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.

Lung cancer stigma: A concept with consequences for patients

BACKGROUND

Patients with lung cancer (LC) report lower quality of life (QoL) and higher levels of psychological distress compared with other cancer populations. Lung cancer stigma (LCS) may in part explain these findings.

AIM

We investigated the prevalence of patient-perceived lung cancer stigma (LCS) and its relationships to symptom burden/severity, depression, and deficits in health-related quality of life (HR-QoL).

METHODS

In this descriptive, observational, and cross-sectional study, 201 participants were sent questionnaires. These included the Cataldo Lung Cancer Stigma Scale (CLCSS), the Lung Cancer Symptom Scale, the Centre for Epidemiologic Studies-Depression Scale, and the Quality of Life Inventory.

RESULTS

Participants were on average 69 years old, 52% women, 95% ever smokers, and 18.5% current smokers. The mean total CLCSS score was 53.1 (SD = 14.1; range = 31-94). LCS was significantly correlated with younger age (P < .001), greater social deprivation (P < .05), being unemployed (P < .001), depression (P < .001), symptom burden (P < .001), and HR-QoL deficits (P < .001). Symptom burden explained 18% of variance in LCS (P < .001). LCS explained 8.5% and 14.3% of the variance in depression (P < .001) and HR-QoL (P < .001), respectively.

CONCLUSION

Patients with lung cancer are vulnerable to LCS. Symptom burden can directly contribute to greater perceived LCS. Greater perceived LCS can be directly related to greater levels of depression and lower HR-QoL. A tailored approach is required to screen for LCS and implement interventions to enhance the psychosocial well-being of patients with perceived LCS.

Achieving Thoracic Oncology data collection in Europe: a precursor study in 35 Countries

BACKGROUND

A minority of European countries have participated in international comparisons with high level data on lung cancer. However, the nature and extent of data collection across the continent is simply unknown, and without accurate data collection it is not possible to compare practice and set benchmarks to which lung cancer services can aspire.

METHODS

Using an established network of lung cancer specialists in 37 European countries, a survey was distributed in December 2014. The results relate to current practice in each country at the time, early 2015. The results were compiled and then verified with co-authors over the following months.

RESULTS

Thirty-five completed surveys were received which describe a range of current practice for lung cancer data collection. Thirty countries have data collection at the national level, but this is not so in Albania, Bosnia-Herzegovina, Italy, Spain and Switzerland. Data collection varied from paper records with no survival analysis, to well-established electronic databases with links to census data and survival analyses.

CONCLUSION

Using a network of committed clinicians, we have gathered validated comparative data reporting an observed difference in data collection mechanisms across Europe. We have identified the need to develop a well-designed dataset, whilst acknowledging what is feasible within each country, and aspiring to collect high quality data for clinical research.

ERS statement on harmonised standards for lung cancer registration and lung cancer services in Europe

The European Respiratory Society (ERS) task force for harmonised standards for lung cancer registration and lung cancer services in Europe recognised the need to create a single dataset for use in pan-European data collection and a manual of standards for European lung cancer services.

The multidisciplinary task force considered evidence from two different sources, reviewing existing national and international datasets alongside the results of a survey of clinical data collection on lung cancer in 35 European countries. A similar process was followed for the manual of lung cancer services, with the task force using existing guidelines and national or international recommendations for lung cancer services to develop a manual of standards for services in Europe.

The task force developed essential and minimum datasets for lung cancer registration to enable all countries to collect the same essential data and some to collect data with greater detail. The task force also developed a manual specifying standards for lung cancer services in Europe.

Despite the wide variation in the sociopolitical landscape across Europe, the ERS is determined to encourage the delivery of high-quality lung cancer care. Both the manual of lung cancer services and the minimum dataset for lung cancer registration will support this aspiration.

Comorbidities in lung cancer: prevalence, severity and links with socioeconomic status and treatment

BACKGROUND

Survival from lung cancer remains poor in Scotland, UK. Although the presence of comorbidities is known to influence outcomes, detailed quantification of comorbidities is not available in routinely collected audit or cancer registry data. The aim of the present study was to assess the prevalence and severity of comorbidities in patients with newly diagnosed lung cancer across four centres throughout Scotland using validated criteria.

