care: Health Professionals’ Perspectives. Accepted for publication 24[th] September 2016. Journal of Supportive Care in Cancer 16. Chambers, S.K.B., P.;Youl, P.;Aitken, J.;Occhipinti, S.;Vinod, S.;Valery, P. C.;Garvey, G.;Fong, K. M.;Ball, D.;Zorbas, H.;Dunn, J.;O'Connell, D. L., Psychological distress and quality of life in lung cancer: the role of health-related stigma, illness appraisals and social constraints. Psychooncology, 2015. 24(11): p. 1569-77. 17. Minichiello, A., et al., Effective strategies to reduce commercial tobacco use in Indigenous communities globally: A systematic review.(Report). 2016. 16(21).

Abstract:
Background: Lung cancer and its treatment have a major physical impact, as well as emotional, social, psychological, spiritual, functional and practical challenges and consequences, both for the patient and his relatives. While coping with the disease they become aware of vulnerability and mortality, they are balancing hope and the realisation of mortal danger(1). Preconceptions which patients are harbouring could be an important factor at coping with the lung cancer. Both smokers (or former smokers) and non-smokers are being stigmatised, and lung cancer is connected with stereotype representation of incurable disease(2). Life is never the same as before the diagnosis. In the comprehensive approach to lung cancer, team work is of paramount importance. Beside the standard oncological treatment, for the patient there is a benefit of an early palliative care. This benefit beside better quality of life (due to better quality of life, less depression and less aggressive treatment) confers also an increase of survival(3). Here, the nurse is an important member of comprehensive care team, and is the one spending the greatest amount of time at bedside. Methods: We reviewed the literature and the current clinical practice. Results: In operationalising psychosocial care in oncology many authors are advocating so called tiered approach(4,5). Providing psycho-social support to lung cancer patients is the task of all medical workers included in the multidisciplinary care. And all cancer patients have the basic psycho-social needs, such as informational needs, basic emotional support, adequate communication, screening of needs on on-going basis and the symptom management. Patients experiencing more profound distress or have more unmet needs, should be directed into the specialist care provided by the mental health professionals or other professionals needed. At the psycho-social care of the lung cancer patients entering the treatment, there should be an emphasis on the adequate patient information concerning the disease, planned treatment, side effects and their management, the possibilities of patient’s contribution to the treatment, and also patients’ fears and existential issues should be addressed. It is important for the patient to get as many information as he deems necessary, being careful about the pace the information is given. Despite the amount of information offered in media in the recent time – many of them unfortunately also untested – many patients in their search for information prefer getting information in one-to-one communication with health provider, in relation with whom they are experiencing confidence, safety, care and professionalism(1). It is important to present the information, at the same time accurate and still preserving the hope even in the face of the odious situation, thus giving the patient and his relatives emotional support and strengthening their functional coping strategies. Therefore, medical professionals should develop good communication skills; these are proven to be associated with less unmet needs(6)by the patient and also with the increase of informed decisions regarding treatment(7). In patients with poorer communication skills, assertiveness support can help with the communication with the medical professionals but also with the relatives. The cognitive behavioural therapy strategies can take a pivotal place. Cognitive interventions are focused on the way of thinking about a situation and through it influences the behavioural and emotional response, like cognitive restructuration, helping the patient in development of positive alternative to negative thought, or distraction, changing the patient focus. Behavioural interventions, such as relaxation techniques, can help controlling physiological responses in stressful situations. An important place in the support of patient’s psycho-social needs is taking into consideration emotional and social support. In addition to patient’s relatives, friends and peers, medical workers represent an integral part of it. In the patient’s preparation for treatment, it is important to recognize those experiencing more profound distress or having more unmet needs, thus needing more help. Research has shown that cancer patients are experiencing more physical problems - the most common are pain, dyspnoea, fatigue, cough(8) - and also have more unmet needs than other patients. In excess of 80 % of lung cancer patients are experiencing some degree of psychological distress. This is more than other cancer type patients are experiencing. Depression estimates are ranging between 11 and 44 % and the fear of recurrence is ranging from 5 % up to the 89 %(8). The severity of distress is varying through the process of treatment and rehabilitation; the time of diagnosis is a period during which more patients are entering psycho-social treatment than later during treatment(1,5). With the aim of early recognition of patients with more profound distress, screening procedures are being implemented. Beside different questionnaires, International Psycho-Oncology Society is striving to implement the distress thermometer with 10 grades(9). The psycho-social interventions, performed by mental health professionals are proven to increase wellbeing, improve adjustment and coping, and reduce distress in people with cancer. In the field of psycho-oncology, the most commonly used methods are cognitive behavioural therapy, learning of relaxation skills, psycho education, and also partnership and family therapy(4). Providing psycho-social treatment for patients with more profound distress is connected with multiple challenges. Beside patient recognition and implementation of screening programmes, the next challenge is patient’s compliance, as psychological treatment can for a patient still be stigmata. Despite limited evidence of its efficacy patients prefer emotional and social help from the nurse than from allied professionals, because their medical expertise is seen as an advantage(5). In many healthcare systems the availability of psycho-social treatment, to the patient who needs it in the proper time, and the development of required resources, still in many cases underutilised, is the next challenge. This, despite proven ethical, emotional as well as economic benefits of psycho-social treatment. Conclusion:The nurse is playing one of the crucial roles in comprehensive treatment of lung cancer patients. She is indispensable in providing psycho-social support to the lung cancer patients, preparing to enter treatment. She is providing the basic psycho-social support, such as patient’s need for relevant information, basic emotional support, communication, screening for needs on an ongoing basis, symptom management. She is also pivotal in recognizing patients, experiencing more profound distress or has more unmet needs and can run a screening programme. REFERENCES: 1. Missel M, Pedersen JH, Hendriksen C, Tewes M, Adamsen L. Diagnosis as the First Critical Point in the Treatment Trajectory: An Exploration of Operable Lung Cancer Patients’ Lived Experiences. Cancer Nurs. 2015;38(6):E12-21. 2. Pujol J-L, Mérel J-P, Roth C. How preconceptions about lung cancer treatment interact with medical discourse for patients who accept chemotherapy? Psychooncology. 2016 Jul 23 [cited 2016 Aug 21]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/27449209 Accessed August 20, 2016 3. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42. 4. Hutchison SD, Steginga SK, Dunn J. The tiered model of psychosocial intervention in cancer: a community based approach. Psychooncology. 2006;15(6):541–6. 5. Brebach R, Sharpe L, Costa DSJ, Rhodes P, Butow P. Psychological intervention targeting distress for cancer patients: a meta-analytic study investigating uptake and adherence. Psychooncology. 2016;25(8):882–90. 6. Walling AM, Keating NL, Kahn KL, Dy S, Mack JW, Malin J, et al. Lower Patient Ratings of Physician Communication Are Associated With Unmet Need for Symptom Management in Patients With Lung and Colorectal Cancer. J Oncol Pract. 2016;12(6):e654-69. 7. Janssens A, Kohl S, Michielsen T, Van Langendonck S, Hiddinga BI, van Meerbeeck JP. Illness understanding in patients with advanced lung cancer: curse or blessing? Ann Palliat Med. 2016;5(2):135–8. 8. Pozo CLP, Morgan MAA, Gray JE. Survivorship issues for patients with lung cancer. Cancer Control. 2014;21(1):40–50. 9. Bultz BD. Guide to implementing screening for distress, the 6th vital sign: Background, recommendations, and implementation. Cancer Journey Action Gr. 2009;(May):4–43.

