Virtual Library

Background
The National Lung Cancer Audit (NLCA) (NHS Information Centre, 2011) reports annually on services provided to 38,000 lung cancer patients in the nited Kingdom (UK). The 2010 NLCA reported that only 58% of lung cancer patients in England and Wales received active treatment (chemotherapy, surgery and radiotherapy), with only 14% of patients receiving surgery. Lung Cancer Nurse Specialists (LCNS) make an important contribution to patient care and patient experience and their input is captured in the audit. The 2010 NLCA revealed a possible association between access to a LCNS and access to treatment: 64% of patients seen by a LCNS received anti-cancer treatment compared to 30% of those who did not (Ford, 2011, The Lancet 2011). The reason for this observation cannot be ascertained from the NCLA data. Thus investigation outside of the audit is required. This study begins that process using case study methodology. The study is funded by a grant from the General Nursing Council Trust. The aims of this study are to explore the role of the LCNS within the lung cancer multi-disciplinary team (MDT), identify ways the LCNS can increase treatment access for people with lung cancer and generaterecommendations for MDTs and for future research.

Methods
A collective case study, comprising four individual LCNS in four different lung cancer MDTs (McDonnell, 2012, Stake 1995). LCNS cases were selected on the basis of variation in access to treatment rates and access to a LCNS according to the NLCA data. The four LCNSs also had different models of working within the MDT and patient pathway. Methods included in-depth individual interviews with the LCNS and clinical lead plus four other MDT members, giving a total interview sample of 24. Observation of practice and documentary analysis were also used. Findings will be tested further in group interviews over the summer.

Results
These findings provide insight into how the LCNS works across the patient pathway to influence access to treatment, while maintaining patient preference as central to practice. The findings are presented here in four themes: practice approaches, people, places and facilitators, with illustrations of how factors combined to increase or decrease access to treatment. Approaches to LCNS practice identified in the study included negotiating, brokering and co-ordinating in order to maximise treatment access and maintain patient focus. The range of people and places the LCNS works with across different disciplines, services and health sectors means they become the lynchpin to clinical treatment decisions. The study indicates how workload, relationships, job security and organisational structures operate as key facilitators to effective treatment decision making

Conclusion
This in-depth qualitative study provides valuable insights into the complex landscape that MDTs operate within and helps to explain why the observed association between seeing a LCNS and access to treatment may occur. The study illustrates the value of qualitative research in understanding quantitative data such as that generated by national registries and audits. Recommendations for MDTs and data capture in the NLCA audit are considered.

Background
The UK National Lung Cancer Forum for Nurses together with the Roy Castle Lung Cancer Foundation have produced a report which aims to showcase the difference Lung Cancer Nurse Specialists (LCNS) make to the lives of patients with lung cancer and their families. Eleven recommendations were made after an examination of peoples experiences of care delivered by LCNSs in addition to LCNSs own accounts of how they help to improve patient outcomes. The recommendations, combined with existing evidence of the positive impact of LCNSs on patient experience from the Cancer Patient Experience Survey and outcomes shown in the National Lung Cancer Audit, builds a compelling picture of the positive value of LCNSs. The report is called Understanding the Value of Lung Cancer Nurse Specialists.

Methods
The National Lung Cancer Audit data was used to gather information about whether patients had been seen by a LCNS and at what point in their pathway. A survey was conducted of patients with lung cancer and their carers with the aim of uncovering people`s experiences of the care delivered by LCNS. A survey of LCNS own accounts of how they help to improve patient outcomes was also undertaken. Information was taken from the Cancer Patient Experience Survey in England to assess the influence that Clinical Nurse Specialists had on the patient`s experience of care. Evidence was analysed from a number of different sources to highlight the potential efficiency savings that LCNS could make due to their role.

Results
Results from the Cancer Patient Experience Survey showed that one of the most important findings being that those patients with access to a CNS gave more positive scores of experience than those without. When considering efficiency savings, one study found that service improvments along the lung cancer pathway led by LCNS could release about 10% of cancer expenditure in the area. The National Lung Cancer Audit revealed that around two thirds of patients seen by a LCNS went on to receive active treatment compared to less than a third who did not see a LCNS who were given active treatment.