METHODS

Between 2005 and 2008, all patients with newly diagnosed lung cancer coming through the multidisciplinary teams in four Scottish centres were included in the study. Patient demographics, WHO/Eastern Cooperative Oncology Group performance status, clinicopathological features and primary treatment modality were recorded.

RESULTS

Details of 882 patients were collected prospectively. The majority of patients (87.3%) had at least one comorbidity, the most common being weight loss (53%), chronic obstructive pulmonary disease (43%), renal impairment (28%) and ischaemic heart disease (27%). A composite score was produced that included both number and severity of comorbidities. One in seven patients (15.3%) had severe comorbidity scores. There were statistically significant variations in comorbidity scores between treatment centres and between non-small cell lung carcinoma treatment groups. Disease stage was not associated with comorbidity score.

CONCLUSIONS

There is a high prevalence of multiple, severe comorbidities in Scottish patients with lung cancer, and these vary by site and treatment group. Further research is needed to determine the relationship between comorbidity scores and survival in these patients.

Fighting lung cancer in the developed world--a model of care in a UK hospital

OBJECTIVES

To highlight the initial management approach for Lung Cancer in a UK Hospital with the aim of translating the principles of such methodology to a developing country, such as Pakistan.

METHODS

A descriptive observational study was carried out at Stobhill Hospital, Glasgow, UK. The investigator (IMB) observed the Lung Cancer Service, attending the weekly 'New patients Clinic', 'Results Clinic', and 'Multidisciplinary team (MDT) meetings'. The process observations and the factual data describing the details of the service were recorded on a pre-designed pro-forma. Observations relating to two aspects of this service (Results Clinic and MDT) are included in this report.

RESULTS

The methodology of communicating results of lung cancer investigations to patients in a pre-planned and staged manner at a dedicated 'Results Clinic' was identified as a useful approach. A format of communication was consistently followed.

CONCLUSION

The MDT consisted of a Respiratory Physician, Clinical Oncologist, Thoracic Surgeon, Radiologist, Pathologist and Palliative Care Specialist. Each patient's case was discussed on an individual basis and the team developed a consensus regarding diagnosis, staging of the disease, further need for diagnostic procedures and treatment options, bearing in mind the patient's performance status, co-morbidity and their wishes. This approach has improved the initial part of the lung cancer patient journey and components of this approach could easily be transferred to a developing country.

The relationship between an inflammation-based prognostic score (Glasgow Prognostic Score) and changes in serum biochemical variables in patients with advanced lung and gastrointestinal cancer

BACKGROUND

The Glasgow Prognostic Score (GPS), an inflammation-based prognostic score formed from standard thresholds of C reactive protein (CRP) and albumin, has prognostic value in patients with advanced cancer. Little is known about the general biochemical disturbance associated with the systemic inflammatory response in cancer.

AIM

To examine the relationship between the GPS and blood biochemistry in patients with advanced lung and gastrointestinal cancer.

METHODS

The GPS (albumin <35 g/l = 1 and CRP >10 mg/l = 1 combined to form a prognostic score of 0 (normal) and 1 or 2 (abnormal)) and a variety of biochemical variables were examined in patients (n = 50) with advanced lung or gastrointestinal cancer and in a healthy control group (n = 13).

RESULTS

The GPS was normal in all the controls, but abnormal in 78% of the cancer group. Serum levels of sodium, chloride, creatine kinase, zinc and vitamin D were lower in the cancer group (all p<0.01), whereas levels of calcium, copper (both p<0.05), alkaline phosphatase, gamma-glutamyl transferase (both p<0.001) and lactate dehydrogenase (p<0.10) were raised. In the patient group, with increasing GPS, there was a median reduction in Karnofsky Performance Status (25%), haemoglobin (22%), sodium (3%), zinc (15%) and survival (93%, all p<0.05) and a median increase in white cell count (129%), alkaline phosphatase (217%), gamma-glutamyl transferase (371%) and lactate dehydrogenase (130%, all p<0.05). CRP levels were strongly and similarly correlated with alkaline phosphatase and gamma-glutamyl transferase, accounting for more than 25% of the variation in their activities.

CONCLUSION

Several correlations were seen between biochemical variables and increasing GPS. In particular, chronic activation of the systemic inflammatory response in cancer was associated with increase in gamma-glutamyl transferase and alkaline phosphatase activity in patients with advanced lung and gastrointestinal cancer.