Abstract:
Purpose: To develop a cost-effective preoperative patient teaching program that includes a patient teaching video along with written material that improves patient satisfaction, decreases patient anxiety, decreases readmission rates associated with post-operative complications, and optimizes overall outcomes of thoracic surgery patients. Overview: Patients undergoing surgery usually have little knowledge of what to expect during the preoperative, postoperative, and recovery period following thoracic surgery. Multiple studies have shown that good quality preoperative teaching increases patient satisfaction, improves patient outcomes, and decreases patient readmission rates following surgery. Although the benefit of preoperative education is widely recognized in the literature, finding the resources available to provide efficient and effective teaching is a challenge. Patients who are diagnosed with a suspicious lung nodule or lung cancer are usually overwhelmed when attempting to navigate through the health care system. During the initial surgical visit a battery of studies and often additional diagnostic procedures are ordered for staging and surgical clearance. The details of the surgery are discussed and the surgical consent is obtained. The patient and family are inundated with so much information that pre-operative teaching is not effective at this time. Further, in outpatient health care settings there is a finite amount of time within a visit for a provider to promote all of the pre-operative patient education. It has been the experience of this thoracic surgery practice that providing the patients and families an opportunity to undergo pre-operative teaching in another setting, such as in their own homes, typically results in increased retention of the information, and patients do better not only in the pre-operative period but in the post-operative and recovery stages as well. Developing a well-designed preoperative teaching program requires a multidisciplinary approach and utilization of resources already available to build upon and promote better programs that optimize patient and caregiver learning and retention. Pre-operative education and teaching is not just to provide information, but also to help patients acquire the knowledge needed to change behaviors and to promote better health. Individuals within the care team with particular interest in patient education should be utilized in helping to develop an effective preoperative teaching program. Collaborating with nurses and advanced practice providers across the care continuum is ideal: these members of the team have both the knowledge base and the access to patients and their families needed to provide effective patient education. Method: “A Patient’s Guide to Thoracic Surgery” is a thoracic teaching manual that was customized to fit our thoracic patient population. It was developed by a group of nurses and advanced practice providers who were interested in developing thoracic patient education at our institution. The booklet includes basic information concerning how to prepare for thoracic surgery, as well as what to expect before and after the surgery. Our thoracic team saw the need for additional education and developed a patient education video, “A Patient’s Guide to Thoracic Surgery Video” that includes pre-operative teaching, what to expect after surgery, and after discharge. The video was funded by a grant that our hospital provides annually, funding various projects that support research, education, and clinical care. The team wrote a script and worked with the hospital IT department to create the video. Patients receive both the pre-operative teaching booklet and video during the initial office visit and the major points of the teaching material are reviewed at this time. The patient is instructed to read through the information and watch the video at their convenience. They are also encouraged to call the office to discuss what they learned and answer any questions they may have. The outpatient nurse practitioner calls and sometimes meets with the patients at least once again prior to surgery to review the patients’ pre-operative studies, update their pre-operative paperwork, and to answer any questions or concerns about their upcoming surgery. The patients are asked if they have read through the material and watched the video. During this encounter, updates on smoking cessation and exercise are documented and discussed. Following surgery, additional teaching is done by the nursing staff and the teaching video and discharge instructions are again reviewed. Furthermore, the patient is phoned for a “day after discharge” call by a thoracic team member to check on the patient’s progress and answer any questions the patient or family may have. The patients and their families are seen in the office for a post-operative visit usually 2-3 weeks after discharge. A 10 question “Thoracic Video Patient Satisfaction Survey” is completed during this initial post-op visit. This survey asks the patients to rate the educational video on content and how helpful they felt the video was in preparing them for surgery and for what to expect after surgery. Results: A “Thoracic Video Satisfaction Survey” has been given to all patients undergoing thoracic surgery at Penn Presbyterian Medical Center; Philadelphia, Pennsylvania over the past several months. Preliminary results have shown that since the implementation of the thoracic teaching video in conjunction with the written material there has been an increase in patient’s satisfaction and a decrease in anxiety associated with thoracic surgery Conclusion: Providing patients with multi-format education materials and the ability to review them on their own time has proven successful at achieving the stated goals. Moving forward we intend to build upon this resource to improve the patient education program at our institution. Additionally, we hope to conduct a formal research project in conjunction with other institutions such as the University of Maryland to continue to develop thoracic patient education and to help identify which programs work best in promoting patient education and changing behaviors in the thoracic surgery population.