Conclusion
The report examines the information made available and the role of the LCNS with the aim of helping to understand that vital contribution they make to the delivery of high quality care and to improved outcomes for patients with lung cancer. The report can be found at http://www.roycastle.org/Resources/Roy%20Castle/Documents/PDF/UnderstandTheValueOfLungCancerNurseSpecialists_V03.pdf

Background
In a recent landmark US study, metastatic NSCLC patients who received palliative care from the time of diagnosis concurrently with standard oncology management reported improvements in quality-of-life, symptom control, reduction in “aggressive therapies” at end-of-life, and a survival advantage compared to those receiving standard oncology management alone. The aim of this qualitative sub-study was to explore Australian health care professionals’ perceptions of early integration of palliative care for patients with incurable lung cancer.

Methods
Members of the lung cancer multi-disciplinary teams of three large metropolitan teaching hospitals in Melbourne were invited to attend a focus group discussion. Data from focus groups were supplemented with interviews from a purposive sample of individual health care providers who were unable to attend the groups. Participants were asked to describe barriers and facilitators to implementation of a model of early integration of palliative care.

Results
Three focus groups and six individual interviews were conducted with 28 health care professionals. Key facilitators and barriers to referral (see table) were grouped into 4 themes: 1. Trust; 2. Care Coordination; 3. Ease of Referral; and 4. Perceived patient/family reaction.

Conclusion
Early involvement of palliative care in patients with incurable lung cancer is acceptable to the majority of treating clinicians. Palliative care services must be embedded into the system, sufficiently resourced and of high quality. For early referral to occur the model ideally involves a physical presence of a palliative care clinician in clinic who is easily accessible for referrals and considered a core team member.

Abstract not provided

Background
Radiotherapy (RT) is a clinically and cost effective modality of treatment for symptom palliation. It plays a significant role in advanced lung cancer, by providing relief from symptoms such as haemoptysis and bone pain, as well as preserving neurological function in patients with brain metastases or spinal cord compression. The standard clinical approach for RT may require multiple attendances for consultation and planning, followed by a waiting period for treatment. However, patients with advanced lung cancer presenting for palliative radiotherapy are often of poor performance status with limited life expectancy. Prompt and streamlined RT is required to improve the experience of care for these patients. The Palliative Radiotherapy Rapid Assessment Clinic (PRRAC) was developed as an innovative and sustainable clinic to align consultation, planning and treatment within a single visit to facilitate efficient access to palliative radiotherapy for patients with advanced lung cancer. The PRRAC aims to i) increase accessibility of palliative RT for symptomatic patients with lung cancer, ii) reduce waiting times and iii) improve patient and referrer satisfaction.

Methods
A retrospective audit of symptomatic patients with lung cancer who received low dose palliative RT from June – November 2012 at Peter Mac, East Melbourne was performed. Patient demographics, dates of initial clinic, planning and RT commencement, and RT dose fractionation schedules were collected. A service model (PRRAC) was developed based on the adaptation of similar clinics in operation in Canada and Brisbane, Australia. The proposed PRRAC will be piloted for 6 months. Eligibility criteria include those patients with symptomatic locally advanced or metastatic lung cancer who require low dose simple RT techniques. Service utilisation and average waiting times will be compared to previous patterns of care. Patient outcomes and surveys of referring physicians will be evaluated prospectively. Overall utilisation of the service will help assess clinical need & sustainability.

Results
The retrospective audit has demonstrated 79 patients with lung cancer who were prescribed low dose palliative RT. The mean age was 70 years and 17% of patients were ECOG status >3. The mean waiting time from initial clinic assessment to planning was 3.6 days (SD 3.7), and from planning to RT commencement was 5.4 days (SD 5.1). 48% of patients were prescribed a single dose of RT. The early results and challenges in developing the prospective PRRAC as a new model of care for patients with lung cancer will be presented.

Conclusion
The PRRAC is expected to improve access of patients to palliative radiotherapy, and shorten waiting time from clinic to RT commencement date with less visits and potentially shorter dose fractionation schedules. It is anticipated that PRRAC will also improve patient and referrer satisfaction. Following successful completion of the project, the PRRAC will be embedded into clinical practice, and extended to other tumour streams.