Assessment of quality of life in the supportive care setting of the big lung trial in non-small-cell lung cancer

PURPOSE

The Big Lung Trial (BLT) was a large, pragmatic trial to evaluate the addition of chemotherapy to primary treatment (ie, surgery, radical radiotherapy, or supportive care) in non-small-cell lung cancer (NSCLC). In the supportive care group, there was a small but significant survival benefit in patients treated with chemotherapy compared with supportive care alone (no chemotherapy). A substudy was undertaken to evaluate the quality of life (QoL) implications of the treatment options. QoL was assessed using European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires C30 (QLQ-C30) and LC17, and daily diary cards.

PATIENTS AND METHODS

EORTC QLQ-C30 and LC17 were collected at 0, 6 to 8, 12, 18, and 24 weeks. Diary cards were completed during the first 12 weeks of the study. The primary end point was global QoL at 12 weeks.

RESULTS

A total of 273 patients were randomly assigned: 138 to no chemotherapy and 135 to chemotherapy. There was no evidence of a large detrimental effect on QoL of chemotherapy. No statistically significant differences in global QoL or physical/emotional functioning, fatigue and dyspnea, and pain were detected at 12 weeks. Higher rates of palliative radiotherapy in the no chemotherapy arm may have lessened differences in QoL. Global QoL, role functioning, fatigue, appetite loss, and constipation were prognostic indicators of survival at 12 weeks.

CONCLUSION

There were no important adverse effects of chemotherapy on QoL.

Standard of care for cancer-related anemia: improving hemoglobin levels and quality of life

The introduction of recombinant human erythropoietin (rHuEPO) has proven to be a major advance in the therapeutic options available for managing anemia in cancer patients. The results of placebo-controlled clinical trials and large, community-based, open-label studies have confirmed that epoetin alfa, a recombinant human erythropoietin, significantly reduces transfusion requirements, and reliably increases hemoglobin (Hb) levels in anemic (Hb level <12 g/dl) cancer patients undergoing chemotherapy. Increased Hb improves patients' energy level and their ability to perform the activities of daily living, as well as their overall quality of life (QOL). These findings are independent of tumor type and disease status and are comparable in patients receiving nonplatinum- and platinum-based chemotherapeutic regimens. Furthermore, more than a decade of use in clinical trials and by physicians in routine clinical practice has demonstrated that epoetin alfa is safe and well tolerated when used to treat cancer patients with anemia. The availability of epoetin alfa as an alternative to transfusion has changed practices in anemia management; physicians can now treat anemia with the goal of achieving adequate Hb levels to relieve anemia-related fatigue, a major symptom contributing to decreased QOL in cancer patients. Incremental benefit analysis has shown that increasing Hb level from 11 g/dl to 12 g/dl yields the greatest improvement in QOL per 1 g/dl increase in Hb. The demonstrated efficacy of epoetin alfa for increasing Hb levels and improving patient QOL have made this agent a rationale choice for management of cancer-related anemia. Ongoing research will continue to provide new insights into best management of anemia with epoetin alfa in cancer patients.

A randomised comparison of radical radiotherapy with or without chemotherapy for patients with non-small cell lung cancer: Results from the Big Lung Trial

BACKGROUND

A meta-analysis of trials comparing primary treatment with or without chemotherapy for patients with non-small cell lung cancer published in 1995 suggested a survival benefit for cisplatin-based chemotherapy in each of the primary treatment settings studied, but it included many small trials, and trials with differing eligibility criteria and chemotherapy regimens.

METHODS

The Big Lung Trial was a large pragmatic trial designed to confirm the survival benefits seen in the meta-analysis, and this paper reports the findings in the radical radiotherapy setting. The trial closed before the required sample size was achieved due to slow accrual, with a total of 288 patients randomised to receive radical radiotherapy alone (146 patients) or sequential radical radiotherapy and cisplatin-based chemotherapy (142 patients).

RESULTS

There was no evidence that patients allocated sequential chemotherapy and radical radiotherapy had a better survival than those allocated radical radiotherapy alone, HR 1.07 (95% CI 0.84-1.38, P=0.57), median survival 13.0 months for the sequential group and 13.2 for the radical radiotherapy alone group. In addition, exploratory analyses could not identify any subgroup that might benefit more or less from chemotherapy.