Abstract:
Ethical decision making is very important in the context of treatment of cancer patients. These decisions can lead to withdrawal or withholding of life-sustaining therapy, or change the goal of the therapy from curative to palliative. “Do-not-reanimate” or “allow-natural-death” orders are also part of ethical decision making. Sometimes pain treatment is adapted or palliative sedation is started. It is necessary to make these decisions to ensure dignity at the end-of-life, which is a human right. Ethical decision making is usually done state-of-the-art in the context of Palliative Care, which means dialogue with the patient, the next of kin and other health-care-professionals involved in the treatment. The decision making process is structured, documented and can be replicated for everyone. Most of the time, these decisions are made by physicians only, without a dialogue, especially in Austria in hospitals or nursing homes. Sometimes patients are involved, but more often only their relatives. Physicians rarely ask other health-care-professionals for their opinion. End-of-life-decision-making seldom occurs as a structured well documented process. But the fact, that by law physicians have to take the final decision, does not prevent them from listening to and involving the perspective of the different persons concerned. If the discussion stops with the question “Who is allowed to decide?” then decisions would only be made because of having legal authority and not because of ethical reasons. (Vanlaere & Gastmans, 2008, Arndt, 2007) From an ethical perspective these decisions are often decisions between the autonomy of patients and the care of health care professionals. It is crucial to preserve the dignity of the suffering human being. It is a challenge to make reasonable ethical decisions in a context characterized by strong pressure for efficient and flexible organisational structures on the one side and complex values on the other side. (Gastmans & Vanlaere, 2005). It is not always clear what is right and what is wrong, or what is good and what is bad. Sometimes health care professionals, especially physicians, try to avoid these decisions by not to deciding anything, but avoidance is also a decision. Ethical decision making is much more difficult, if the suffering person cannot express his wishes anymore. Then, physicians and other health care professionals, who are included in the decision-making-process, have to find out the person`s wishes. It is very important that ethical decision making is based on indication for treatment, futility and the wish of patient. (Bundeskanzleramt, 2015) Ethical decision making should include all persons involved – physician, patient, relatives, nurses and also, if appropriate pastor or other religious leader, social workers and other health care professionals. The involvement of patients and – if they wish – their next of kin is necessary. Austrian medical guidelines (Valentin et al. 2004) recommended that nurses and other members of the multidisciplinary team had to be involved in such decisions. The decision making process should be structured, documented and - depending on the context – regularly evaluated. Several models exist for ethical decision making and help to guide and structure the dialogues. Individual ethical case conferences could be part of clinical ethical counseling, which also includes ethical education and providing guidelines. (Zentrale Ethikkommission, 2006). Examples of such decision-making-models are the model of Gastmans and Vanlaere (Vanlaere & Gastmans, 2008) based on the personalism and care-ethic, the Nijmwegener-model of Steinkamp and Gordijn (Steinkamp, 2012) and the model of Arndt (2007). Decision-making-models are not simply checklists. Health care professionals have to use them with empathy in the context of their own experience and values. (Körtner, 2012). General guidelines could deviate from frequently arising problems, but there always would be individual cases, which represent marginal cases because they burst all limits (Körtner, 2012). By using decision-making-models health care professionals have to be alert, not to use those strictly according to the written instructions. The sensitivity for the individual and his special situation has to be preserved. A discussion or counselling, where all persons concerned make a choice together according to their values and principles, is the best guarantee for a well-grounded ethical decision and gives more sense of security for a good result. Nevertheless, there is no guarantee for a right or good action. (Körtner, 2012). Because of the emotional burden of end-of-life-decisions, these models are also helpful to include all important aspects. The participants of these dialogues have to respect the values of the others and to see the situation from their point of view. Using decision-making-models guarantees to involve all relevant individuals. Furthermore, the decision making process becomes repeatable and visible. Finally, it is important to mention that ethical-decision-making can’t be reduced to using decision-making-models. Ethical thinking is a result of dynamic mutual reactions between emotions, intuition, standardization and rational reasoning. (Van der Arend & Gastmans, 2009) The role of nurses in this decision making process and also in the realization of these decisions is rarely recognized. But nurses play an important role in ethical decision making - as national (Ruppert et al., 2012) studies show. Nurses have the closest relationship to the patient compared to all health care professionals. They communicate daily with patients, know their problems, emotions, understand the social context and values. Furthermore, nurses execute the end-of-life-decisions, by, for example, not calling the rescue team. Therefore, it is very important, that nurses reflect and create actively their role in the ethical decision making process. They have to know which end-of-life-decisions are available and legal in the country where they work. Furthermore, they need knowledge in nursing ethics and ethical frame conditions of their organisations. Nurses have to become part of the ethical-decision-making; especially, if discussing ethical problem with the help of decision-making-models becomes routine because this has a vital impact on the daily nursing practise. Then nurses get used to reflect their acts, the values and principles laying behind and to involve the perspectives, values and norms of other individuals. If decision-making is consciously trained, it has a positive impact on situations, where reflection isn’t possible. (Arndt, 2007) Literature: Arndt, Marianne (2007): Ethik denken. Maßstäbe zum Handeln in der Pflege. Stuttgart: Thieme Verlag, 2. Unveränderte Auflage. Bundeskanzleramt (2015): Sterben in Würde. Empfehlungen zur Begleitung und Betreuung von Menschen am Lebensende und damit verbundene Fragestellungen. Stellungnahme der Bioethikkommission. Gastmans, Chris & Vanlaere, Linus (2005): Cirkels van zorg. Ethisch omgaan met ouderen. Leuven: Ten Have. Körtner, Ulrich (2012): Grundkurs Pflegeethik. Wien: Facultas Verlag, 2. Auflage. Ruppert Sabine; Heindl Patrik & Kozon Vlastimil (2012): Rolle der Pflege bei ethischen Entscheidungen. In: Imago Hominis 19 (2), S. 97-105. Steinkamp, Norbert (2012): Methoden ethischer Entscheidungsfindung im Pflegealltag. In: Monteverde Settimio (Hrsg.): Handbuch Pflegeethik. Ethisch denken und handeln in den Praxisfeldern der Pflege. Stuttgart: W. Kohlhammer Verlag, S. 175-192. Valentin, Andreas; Druml, Wilfred & Steltzer, Heinz (2004): Konsensuspapier der Intensivmedizinischen Gesellschaften Österreichs (2004): Empfehlungen zum Thema Therapiebegrenzung und -beendigung an Intensivstationen. In: Wiener Klinische Wochenschrift, 116/21-22: 763-767. Van der Arend, Arie & Gastmans, Chris (2009): Ethisch zorg verlenen. Handboek voor de verpleegkundige beroepen. Baarn: Hbuitgevers, 4. korrigierte Druck, 5. Auflage. Vanlaere, Linus & Gastmans, Chris (2008): Een goed gesprek voor een zo goed mogelijke zorg. Een zorgethische en personalistische overlegmethode. In: Tijdschrift voor Gezondheitdszorg en ethiek 18(2), S. 45-49. Zentrale Ethikkommission bei der Bundesärztekammer (2006): Ethikberatung in der klinischen Medizin. Deutsches Ärzteblatt 103 (24): A1703-1707.

Abstract not provided

Abstract:
Background Malignant pleural mesothelioma (MPM) is an aggressive cancer of the lining of the chest wall and lung, its aetiology lies in asbestos exposure. With over 2,500 people diagnosed each year, the UK has the highest incidence of mesothelioma in the world. Chemotherapy is an established treatment for MPM but response rates are variable, evidence is lacking in new drug therapies and mortality remains high (in the UK half of patients die within 8.5 months of diagnosis) (Maggioni 2016, HSCIC 2015). Surgery is therefore an important option. Very little robust, randomised controlled trial evidence (RCT) exists regarding surgical interventions for mesothelioma and many studies are observational (Cao et al 2014). This has prompted global variations in surgical approaches (Mclean 2013). Extended Pleurectomy Decortication (EPD) is a surgery for patients considered to have resectable MPM. EPD involves the removal of the lining of the chest wall, lining of the lung, with the sac of the heart and / or diaphragm (as required to achieve complete tumour removal) but leaving the lung in-situ. However, evidence on survival or symptom improvement benefits of this surgery is limited (Cao et al 2014, Teh et al 2011). Challenges in surgical research are the lack of clinical trials and few patients choosing to enter RCTs for surgery (Treasure & Morton, 2012, Horton 1996). Potential explanations for this include restrictive trial regulation, patients declining randomisation, and difficulties in recruitment practice such as presenting trial arm options neutrally (Treasure & Morton 2012). The Mesothelioma and Radical Surgery 2 (MARS 2) Trial, a UK based study, will evaluate whether EPD can improve the length and / or quality of life in patients with surgically treatable disease and its cost-effectiveness. It will randomise participants to chemotherapy or chemotherapy plus surgery. The feasibility stage has demonstrated the ability to recruit and randomise to this study and the plan is to proceed to full trial. This paper presents findings from a nested qualitative patient experience sub-study within MARS 2 that investigated patient experience of the study interventions. It more specifically identifies the support and information needs for people regarding i) the interventions (surgery and chemotherapy) and ii) trial recruitment, consent and participation. This paper focuses on the findings related to support needs of the trial interventions. A summary of results will be provided along with reflections on the implications for future practice. Methods An in-depth longitudinal qualitative study with interviews of 16 participants randomised to chemotherapy (n=8) and chemotherapy + surgery (n=8). Interviews were conducted after randomisation (but before surgery in the surgical cohort). Surgical patients had an additional interview post-surgery. Framework analysis methods were used (Ritchie and Lewis, 2014). Follow-up interviews were at 6 and 12 months post-randomisation. This paper presents findings up to and including the 6 months follow-up. Results Participants reported being well informed about their illness, but had struggled to absorb and understand the extent of information delivered at diagnosis. This was influenced by the range of significant subjects that were covered in a number of consultations with different healthcare staff providing distinct specialist services. The topics discussed included diagnostic information about mesothelioma, treatment options and consequences, trials processes and logistics, and legal and financial information regarding classification of MPM as an industrial disease. Despite feeling well informed about their treatment some participants reported not being prepared for the full extent of the problems they experienced. Both chemotherapy and surgery were challenging treatments although they were associated with different physical effects. Adverse consequences of treatment were described including neutropenic sepsis and dehydration post chemotherapy, and bleeding, prolonged pneumothorax and infection post-surgery. For most participants pain and breathlessness were experienced post-surgery while nausea, anorexia, taste changes and constipation were associated with chemotherapy. Fatigue that impacted on daily living was experienced by both groups. Interventions to manage the consequences of treatment were recounted; some had been recommended by healthcare staff while others had been developed by patients from their own initiative. Participants reported struggling to cope with the effect of treatment whilst trying to deal with the broader context of coming to terms with their illness. Uncertainty was expressed in relation to treatment plans (exacerbated by the logistics surrounding participation in a clinical trial), severity and duration of side effects, rehabilitation and recovery and treatment outcomes. Participants employed a number of strategies to help with coping. These included ‘playing things down’, ‘weighing the balance’, ‘managing expectations’, ‘taking control’ ‘manning up’ and ‘trust in the doctor and/or treatment’. Many of these strategies facilitated staying positive, maintaining hope and finding comfort which was important to participants. Family members played a key role in coping. A diverse range of healthcare staff provided information, advice and practical interventions across the care pathway from community, surgical, respiratory and oncology services. Discussion Patient’s perspectives on the experience of receiving radical surgery and/or chemotherapy for mesothelioma were identified by the study. This provided valuable insights into their impact on patient’s feelings about their illness and treatment and how they coped with the challenges they were presented with. Multiple sources of uncertainty were expressed by participants. The contribution of healthcare staff to supporting coping and providing information and advice was appraised positively by participants. However, we identified that fragmentation could occur due to the diverse services involved in providing care with no single point of contact or co-ordination. Conclusion Understanding the patient’s perspective of the challenges associated with treatment, alongside their strategies for coping, provides insights for the services that can support patients undergoing arduous treatments for mesothelioma. The study reveals ways to facilitate strategies to help patients manage the condition, as well as treatment side-effects. Interventions to reduce uncertainty have been identified as a priority for service improvement.

