Effect of time delay on survival in patients with non-small cell lung cancer — A Malaysian study

European Respiratory Society guideline on various aspects of quality in lung cancer care

This European Respiratory Society guideline is dedicated to the provision of good quality recommendations in lung cancer care. All the clinical recommendations contained were based on a comprehensive systematic review and evidence syntheses based on eight PICO (Patients, Intervention, Comparison, Outcomes) questions. The evidence was appraised in compliance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Evidence profiles and the GRADE Evidence to Decision frameworks were used to summarise results and to make the decision-making process transparent. A multidisciplinary Task Force panel of lung cancer experts formulated and consented the clinical recommendations following thorough discussions of the systematic review results. In particular, we have made recommendations relating to the following quality improvement measures deemed applicable to routine lung cancer care: 1) avoidance of delay in the diagnostic and therapeutic period, 2) integration of multidisciplinary teams and multidisciplinary consultations, 3) implementation of and adherence to lung cancer guidelines, 4) benefit of higher institutional/individual volume and advanced specialisation in lung cancer surgery and other procedures, 5) need for pathological confirmation of lesions in patients with pulmonary lesions and suspected lung cancer, and histological subtyping and molecular characterisation for actionable targets or response to treatment of confirmed lung cancers, 6) added value of early integration of palliative care teams or specialists, 7) advantage of integrating specific quality improvement measures, and 8) benefit of using patient decision tools. These recommendations should be reconsidered and updated, as appropriate, as new evidence becomes available.

Influence of timeliness and receipt of first treatment on geographic variation in non-small cell lung cancer mortality

Mortality from non-small cell lung cancer (NSCLC) exhibits substantial geographical disparities. However, there is little evidence on whether this variation could be attributed to patients' clinical characteristics and/or socioeconomic inequalities. This study evaluated the independent and relative contribution of the individual- and area-level risk factors on geographic variation in 2-year all-cause mortality among NSCLC patients. In the Hierarchical-related regression approach, we used the Bayesian spatial multilevel logistic regression model to combine individual- and area-level predictors with outcomes while accounting for geographically structured and unstructured correlation. Individual-level data included 3330 NSCLC cases reported to the Victoria Lung Cancer Registry between 2011 and 2016. Area-level data comprised socioeconomic disadvantage, remoteness and pollution data at the postal area level in Victoria, Australia. With the inclusion of significant individual- and area-level risk factors, timely (≤14 days) first definitive treatment (odds ratio [OR] = 0.73, 95% credible interval [Crl] = 0.56-0.94) and multidisciplinary meetings (MDM) (OR = 0.74, 95% Crl = 0.59-0.93) showed an independent association with a lower likelihood of NSCLC 2-year all-cause mortality. Timely and delayed (>14 days) first nondefinitive treatment, no treatment, advanced clinical stage, smoking, poor performance status, public hospital insurance and area-level deprivation were independently associated with a higher likelihood of 2- and 5-year all-cause mortality. NSCLC's 2-year all-cause mortality exhibited substantial geographic variation, mainly associated with timeliness and receipt of first definitive treatment, no treatment followed by patient prognostic factors with some contribution from area-level deprivation, MDM and public hospital insurance. This study highlights NSCLC patients should receive the first definitive treatment within the recommended 14-days from diagnosis.

Impact of Timing of Lobectomy on Survival for Clinical Stage IA Lung Squamous Cell Carcinoma

BACKGROUND

Because the relationship between the timing of surgery following diagnosis of lung cancer and survival has not been precisely described, guidelines on what constitutes a clinically meaningful delay of resection of early-stage lung cancer do not exist. This study tested the hypothesis that increasing the time between diagnosis and lobectomy for stage IA squamous cell carcinoma (SCC) would be associated with worse survival.

METHODS

The association between timing of lobectomy and survival for patients with clinical stage IA SCC in the National Cancer Data Base (2006-2011) was assessed using multivariable Cox proportional hazards analysis and restricted cubic spline (RCS) functions.

RESULTS

The 5-year overall survival of 4,984 patients who met study inclusion criteria was 58.3% (95% CI, 56.3-60.2). Surgery was performed within 30 days of diagnosis in 1,811 (36%) patients, whereas the median time to surgery was 38 days (interquartile range, 23, 58). In multivariable analysis, patients who had surgery 38 days or more after diagnosis had significantly worse 5-year survival than patients who had surgery earlier (hazard ratio, 1.13 [95% CI, 1.02-1.25]; P = .022). Multivariable RCS analysis demonstrated the hazard ratio associated with time to surgery increased steadily the longer resection was delayed; the threshold time associated with statistically significant worse survival was ∼90 days or greater.

CONCLUSIONS

Longer intervals between diagnosis of early-stage lung SCC and surgery are associated with worse survival. Although factors other than the timing of treatment may contribute to this finding, these results suggest that efforts to minimize delays beyond those needed to perform a complete preoperative evaluation may improve survival.