CONCLUSIONS

Despite not suggesting a survival benefit for the sequential addition of chemotherapy to radical radiotherapy, possibly because of the relatively small sample size and consequently wide confidence intervals, the results can still be regarded as consistent with the meta-analysis, and other similarly designed recently published large trials. Combining all these results suggests there may be a small median survival benefit with chemotherapy of between 2 and 8 weeks.

The correlation between fatigue, physical function, the systemic inflammatory response, and psychological distress in patients with advanced lung cancer

BACKGROUND

Functional disability is reported frequently in fatigued cancer patients, but little is known about the correlation between fatigue and objective physical function. In addition, from previous work, the systemic inflammatory response and psychological distress appear to be related to fatigue.

METHODS

Thirty-eight patients with metastatic or locally advanced lung carcinoma and 15 age-matched and gender-matched, healthy controls completed the Functional Assessment of Chronic Illness Therapy-Fatigue scale, a visual analogue weakness score, and the Hospital Anxiety and Depression (HAD) scale. Hemoglobin concentrations, C-reactive protein (CRP) concentrations, creatine kinase concentrations, white blood cell count, body composition, Karnofsky performance status (KPS), grip strength, and chair-rise time also were measured in both groups. The cancer patients were then grouped into tertiles on the basis of fatigue scores.

RESULTS

The cancer patients had greater fatigue compared with the control group (P < 0.001). They also weighed less, had lower hemoglobin and creatine kinase levels and higher CRP levels, and had lower KPS, poorer grip strength, longer chair-rise times, and increased HAD scale scores (all P < 0.01). KPS and chair-rise time were correlated strongly (r(2) = 0.565; P < 0.001). With increasing fatigue, KPS was lower, and chair-rise time and HAD scale scores were greater (P < 0.01). On multiple regression analysis, only KPS, weakness, and HAD scale scores were correlated independently with fatigue (r(2) = 0.570; P < 0.001).

CONCLUSIONS

Objective physical function (as measured by chair-rise time) in patients with advanced lung cancer was poorer with increasing fatigue. Results of the current study suggest that fatigue is not a result primarily of weight loss or anemia but is related to KPS and psychological distress.

Chemotherapy versus supportive care in advanced non-small cell lung cancer: improved survival without detriment to quality of life

BACKGROUND

In 1995 a meta-analysis of randomised trials investigating the value of adding chemotherapy to primary treatment for non-small cell lung cancer (NSCLC) suggested a small survival benefit for cisplatin-based chemotherapy in each of the primary treatment settings. However, the meta-analysis included many small trials and trials with differing eligibility criteria and chemotherapy regimens.

METHODS

The aim of the Big Lung Trial was to confirm the survival benefits seen in the meta-analysis and to assess quality of life and cost in the supportive care setting. A total of 725 patients were randomised to receive supportive care alone (n = 361) or supportive care plus cisplatin-based chemotherapy (n = 364).

RESULTS

65% of patients allocated chemotherapy (C) received all three cycles of treatment and a further 27% received one or two cycles. 74% of patients allocated no chemotherapy (NoC) received thoracic radiotherapy compared with 47% of the C group. Patients allocated C had a significantly better survival than those allocated NoC: HR 0.77 (95% CI 0.66 to 0.89, p = 0.0006), median survival 8.0 months for the C group v 5.7 months for the NoC group, a difference of 9 weeks. There were 19 (5%) treatment related deaths in the C group. There was no evidence that any subgroup benefited more or less from chemotherapy. No significant differences were observed between the two groups in terms of the pre-defined primary and secondary quality of life end points, although large negative effects of chemotherapy were ruled out. The regimens used proved to be cost effective, the extra cost of chemotherapy being offset by longer survival.

CONCLUSIONS

The survival benefit seen in this trial was entirely consistent with the NSCLC meta-analysis and subsequent similarly designed large trials. The information on quality of life and cost should enable patients and their clinicians to make more informed treatment choices.

Chemotherapy for patients with non-small cell lung cancer: the surgical setting of the Big Lung Trial

OBJECTIVES

The non-small cell lung cancer (NSCLC) meta-analysis suggested a survival benefit for cisplatin-based chemotherapy when given in addition to surgery, radical radiotherapy or 'best supportive care'. However, it included many small trials and trials with differing eligibility criteria and chemotherapy regimens. The aim of the Big Lung Trial was therefore to run a large pragmatic trial to confirm the survival benefits seen in the meta-analysis.