Abstract:
Lung cancer is the commonest cancer worldwide with 1.6 million people diagnosed each year. People with lung cancer experience a high level of supportive care needs and many of these needs are unmet. Systematic supportive care is therefore vital in this patient group. Patient Reported Outcome Measures (PROMs) can be used to identify the supportive care needs of people with lung cancer and the collection of PROMs data is reported to have a number of positive effects on patient outcomes. Enhancing the utility of PROMs within clinical practice is the use of health technologies that have the ability to collect PROM data remotely from patients in their own homes and send this information in ‘real time’ immediately to relevant health/social care professionals for subsequent intervention. The Advanced Symptom Management System is one of the most evolved remote patient monitoring systems in cancer care. This presentation will initially focus on remote patient monitoring within the context of lung cancer before considering the implications for the future and the ultimate vision of connected health for all.

Abstract:
Introduction Systemic therapy (ST) with chemotherapy (Cht), targeted agents or immunotherapy (IT) represents the mainstay therapy for patients with advanced lung cancer; while adjuvant systemic therapy is recommended in a majority of patients with operable and locally advanced disease. The goal of ST is to prolong life without compromising quality of life (QoL). Despite the ability of ST to prolong life or even cure patients, QoL and life span might be compromised due treatment toxicity. In addition, uncontrolled adverse events (AEs) might lead to treatment interruption or discontinuation. Therefore, effective management of adverse events of anti-cancer drugs, the so-called “supportive care to systemic therapy” is extremely important for a true benefit, i.e. treatment effectiveness in a routine practice. During the last decade several improvements in prevention, treatment and amelioration of ST AEs been achieved. To implement them in everyday clinic practice a good understanding of adverse events, supportive care measures and professional skills of all team members are needed. Registered nurses, specialized in the oncology, the so called “oncology nurses” are key providers of supportive care in everyday clinical practice. Supportive care for prevention and treatment of adverse events Chemotherapy-induced nausea and vomiting (CINV) has been a priority in the supportive care of cancer patients ever since the first use of Cht (1). The introduction of 5-HT3 and NK1 antagonists into anti-emetic therapy resulted in much better control of CINV in lung cancer patients receiving highly emetogenic, platinum-based therapy. With proper use of available drugs complete control of vomiting could be achieved in up to 90% of these patients. However, despite the efficacy of new anti-emetic therapies a proper us of anti-emetics and other preventive measures are vital. Chemotherapy-induced neutropenia with febrile neutropenia (FN) as its ultimate and most serious complication are often observed in patients receiving Cht. The risk of FN can be predicted by assessing patient characteristics and mylotoxicity of the Cht regimen; and granulocyte-colony-stimulating factors (G-CSF) can be used to prevent it (2). Even thought, most of the regimens for lung cancer do not classify to high, i.e. more than 20% risk of febrile neutropenia, the primary prophylaxis with G-CSF is often necessary due to high comorbidity index, poor PS or extensive disease often present in lung cancer patients. In case of FN, a risk-base approach provided by MASCC helps us to decide which patients need hospitalization and which can be treated by antimicrobial therapy at home (3). Oral mucositis and diarrhea related to mucosal damage are frequent complications of Cht as well as targeted therapy with TKIs that can significantly affect patient’s QoL and the ability to deliver full doses and complete therapy. Oral care protocols are essential components in prevention and treatment of stomatitis, while intensive local therapy protocols with antibiotics, anesthetics and/or corticosteroids help to ameliorative symptoms (4). Diarrhea is quite common in lung cancer patients receiving Cht with an even higher occurrence in patients treated with TKIs (5). It could be life threatening in elderly, fragile patients and in patients with concurrent neutropenia, thus requiring a rapid and effective control. When dietary strategy does not work, or when patients present with severe grade 3/4 diarrhea pharmacologic intervention with loperamide or even somatostatin analogues should be initiated quickly. Skin changes (rash, dry skin, paronychia) are the most frequent AEs associated with targeted therapy for lung cancer next to diarrhea. Even though, they are usually mild or moderate they hava negative impact on patient’s QoL and might lead to dose modifications or even discontinuation. Prophylactic measures with regular use of moisturizing products, sunshine protection and careful skin hygiene are necessary. In case of severe but still localized changes topical corticosteroids/antibiotics are indicated while a severe and prolonged toxicity usually requires TKIs dose interruptions (6). Fatigue is a common symptom reported in up to 80% of LC patients. In most cases it is impossible to distinguish to what extend it is the adverse event of ST and to what of disease. It is increasingly reported in patients receiving targeted therapy or immunotherapy, and major improvements in recognition and treatment of fatigue have been achieved recently (7). Immunotherapy with checkpoint inhibitors (CPIs) represents a novel approach. By breaking of immune self-tolerance it might lead to autoimmune/inflammatory adverse events, designated as immune-related adverse events (irAEs), mainly including rash, diarrhea, hepatitis and endocrinopathies (8). Although most of irAEs are of low grade, some of them progress rapidly and prompt medical attention with treatment interruption and the administration of glucocorticoids is critical. Implications for nursing Oncology nurses should have in-depth knowledge on adverse events of systemic therapy and must be familiar with the supportive care protocols. Nursing interventions for prevention and treatment of particular adverse events are presented in Table 1. Oncology nurses play a key role in continuous education of patients, their families and caregivers on adverse events. They are valuable members of the multidisciplinary team performing ongoing assessment of AEs and monitoring of patients and actively discussing potential solutions and improvements with other team members, thus providing a high-quality patient-centered care. Figure 1