Does timeliness of care in Non-Small Cell Lung Cancer impact on survival?

OBJECTIVES

To measure time intervals in the management of Non-Small Cell Lung Cancer (NSCLC) patients, identify factors associated with this and evaluate the impact of timeliness of care on survival.

MATERIALS AND METHODS

A retrospective cohort of South Western Sydney (SWS) patients with newly diagnosed NSCLC from 2006 to 2012 was identified from the SWSLHD Clinical Cancer Registry. Time intervals evaluated in days were "Diagnosis to Initial Treatment" and "Referral to Initial Treatment". Treatment included surgery, radiotherapy, systemic therapy and palliative care. Negative binomial regression and Cox regression were used to identify factors associated with timeliness of care and survival respectively.

RESULTS

1926 NSCLC patients were identified of whom 1729 had initial treatment recorded. Initial treatment was palliative care in 35% (n=611), radiotherapy in 29% (n=498), surgery in 18% (n=314) and systemic therapy in 18% (n=306). Median time from diagnosis to treatment was 32days (IQR 15-58). Median time from specialist referral to treatment was 35days for surgery (IQR 21-49), 21days for radiotherapy (IQR 13-32) and 25days (IQR 15-35) for systemic therapy. On multivariable analysis, age between 70 and 79 years, ECOG performance status 0-1, Stage I-III NSCLC and systemic treatment were associated with longer Diagnosis to Treatment: intervals. Diagnosis to Treatment: interval was not associated with mortality in Stage I & II NSCLC. A longer interval was associated with reduced mortality in Stage III (HR 0.99, 95%CI 0.99-1.0, p=0.03) and Stage IV NSCLC (HR=0.99, 95% CI 0.99-0.99, p=0.0008).

CONCLUSIONS

At the population level, longer Diagnosis to Treatment: time intervals were not associated with adverse survival outcomes in NSCLC. However, delays to treatment may impact on other outcomes such as patient's psychological wellbeing and quality of life which were not measured in this study.

Lung Cancer Mortality Among Women in Xuan Wei, China

The identification of spatial clusters of lung cancer mortality can be a useful instrument in detecting locations with high risk of this disease. This study compared 2 methods for identifying spatial clusters of village-level women lung cancer mortality rates in Xuan Wei. One used a local indicator of spatial association to detect which groups of neighboring villages had lung cancer mortality rates that were significantly related to each other. The other was a spatial scan technique that calculated a maximum likelihood ratio of lung cancer deaths relative to the underlying population in order to identify the group of villages with relatively higher risk. As each technique based its cluster detection process on its own criteria, different clusters of villages were identified. However, the overlapping indicated that the 2 methods illustrated different components of the same clusters. These spatial analytic techniques were complementary to each other and can be used jointly rather than separately.

Survival of lung cancer patients in a resource-limited country

AIM

Data on lung cancer survival are lacking in developing countries. Our objectives were to describe the survival of our lung cancer patients and to determine independent prognostic factors affecting survival.

METHOD

All patients diagnosed with lung cancer from August 2007 to August 2010 were recruited from a single referral hospital of the state of Pahang, Malaysia. Detailed demographic data, ECOG (Eastern Cooperation Oncology Group) performance status, stage of disease and treatment were recorded. The date of histology or cytology confirmation was used as the date of entry. Survival time was calculated from the date of entry to the date of death.

RESULTS

One hundred forty-nine patients were included for survival analysis. The median age was 62 years and patients were predominantly males (78%) and smokers (78%). The majority had non-small cell lung cancer (NSCLC) (94%); only six patients (4%) had small cell lung cancer. All patients presented with stage 3 or stage 4 disease. Overall median survival was 18 weeks. "No definitive treatment" and "ECOG 3-4" were the significant independent predictors of death, with the hazard ratios of 2.1 (95% confidence interval [CI] 1.4, 3.0) and 1.6 (95% CI 1.1, 2.3) times, respectively. Among NSCLC patients on treatment, 1- and 2-year survival rates were 27% and 15%, respectively.

CONCLUSION

The majority of lung cancer patients in Pahang presented with advanced disease. No definitive treatment and ECOG 3-4 were independent poor prognostic factors.

Prognostic implications of treatment delays in the surgical resection of lung cancer

The survival of patients with lung cancer remains low in most developed countries, which is largely attributable to the advanced stage of the disease when it presents. It seems obvious that if lung cancer could be found at an earlier stage, the prognosis of patients would be improved. The evidence from the medical literature on this point is conflicting; most studies suggest that delays in diagnosis are not prognostically important. When strategies are in place to expedite the investigation of individuals suspected of having lung cancer, the stage of disease typically shifts toward earlier-stage disease and resection rates increase.