METHODS

In the surgery setting, a total of 381 patients were randomised to chemotherapy (C, 192 patients) or no chemotherapy (NoC, 189 patients). C was three 3-weekly cycles of cisplatin/vindesine, mitomycin/ifosfamide/cisplatin, mitomycin/vinblastine/cisplatin or vinorelbine/cisplatin.

RESULTS

Chemotherapy was given before surgery in 3% of patients whilst 97% received adjuvant chemotherapy. Baseline characteristics were: median age 61 years, 69% male, 48% squamous cell, 93% WHO PS 0-1, 27% stage I, 38% stage II, and 34% stage III. Complete resection was achieved in approximately 95% of patients. In the C group, 13% received no chemotherapy, 21% one or two cycles, and 64% all three cycles of their prescribed chemotherapy (60% of the latter with no delays or modification). 30% had grade 3/4 toxicity, mainly haematological, nausea/vomiting and neutropenic fever, and six patients were reported as having a treatment-related death. 198 (52%) of patients have died, but there is currently no evidence of a benefit in overall survival to the C group: HR 1.02 (95% CI 0.77-1.35), P = 0.90).

CONCLUSIONS

This trial has failed to observe a survival benefit with adjuvant chemotherapy following complete resection of stage I-III NSCLC. However, the hazard ratio and 95% confidence intervals are consistent with the previously reported meta-analysis and two large recently reported trials, which suggest a small survival benefit with cisplatin-based chemotherapy.

Does knowledge of cancer diagnosis affect quality of life? A methodological challenge

Background

As part of an assessment of quality of life in lung cancer patients an investigation was carried out to examine whether the knowledge of their diagnosis affected their quality of life.

Methods

Every patient in a defined geographical area with a potential diagnosis of lung cancer was interviewed at first consultation and after a definitive treatment has been given. Quality of life was assessed using three standard measures: the Nottingham Health Profile (NHP), the EORTC quality of life questionnaire (QLQ-C30) and its lung cancer supplementary questionnaire (QLQ-LC13). Comparison was made in quality of life scores between patients who knew their cancer diagnosis and those who did not.

Results

In all, 129 lung cancer patients were interviewed. Of these, 30 patients (23%) knew and 99 (78%) did not know their cancer diagnosis at the time of baseline assessment. The patient groups were similar in their characteristics except for age (P = 0.04) and cell type (P < 0.0001). Overall, there were no significant differences between these two groups with regard to their scores on the three instruments used. A major finding was that both group scored almost the same on emotional reactions (P = 0.8) and social isolation (P = 1.0) as measured by the NHP, and emotional (P = 0.7) and social functioning (P = 1.0) as measured by the EORTC QLQ-C30. In addition there were no significant differences in patients' symptom scores between those who knew their diagnosis and those who did not, nor did any consistent pattern emerge. The only significant difference was for sleep difficulties (P = 0.02).

Conclusion

The findings suggest that the knowledge of cancer diagnosis does not affect the way in which patients respond to quality of life questionnaires.

The approach to the surgical management of cancer in four European countries

Outcome of lung cancer appears poorer in the UK than elsewhere in Europe. This may be due to a less aggressive approach in treatment. This study investigated whether clinicians' perceptions of their approach differed between European countries. A questionnaire was circulated to cancer specialists in four countries (Belgium, Greece, Switzerland and the UK) asking about management. An aggression score was calculated using the proportion of standard cases that would proceed to operation at different ages and levels of pulmonary function. The principle problems suggested by most of the 314 respondents were inoperability before symptoms (particularly in the UK) and confounding effects of comorbidity. Surgeons particularly blamed delay in referral. The aggression scores (Belgium 54%, UK 49%, Switzerland 47% and Greece 37%) did not suggest the UK is an outlier, but the UK was more conservative in its approach to N2 disease and isolated cerebral metastasis. The aggression scores of surgeons were greater than those of the others (51% versus 42%). Lung cancer was felt to present late with potentially confounding symptoms, but delay in the clinical process was thought to be less important. Although the UK was more conservative with special cases, its approach to typical cases could account for differences in patient survival.

Quality of life in lung cancer patients: does socioeconomic status matter?