Abstract:
Abstract – IASLC – 2016 Vienna, Austria Chronicity is a word that over the past few years has been utilized when talking about lung cancer treatments. From the developments of the TKIs in the early 2000’s to the approval of immunotherapy for lung cancer in 2015, we are seeing that progression free survival and in some instances overall survival continues to be on the rise. So what does this mean for the medical oncology community? Patients can be on therapies longer than a year and sometimes for several years. We now as providers face the challenge of becoming experts in the management of long-term toxicity of these agents. Side effects of the targeted and immunotherapy drugs are not as predictable as their chemotherapy predecessors, and we are now dealing onset times ranging from days to years after beginning therapy. Immunotherapy drugs are the newest treatment craze and rightfully so, as we have seen documented 12 month overall survival in both non-squamous and squamous cell carcinoma for some of these agents and even up to 24 months for some patients. Although this has brought optimism to both providers and patients alike, it has also brought forth a multitude of side effects that remind us that we are still novices in this field and necessitate the collaboration with our non-oncologic colleagues as some of these side effects can be life-long. This lecture will review the mechanism of action of the immunotherapy agents as well as review those that are currently available for NSCLC with review of the data leading to their approval and the current and potential future challenges that lie ahead.

Abstract:
With the emergence of immunotherapy in lung cancer, patients now have access to treatments that have the potential to improve prognosis. Patients diagnosed with advanced non-small cell lung cancer (NSCLC) (either squamous or non-squamous) have previously had limited treatment options. With the emergence of new drugs, particularly in the immune-oncology setting, this is now changing. Recent clinical trial evidence demonstrates that compared with docetaxel, patients who received Nivolumab or Pembrolizamab had better overall survival and also significantly fewer Grade 3-4 adverse events (AEs). However the nursing experience of caring for lung cancer patients on an immunotherapy remains quite limited. Up to recent times immunotherapy drugs were limited to the clinical trial setting or early patient access schemes. Often patients on clinical trials are managed and monitored by research nurses which can further limit the experience for Lung Cancer Clinical Nurse Specialists caring for patients on immunotherapy. The two main clinical trials for immunotherapy in the UK were CHECKMATE (Nivolumab) and KEYTRUDA (Pembrolizamab). The aim of this presentation is to look at two patient case studies and review their experience of taking an immunotherapy. The presentation will focus on how immunotherapy has impacted on their lung cancer and also on their life. As part of the patient case studies there will be a focus on the nursing role in supporting and caring for patients on immunotherapy in a safe and effective manner. The presentation will examine the main adverse event profiles of immunotherapy and how these differ to chemotherapy. The presentation will open with a brief synopsis of the mode of action of immunotherapy which is a 2 minute film. The main focus of the presentation however, will be on the patient experience and the nurses’ role. Currently in the UK there is a scarcity of information available to oncology nurses on the nursing care of patients on immune-oncology treatments. However, there are many transferable skills which can be utilised when caring and supporting patients and their carers who either about to commence on immune-oncology. According to Reiger (2003) oncology nurses have a better opportunity than any other member of the healthcare team to develop the required rapport for effective educational pre-treatment consultations with both the patient and the carer. With regards to lung cancer clinical nurse specialists this rapport is often developed from the point of meeting the patient and carer at diagnosis and then supporting them through first line treatment and beyond to follow up. Often oncology nurses will build a rapport with patients when they attend to undergo treatment and are often a point of contact for patients to report side effects to. Including the patient’s carer in pre-treatment consultations and at key points in the patient pathway is very important. Often patients will be receive a lot of information about their diagnosis and proposed treatment plans and this can be very overwhelming (Malton 2002). Having the carer present means that they can ask questions about treatment side effects, how long the intended benefit of the treatment is and how the patient will be monitored during treatment. The pre-treatment consultation should be undertaken separately to the consent to treatment appointment to allow both the patient and the carer to digest information and write down any questions about the treatment they may have. In the current setting patient information for Nivolumab is under design meaning there may be limited information available to give the patient. There are patient alert cards which patients can keep in their wallets which detail the main side effects of Nivolumab. However, it is also important the nurse undertaking the pre-treatment consultation has a good understanding of Nivolumab, how it works and the potential side effects to monitor for so that they can counsel the patient and their carer accordingly and be able to answer any questions they may have. A clear and concise approach should be used in the pre-treatment consultation with key communication skills of planning, preparation and delivering the message, listening and questioning skills should also be implemented (Wiffen 2007). References. Malton S (2012) How to counsel cancer patients about their oral chemotherapy. Clinical Pharmacist 4: 171 Wiffen P, Mitchell M, Snelling M, Stoner N (2007) Oxford Handbook of Clinical Pharmacy. 1st edn. Oxford University Press, Oxford Rieger P, Yarbro C (2003) Role of the oncology nurse. In: Cancer Medicine. 6th edn. Kufe DW, Pollock RE, Weichselbaum RR, eds. BC Decker, Hamilton

Abstract:
Where Are We With TKI Toxicities? (Extended Abstract) Thoracic oncology nursing is now entering over 10 years of experience with managing tyrosine kinase inhibitor (TKI) toxicities, most notably, epidermal growth factor receptor (EGFR) inhibitor associated rash. The three approved EGFR inhibitors used to treat non-small cell lung cancer (NSCLC) are afatinib, erlotinib, and gefitinib. Most recently, the drug Osimertinib, for EGFR mutation resistance known as T790M, has now been approved for use. Grading of the EGFRI rash has been difficult due to its inconsistency in comparison to non-EGFRI rashes in the general medical community and other oncologic rashes. Consensus guidelines for the management of EGFR inhibitor associated rash have been produced and disseminated in the oncology community.[1,2] There is a correlation between EGFRI rash and overall survival in NSCLC patients, making it imperative to keep patients with rash on the EGFRI therapy.[3,4] It remains a challenge for oncology nurses to understand and manage this sometimes severe rash (see figure 1). Figure 1. Other cutaneous toxicities such as scalp rash, paronychia, hypertrichosis- namely trichomegaly (see figure 2), fissuring, pruritis, and xerosis have all been reported. The Multinational Association for the Supportive Care in Cancer (MASCC) has produced recommendations for these toxicities as well.[2] While they are often a minor annoyance, they can sometimes also become severe and cause dose reductions and a significant impact on activities of daily living (ADL’s). Identification, prevention, and management are important tasks for oncology nurses to master to allow patients to remain on therapy. Figure 2. Other classes of TKI toxicities include the Anaplastic Leukemia Kinase (ALK) inhibitors, where there are currently 3 drugs approved for use, alectinib, ceritinib, and crizotinib. Each of the ALK inhibitors carries different yet important toxicities, ranging from nausea/vomiting, diarrhea, edema, bradycardia, pneumonitis, myalgias with elevated CPK levels, and hepatotoxicity. Several other TKI’s are in development for potential use in lung cancer, such as HER2 inhibitors, BRAF inhibitors, and drugs targeting pathways dealing with RET, MET and KRAS (see table 1).[5-7]