Background
This study aims to investigate the influence of a geriatric assessment (GA) on cancer treatment decisions in older lung cancer patients (pts). We also studied the changes in functionality during treatment and the occurrence of severe chemotherapy-related toxicity.

Methods
For this analysis, we selected the lung cancer cohort that was part of a larger study on GA in older cancer pts in 6 tumor types in two Belgian university hospitals[1]. Between July 2009 and September 2011, pts aged 70 years or older with a newly diagnosed or progressive lung cancer were evaluated at baseline using a uniform GA including geriatric screening with G8 and the Flemish Triage Risk Screening Tool (fTRST), pain, social data, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), fall history, Mobility-Tiredness Test (MOB-T), Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), Mini Nutritional Assessment (MNA), ECOG-Performance Status (ECOG-PS), Charlson Comorbidity Index (CCI) and poly-pharmacy assessment. GA results were communicated to the treating physician and, after the treatment decision, the physician was interviewed using a predefined questionnaire focusing on unknown geriatric problems revealed by GA and impact on cancer treatment decisions. Between two and three months of follow-up, functionality was reassessed and severe toxicity in pts receiving chemotherapy was recorded.

Results
Seventy three lung cancer pts were included with a median age of 76 years; 82.2% were non-small cell lung cancer (NSCLC) and 74% were stage IV. Treatment was modified from standard according to standard clinical assessment (including age) in 56.1%. GA revealed unknown geriatric problems in 25.8% of cases, leading to a geriatric intervention in 10.6%. 30% of physicians consulted the GA before final treatment decision and in three pts (4%) only this led to a modification of the proposed treatment: dose reduction, no chemotherapy or no radiotherapy. At follow up (n=50), functional decline was observed in 24% and 54% of pts for ADL and IADL, respectively. Grade III-IV toxicity occurred in 14/42 pts treated with chemotherapy (33%), mainly non-haematological (64%).

Conclusion
This analysis indicates that the treatment of older lung cancer pts is often influenced (deviated from standard) by standard clinical assessment and age. Although GA revealed previously unknown information in 25.8% of pts, only a minority of physicians consulted these results before the final cancer treatment decision. There was little impact on geriatric intervention and even less on cancer treatment decision. This discrepancy reveals the need to get physicians treating lung cancer acquainted with GA and geriatric interventions in an attempt to decrease chemotherapy related toxicity and improve quality of care. Further evaluation of GA and geriatric interventions in larger pt groups as well as their implementation in clinical practice is warranted.

Background
Although lung resection still provides the best long-term outcome for lung cancer, it is also associated with a considerable decay in physical and psychosocial health status[1,2]. If not controlled, these symptoms can hamper postsurgical recovery, and lead to unscheduled healthcare use[3]. This study aimed to determine the clinical relevance of and functional requirements for a telerehabilitation (TR) service to support recovery following lung resection.

Methods
A sociotechnical scenario-based design approach was used, characterized by early and systematically involvement of patients and healthcare providers during an iterative design process (figure 1). First, end users’ requirements for the TR service were explored by means of semi-structured interviews. Subsequently a small focus group with healthcare providers from the Netherlands Cancer Institute – Antoni van Leeuwenhoek hospital (NKI-AVL) in Amsterdam was organised to establish requirements for the TR service in more detail. The findings from the interviews and focus group were summarized in a scenario and validated by healthcare professionals from the NKI-AVL. Figure 1

Results
Survivors and professionals expected a TR service to be beneficial for improving quality of current care, and identified three modules that should be included in the TR service: ambulant monitoring of recovery and symptoms, home exercise programs and patient-provider contact. The functional requirements for these three modules and general requirements as reported by the patients and professionals are presented in table 1. The results also indicated that successful implementation of the service will be promoted by structurally embedding the service in existing healthcare processes, and record clearly the specific roles and responsibilities of all involved healthcare professionals. Figure 1

Conclusion
End-users showed positive intention to use a TR service for home-based symptom monitoring and rehabilitation. At this moment, a prototype of the TR service is designed, which will be evaluated this summer in patients and healthcare providers to improve end-users’ acceptance.

Abstract not provided