BACKGROUND

As part of a prospective study on quality of life in newly diagnosed lung cancer patients an investigation was carried out to examine whether there were differences among patients' quality of life scores and their socioeconomic status.

METHODS

Quality of life was measured at two points in time (baseline and three months after initial treatment) using three standard instruments; the Nottingham Health Profile (NHP), the European Organization for Research and Cancer Treatment Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer supplement (QLQ-LC13). Socioeconomic status for each individual patient was derived using Carstairs and Morris Deprivation Category ranging from 1 (least deprived) to 7 (most deprived) on the basis of the postcode sector of their address.

RESULTS

In all, 129 lung cancer patients entered into the study. Of these data for 82 patients were complete (at baseline and follow-up). 57% of patients were of lower socioeconomic status and they had more health problems, less functioning, and more symptoms as compared to affluent patients. Of these, physical mobility (P = 0.05), energy (P = 0.01), role functioning (P = 0.04), physical functioning (P = 0.03), and breathlessness (P = 0.02) were significant at baseline. However, at follow-up assessment there was no significant difference between patient groups nor did any consistent pattern emerge.

CONCLUSION

At baseline assessment patients of lower socioeconomic status showed lower health related quality of life. Since there was no clear trend at follow-up assessment this suggests that patients from different socioeconomic status responded to treatment similarly. In general, the findings suggest that quality of life is not only the outcome of the disease and its treatment, but is also highly dependent on each patients' socioeconomic characteristics.

A prospective study of the impact of weight loss and the systemic inflammatory response on quality of life in patients with inoperable non-small cell lung cancer

The relationship between weight loss, the systemic inflammatory response and quality of life in patients with inoperable non-small cell lung cancer (NSCLC) was studied. The extent of weight loss, the systemic inflammatory response (C-reactive protein) and quality of life (EORTC-QLQ-C30) was measured in 106 patients with inoperable NSCLC (stage III and IV). Approximately 40% had more than 5% weight loss and almost 80% had elevated circulating C-reactive protein concentrations (>10 mg/l). The functional scale scores of the EORTC-QLQ-C30 were poor (50 or less) and the fatigue symptom score was also poor (50 or more). When patients were grouped according to whether or not they had experienced more than 5% weight loss, Karnofsky performance status and global quality of life were lower (P<0.05) and symptom scores fatigue (P<0.05) and pain (P<0.01) were greater in the weight-losing group. When the weight-stable cancer patients were grouped according to whether or not they had evidence of a systemic inflammatory response, the symptom fatigue was higher in the inflammatory group (P<0.05). In the weight-stable cancer patients C-reactive protein concentration was correlated with fatigue r=0.31 (P<0.05). The results of the present study indicate that both weight loss and the systemic inflammatory response impact on different aspects of quality of life. In particular, fatigue is associated with the presence of a systemic inflammatory response independent of weight loss.

Lung cancer: the importance of seeing a respiratory physician

Patients with lung cancer present to and are managed by a variety of clinicians. In this study the effect of involvement by a respiratory physician on the diagnosis, staging, treatment and survival of a large unselected group of lung cancer patients was investigated. The study population was derived from the Scottish Cancer Registry. A total of 3,855 patients diagnosed during 1995 with lung cancer were studied. The data were validated and supplemented by references to medical records. The study found that a respiratory physician had been involved in the initial management of 2,901 (75.3%) patients. These patients were found more likely to have had the cancer diagnosis confirmed by histological methods and to have received active treatment with surgery, radiotherapy or chemotherapy. Survival, 1 yr after diagnosis was higher in patients who saw a respiratory physician (24.4 versus 11.1%) and benefit was found to have remained 3 yrs after diagnosis (8.1 versus 3.7%). Although the patients who had not seen a respiratory physician were generally older, and had more extensive disease, after correcting for age, stage and other prognostic factors, the relative hazard ratio of death for those not managed by a respiratory physician was 1.44. The data from this study supports the recommendations of recent lung cancer guidelines for the early involvement by a respiratory physician.