BRAF mutations	4% NSCLC Most common is V600E Drugs in trials: dabrafenib, vemurafenib, dasatinib,
RET rearrangements	1-2% NSCLC Highly associated with young, never-smokers Drugs in trials: vandetanib, cabozantinib, sunitinib, ponatinib
MET amplification	Drugs in trials: crizotinib, tivantinib, onartuzumab, MET inhibitors
HER2 mutations	Drugs in trials: trastuzumab, afatinib, dacomitinib, neratinib
KRAS mutations	25-30% NSCLC, most common mutation MEK, PI3K, FAK inhibitors

It is important for thoracic oncology nurses to have a firm understanding of these drugs and their toxicities. Management strategies must be tailored to the patient’s symptoms and side effects, as well as to the specific drug and dosage. References: 1. Burtness B, Anadkat M, Basti S, et al (2009). NCCN task force report: management of dermatologic and other toxicities associated with EGFR inhibition in patients with cancer. JNCCN, 7(suppl 1):S5-S21. Available at http://www.nccn.org/JNCCN/PDF/2009_Derm_Tox_TF.pdf 2. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al (2011). Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatologic toxicities. Support Care Cancer, 19(8):1079-1095. DOI:10.1007/s00520-011-1197-6 3. Lee SM, Khan I, Upadhayay S, et al (2012). First-line erlotinib in patients with advanced non-small-cell lung cancer unsuitable for chemotherapy (TOPICAL): a double-blind, placebo-controlled, phase 3 trial. Lancet Oncol, 13(11):1161-1170. DOI:10.1016/S1470=2045(12)70412-6 4. Liu H, Wu Y, Lv T, et al (2013). Skin rash could predict the response to EGFR tyrosine kinase inhibitor and the prognosis for patients with non-small cell lung cancer: a systematic review and meta-analysis. PLOS One. DOI:10.1371/journal.pone.0055128 5. Cardarella S, Ogino A, Nishino M, et al. (2013). Clinical, pathologic, and biologic features associated with BRAF mutations in non-small cell lung cancer. Clin Cancer Res. 2013; 19:4532-4540. 6. Tsuta K, Khono T, Yoshida A, et al. (2014). RET-rearranged non-small-cell lung carcinoma: a clinicopathological and molecular analysis. Br J Cancer. 110:1571-1578. 7. Awad MM, Oxnard GR, Jackman DM, et al. (2016). MET Exon 14 mutations in Non-small-cell lung cancer are associated with advanced age and stage dependent MET genomic amplification and c-MET overexpression. J Clin Oncol. 34(7):721-30.

Abstract:
Use of Inspiratory Muscle Training (IMT) in Managing Dyspnoea in Lung Cancer Patients Lung cancer, the most common cause of cancer-related death in men and women, is responsible for 1.3 million deaths worldwide annually. Lung cancer (LC) patients face many symptoms throughout the cancer trajectory and these often co-occur. Among the most prevalent (ranging from 21–90%), burdening and debilating symptoms that patients face is dyspnoea. Although this symptom tends to become more frequent and persistent towards end-of-life, evidence show that even in early stage NSCLC patients who are most likely to be cured may also be faced with debilitating dyspnoea that results in poor QOL during survivorship (Sarna et al 2008). Dyspnoea in the setting of lung cancer has a complex aetiology that includes: direct involvement of lung tissue by cancer, indirect respiratory complications related to the cancer, treatment related complications (fibrosis secondary to chemotherapy or radiation), respiratory co-morbidities (pulmonary embolism) and other co-morbid conditions (i.e. COPD)(Kvale et al 2007). Due to its complex aetiology, dyspnoea also has a multimodal management strategy including both pharmacological and non-pharmacological interventions (Kloke & Cherny 2015). Pharmacological management options include bronchodilators, corticosteroids, anxiolytics, antidepressants, opiods and oxygen (Ferrell et al 2011; Kloke & Cherny 2015). The non-pharmacological interventions include patient’s education on measures for ameliorating the symptom, such as opening windows, using small ventilators, adequate positioning, respiratory training and relaxation techniques (Galbraith et al 2010; Molassiotis et al 2015). A non-pharmacological intervention that has been widely used for the management of respiratory symptoms in asthma and COPD but not lung cancer is Inspiratory Muscle Training (IMT). This method can reduce dyspnoea mainly through two distinct ways. Firstly, by strengthening the inspiratory muscles therefore lessening the effort during a given task (dyspnoea) and secondly by providing a means for controlled breathing. An improved inspiratory muscle strength and endurance can lead to the better management of dyspnoea and therefore facilitate the increase in the level of activity and improving the quality of life for patients. Despite the wealth of data on the effect of IMT on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adults with COPD, there are no available data for lung cancer patients. Whilst the literature shows that COPD and lung cancer are correlated (Sekine et al 2012), this is not sufficient to advocate towards the use of IMT in lung cancer patients experiencing dyspnoea. Despite the scarcity of evidence, the fact that both COPD and lung cancer patients face many common problems such as increased resistance to airflow, air trapping and hyperventilation of the lung , increases the likelihood that IMT can also have a positive effect on lung cancer patients’ dyspnoea. Aim This randomised study aimed to assess the feasibility and effectiveness of inspiratory muscle training in patients with lung cancer regarding their dyspnoea, psychological distress and quality of life. Design The trial is a two-arm, non-blinded, randomised controlled, proof-of-principle study. Patients were randomly assigned to IMT or a control group. The IMT group received standard care and additionally included the intervention with home follow-up every month for 3 months. Patients were recruited from the outpatients’ clinics of two large cancer centres in the UK and one in Cyprus. Participants were eligible if they a) were adults with histological diagnosis of primary LC or mesothelioma; b) had refractory dyspnoea not responding to current treatment for the past 2 weeks (breathlessness daily for 3 months at rest or on minimal exertion where contributing causes have been treated maximally); c) expected prognosis of >3 months as judged by the clinicians and d) had oxygen saturation above 85 % at rest. Patients were excluded if: they suffered from unstable COPD with frequent or acute exacerbations, had rapidly worsening dyspnoea requiring urgent medical intervention, they received palliative radiotherapy to the chest received within 4 weeks or chemotherapy within 2 weeks, they were experiencing intractable cough, and those having unstable angina or clinically significant pleural effusion needing drainage. Intervention A pressure threshold device was used to deliver IMT, which controls a constant inspiratory pressure training load that is maintained unless the patient drastically alters his/her breathing pattern. Based on the literature on COPD patients, the intervention protocol included five sessions weekly for 12 weeks for 30 mins/day, divided over two sessions (the actual intervention had duration of 3-5 min for each session and progressively the time was increased to 30mins/day). The IMT resistance level was set to a low level (baseline) that allowed the patient to inhale comfortably. Progressively, the resistance level was increased according to the patient’s performance. Outcome measures Outcome measures were completed at baseline and monthly for 3 months, and included: physiological parameters (FEV1,FVC); perceived severity of breathlessness using six 10-point NRS; modified Borg Scale; quality of life using the short form Chronic Respiratory Disease Questionnaire; Hospital Anxiety and Depression Scale, and safety. Results The final sample included 46 patients (M=37, F=9) at a mean age of 69.5 years old and a mean of 16 months post-diagnosis mainly with NSCLC and advanced disease (70%). Statistical and clinically important differences were seen with regard to distress from breathlessness (p=0.03), ability to cope with breathlessness (p=0.01), satisfaction with breathlessness management (p=0.001), fatigue (p=0.005), emotional function (p=0.011), breathlessness mastery (p=0.015) and depression (p=0.028). Changes were more evident in the 3-month assessment where the effect of the intervention came to its peak. Discussion This trial showed that the IMT is feasible and potentially effective in patients with lung cancer. A larger trial will provide more concrete conclusions on the usefulness of IMT in the management of dyspnoea in lung cancer patients with relatively stable disease, relatively higher performance status and life expectancy of >3 months. However, those patients with acute or severe dyspnoea should be treated according to established protocols rather than IMT. References Sarna L, Cooley ME, Brown JK, Chernecky C, Elashoff D, Kotlerman J (2008). Symptom Severity 1 to 4 Months After Thoracotomy for Lung Cancer. Am J Crit Care; 17(5):455–467. Simon ST, Müller-Busch C, Bausewein C (2011). Symptom management of pain and breathlessness. Internist (Berl); 52: 28, 30–35. Galbraith S, Fagan P, Perkins P et al (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage; 39: 831–838 Kloke M & N. Cherny N (2015). Treatment of dyspnoea in advanced cancer patients: ESMO Clinical Practice Guidelines. Annals of Oncology 26 (Supplement 5): v169–v173, 2015 doi:10.1093/annonc/mdv306. Kvale PA, Selecky PA, Prakash UB (2007). Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition) Chest; 132(3 Suppl):368S–403S Ferrell B, Koczywas M, Grannis F, Harrington A. (2011) Palliative Care in Lung Cancer. Surg Clin North Am. 91(2): 403–ix. Molassiotis A, Charalambous A, Taylor P, Stamataki Z, Summers, Y (2015). The effect of resistance inspiratory muscle training in the management of breathlessness in patients with thoracic malignancies: a feasibility randomised trial. Support Care Cancer, 23:1637–1645.

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Abstract:
In this presentation some of the existing beliefs and ideas concerning survivorship in the context of a diagnosis of lung cancer will be briefly considered. The changing face of cancer in the 21[st] century will be highlighted using data from the United Kingdom (UK) as an exemplar to show survival patterns. Consideration will then be given to the commonalities of the concerns of people with lung cancer and people with other cancers common in the developed world where survivorship services currently prioritised. Finally a challenge will be offered to the lung caner community for the coming year.

Background:
The advanced practice nurse in lung cancer (APNLC) has shown to play a key role in meeting the complex supportive care needs of patients with lung cancer. Nurses working in novel advanced practice nursing (APN) roles encounter a range of barriers to effective practice particularly in countries without an existing regulation of these novel roles. Being accepted by patients and healthcare professionals (HCPs) is fundamental for successful role implementation. The University Hospital of Lausanne (CHUV) was the first comprehensive cancer center in Switzerland to integrate an APNLC into the specialized multidisciplinary team (MDT) of the thoracic cancer center. To overcome barriers to implementing the APNLC role and promote its long-term viability, we aimed to explore the acceptability of this novel APNLC role from the perspective of the MDT and the patients cared for by the APNLC.

Methods:
This qualitative study was part of a larger implementation study (ClinicalTrials.gov, Number: NCT02362204). During summer 2015, we conducted focus groups and semi-structured interviews in the thoracic cancer center of CHUV. Participants were purposefully sampled and included patients with lung cancer (n=4) and HCPs from the MDT [physicians (n=6), nurses (n=5)], a social worker and the APNLC. Semi-structured individual interviews were conducted to examine the perspectives of patients and the APNLC alike. Focus groups were employed to gather perspectives from the MDT. Data were analyzed using thematic content analysis.

Results:
Three main themes emerged describing the acceptability of the APNLC: “role identification”, “role-specific contribution” and “flexible service provision”. Physicians and patients identified the specific APNLC role within the MDT. In particular, they valued specific contributions to continuity of care, psychosocial support and self-management of symptoms. Nurses perceived the APNLC role as overlapping with the traditional oncology nurse role. They were concerned about losing part of their traditional role. Flexibility in service provision was seen as strength of the APNLC role yet also posed organizational challenges related to the work-load.

Conclusion:
The new APNLC role appears to be well-accepted by patients and physicians. Barriers identified during the implementation of the APNLC role were primarily related to intra-professional and organizational challenges. The intra-professional role tension could challenge effective role implementation. To maximize the acceptability of a new APNLC role - particularly in countries that are in an early stage of APN role development - we recommend formalizing nursing role expectations, providing appropriate support/resources and promoting a national plan for APN accreditation and certification.

Background:
Immunotherapy is rapidly becoming recognized as the fourth pillar of treatment for lung cancer. As an academic center of excellence, our staff have developed expertise with immune-oncology (I-O) agents though clinical trials. Currently two agents (Nivolumab and Pembrolizumab) have been FDA-approved for the treatment of lung cancer. Variability existed in patient assessment, patient education and staff education regarding how to identify and manage immune-related adverse events (IrAEs).

Methods:
Initial evaluation consisted of an online staff survey and interviews to assess the educational materials available for instruction of both patients and staff. A review of existing educational materials was conducted to determine the breadth of information available as well as knowledge gaps. The evaluation revealed a lack of standardization, with inconsistency in the educational messages being delivered. A focused working group including CNS, APRNs, Pharmacists and RNs from the academic hub and broader community care center network was convened with the goal of developing educational platforms for nursing staff as well as patients. Bringing stakeholders together was felt to be important to increase buy-in across the spectrum of care locations, as well as to ensure that the program was effective and appropriate for all sites. Program components included the following: -Education for staff to better identify and manage IrAEs -Development of an electronic nursing flow-sheet to standardize patient assessment and document IrAEs in the lung cancer population. -Automatic notification through the EMR to alert staff in non-oncology settings regarding I-O patients. -Development of a forum for patient education to better understand I-O therapy and how to identify and manage IrAEs. - Development of lung cancer specific telephone triage guidelines

Results:
The outcomes of implementing the I-O program include increased patient participation in educational forums and improved patient satisfaction metrics. Incorporation of the I-O assessment flow-sheet and telephone triage guidelines will improve staff competency, as well as standardize documentation and monitoring of IrAEs. These metrics will allow for more accurate tracking of IrAes throughout the course of treatment.

Conclusion:
The I-O Integrated Education and Assessment Program standardizes practice across all oncology care delivery sites within our network. This program allows patients to receive the highest level of care at convenient regional locations closer to home, with the goal of maintaining patient safety while maximizing the benefit they may receive from I-O therapies. An integrated

Background:
A diagnosis of advanced lung cancer inevitably results in deterioration in both health and functional status. This threatens a person’s independence and dignity and can be a burden to their family and carers. The lung cancer nursing team at Oxford identified a lack of timely therapy provision for their patient group and sought to improve this, concluding that having an occupational therapist (OT) in the team would significantly expand/diversify the service that could be offered to patients. Lung cancer therapy goals were identified as a) working with patients and carers to anticipate functional need rather than waiting for a crisis to occur b) providing a rapid, flexible and responsive service to those with existing needs and c) working in a keyworker role outside of traditional therapy expertise supporting patients at diagnosis, making treatment decisions and providing information .

Methods:
Funding was obtained from Macmillan Cancer Support for a three year project looking at delivering a new model of care. An Advanced Therapist Practitioner (ATP) with an OT background was recruited and embedded into the nursing team full time. Referrals were received from all members of the lung cancer MDT, the inpatient team, primary and palliative care. Interventions included home assessment, outpatient clinic review, breathlessness and anxiety management, provision of aids, support, education and advice.

Results:
Data was gathered from a one year period when there were 305 new lung cancer diagnoses. 165 (54%) patients had identified therapy needs. A further 40 (13%) patients were seen by the ATP as part of her generic keyworker role. 205 referrals resulted in a total of 1005 interventions averaging 5 per person. Interventions were allocated to three levels ranging from simple telephone calls and liaison to complex case management. Average time from referral to first contact with the patient was half a day. The value of the role was measured in three ways: User Feedback Event, Satisfaction Questionnaire and a Stakeholder Questionnaire. Outcomes were overwhelmingly positive.

Conclusion:
Lung cancer patients have high functional needs. An ATP can become an integral part of traditional specialist nursing teams, is able to work in a keyworker capacity and is well accepted and used by the lung cancer MDT. The ATP role provides a strong bridge between primary and secondary care environments and preserves independence and dignity for longer. Evidence from users and stakeholders demonstrated high levels of satisfaction and quality of care.

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Background:
The United Kingdom National Lung Cancer Forum for Nurses Workshop 2015 produced guidance to support Lung Cancer nurse Specialists in developing and evaluating nurse-led clinics. Nurse-led clinics have been in existence for years with little guidance on structure and evaluation. They are safe and effective. Nurses provide individual care that makes a difference to patient outcomes. There is vast evidence available for nurse-led services but significantly less on lung cancer specific services despite a growing body of evidence to support this.

Methods:
A literature search was performed. This included developing a lung cancer nurse-led clinic, evaluation, audit tool and measurement. The initial search found limited number of relevant documents. Therefore the search was widened to include developing general nurse-led services. The NLCFN members were surveyed to evaluate current nurse-led clinics. The questionnaire comprised of eighteen questions incorporating all aspects of nurse-led follow up.

Results:
60% responded, suggesting a high interest in the area. Over half of the respondents ran nurse-led clinics. These included telephone, results, post-surgery, Health & Well being, TKI and breathlessness clinic. However 67% had not evaluated or audited these, 74% didn’t have patient information leaflets and 96% had access to medical cover. The seven most important steps in developing a lung cancer nurse-led clinic are: Aims and Objectives, Planning and Consultation, Multidisciplinary Support, Infrastructure, promoting the nurse-led service, Professional Development and Audit and Evaluation. These formed the basis of this framework.

Conclusion:
NICE (2011), suggests that patients should be offered a “follow-up led by a LCNS” . However, nurse-led clinics are challenging and there are many practical and emotional hurdles to be overcome. This framework supports LCNS’s in developing and evaluating nurse-led clinics . It gives clear guidance to be considered when developing and new service as well as advising on audit/evaluation tools and developing patient information leaflets.

Background:
In the United Kingdom thoracic cancer is mainly diagnosed in an older population, who generally have significant co-morbidities, and advanced stage disease. Due to this, they experiences high levels of disease burden, both physical and psychological, impacting on individuals’ functional independence and quality of life (QoL). The national governing bodies, such as NICE and LCA, recommend that all patients should have access to an Holistic Needs Assessment (HNA) and rehabilitation services. At Guy's And St Thomas' NHS Foundation Trust (GSTFT) we have developed a multi-disciplinary team (MDT), consisting of Dietetics, Occupational Therapy (OT) and Physiotherapy (PT), who are present within the outpatient thoracic oncology clinics and aim to address the rehabilitation and supportive care needs of all patients.

Methods:
All new thoracic oncology patients attending outpatient consultant lead clinics at GSTFT were offered an HNA, in order to identify their individual concerns/needs. The assessments are completed by the MDT and individual intervention plans created. Over a three-month period, January to March 2015, data was collected on patient's diagnosis, treatment offered, treatment intent, symptom concerns, QoL indicators, onward MDT referrals and mortality.

Results:
82 patients completed the assessments, of these 85% reported unmet needs/concerns. The main tumour types seen were Adenocarcinoma, Squamous cell carcinoma, mesothelioma and small cell lung cancer. Of those reporting symptoms the most common were; breathlessness (55%), fatigue (52%), reduced appetite (43%), weight loss (41%), pain (37%), emotions/mood (33%). sleep concerns (33%), and reduced mobility (32%). 69 patients had onward referrals to supportive care services. The most common referrals were; OT (65%), PT (60%), Dietitian (43%), and patient information (38%). 66% of patients were provided with on the spot MDT intervention.

Conclusion:
Providing thoracic oncology patients access to an MDT service on their initial oncology visit, has enabled early identification of the key symptoms this patient group experience, as well as the need for allied health services. This has supported the role of early rehabilitation as being integral to improving patient's level of symptom burden and QoL. Moving forward it would be beneficial to do a comparative study of the symptoms and intervention needs of this patient group over a longitudinal analysis, with the aim of showing the impact of early rehabilitation on patient's QoL, survivorship, and life expectancy.

Background:
Patients with lung cancer (LC) report lower quality of life (QoL) and higher levels of psychological distress compared to other cancer populations (Hewitt et al, 2013). Lung cancer stigma (LCS) may in part explain these findings. Evidence from studies in the Unites States has shown associations between LCS and lower QoL, higher symptom burden and higher levels of anxiety and depression (Cataldo et al, 2013). Whether these associations exist in people diagnosed with LC in the United Kingdom is unknown. Therefore this study explored the prevalence of LCS and its relationship with patient outcomes as well as QoL in a Scottish population.

Methods:
This study was a cross-sectional study. Patients (n=201) diagnosed with LC were recruited by health care professionals at follow-up clinics at four hospitals in Scotland. Participants completed questionnaires to collect demographic data and assess perceived LCS, QoL, symptom severity and level of depression. Clinical data was collected by casenote review. Bivariate correlations were performed to investigate the relationships between stigma, demographics, and patient outcomes. Multiple regression further explored the individual contributions of LCS on symptom burden and quality of life.

Results:
Participants had a mean age of 69 years (range 41-89 years), 46.8% were males, 92.0% were ever smokers, 17.9% current smokers. The mean LCS score was 53.1 (SD=14.1, range 31-124,). There were significant correlations between higher LCS and age (r= -0.28, p<0.001), being a current smoker (r= 0.17, p<0.05), deprivation index (r=0.15, p<0.05) depression (r=0.40, p<0.001), symptom burden (r=2.60, p<0.001), and QoL (r= - 0.52, p<0.001). Multiple regression revealed an overall model that explained 30.6% of the total variance of stigma (F=14.82, p<0.001). Perceived stigma also accounted for significant unique variance in QoL (4.3%, p<0.001) and depression (3.6%, p<0.001) above and beyond that accounted for by relevant variables. No contribution of stigma on symptom burden was found.

Conclusion:
Stigma was correlated with depression, and QoL. Therefore, it is expected that depression and stigma share some of the explanation of variance of QoL. Nevertheless, stigma was found to have a unique contribution on QoL, and on depression. With this in mind, management of patients with LC could determine the patients’ experience of stigma to tailor treatment plans to improve QoL and psychosocial outcomes. Being younger was correlated with higher LCS. This might reflect changed attitudes toward smoking due to changed marketing strategies in the 1960s.

Abstract not provided