How quality of life data contribute to our understanding of cancer patients' experiences? A study of patients with lung cancer

A prospective study was conducted to measure quality of life in newly diagnosed lung cancer patients attending a chest clinic in a large teaching and district general hospital in a geographically defined area (northern sector of Glasgow, Scotland). Quality of life was assessed at two points in time, pre-diagnosis (baseline) and 3 months after diagnosis (follow-up) using three standard measures; the Nottingham Health Profile (NHP); the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and its lung cancer supplement (QLQ-LC13). Out of 133 lung cancer patients diagnosed during the study period, 129 patients (97%) were interviewed pre-diagnosis. Of these, only 63% of the patients had an active treatment. Ninety-six patients were alive at follow-up, of whom 82 patients were re-interviewed. Thus, only 82 patients who had complete data were used in the analysis. Comparing patients' pre-diagnosis and follow-up scores on the NHP, only sleep difficulties improved slightly. Patients reported increased perceived health problems of all other characteristics studied (energy, p = 0.0004; physical mobility, p = 0.0008). Similar results were observed on the EORTC questionnaires indicating that patients' functioning and global quality of life had decreased. The only significant improvement after 3 months was seen in patients' cough (p = 0.006). There were marked increases in hair loss (p < 0.0001), constipation (p = 0.007), and sore mouth (p = 0.0004). The findings suggest that patient-centred variables should receive sufficient consideration in the treatment of lung cancer. The study results clearly indicate that information on quality of life contributes to our understanding of patients' experiences of their cancer treatment.

The systemic inflammatory response, weight loss, performance status and survival in patients with inoperable non-small cell lung cancer

The relationship between the magnitude of systemic inflammatory response and the nutritional/functional parameters in patients with inoperable non-small cell lung cancer were studied. The extent of weight loss, albumin, C-reactive protein, performance status and quality of life was measured in 106 patients with inoperable non-small cell lung cancer (stages III and IV). Survival analysis was performed using the Cox proportional hazard model. The majority of patients were male and almost 80% had elevated circulating C-reactive protein concentrations (>10 mg x l(-1)). On multivariate analysis, age (P=0.012), tumour type (0.002), weight loss (P=0.056), C-reactive protein (P=0.047), Karnofsky performance status (P=0.002) and fatigue (P=0.046) were independent predictors of survival. The patients were grouped according to the magnitude of the C-reactive protein concentrations (< or =10, 11-100 and >100 mg x l(-1)). An increase in the magnitude of the systemic inflammatory response was associated with increased weight loss (P=0.004), reduced albumin concentrations (P=0.001), reduced performance status (P=0.060), increased fatigue (P=0.011) and reduced survival (HR 1.936 95%CI 1.414-2.650, P<0.001). These results indicate that the majority of patients with inoperable non-small cell lung cancer have evidence of a systemic inflammatory response. Furthermore, an increase in the magnitude of the systemic inflammatory response resulted in greater weight loss, poorer performance status, more fatigue and poorer survival.

Longitudinal study of resting energy expenditure, body cell mass and the inflammatory response in male patients with non-small cell lung cancer

The aim of this study was to examine the inter-relationship between the inflammatory response and resting energy expenditure in patients with non-small cell lung cancer (NSCLC) before and after the onset of weight loss. Healthy subjects (n=7) and patients with NSCLC without weight loss (n=12) were studied. Resting energy expenditure adjusted for metabolically active tissue, as measured by total body potassium, was approximately 15% higher in the NSCLC group (P<0.01). Moreover, the resting energy expenditure, correlated with the magnitude of the inflammatory response (r=0.753, P<0.01). Six cancer patients subsequently lost weight and the relationship between resting energy expenditure and the inflammatory response was maintained. These results highlight the impact of the inflammatory response on the increase in the resting energy expenditure which precedes the onset of weight loss in patients with NSCLC.

Management and survival of patients with lung cancer in Scotland diagnosed in 1995: results of a national population based study

BACKGROUND

The prognosis of patients with lung cancer in Scotland is poor and not improving. This study was designed to document factors influencing referral, diagnostic evaluation, treatment, and survival in patients with lung cancer.

METHODS

Patients diagnosed during 1995 were identified from the Scottish Cancer Registry and their medical records were reviewed. Adequate records were available in 91.2% of all potentially eligible cases.

RESULTS

In 1995, patients in Scotland with lung cancer had a high rate of microscopic verification (74.1%) and 75.3% were assessed by a respiratory physician; however, only 56.8% received active treatment (resection 10.7%, radiotherapy 35.8%, chemotherapy 16.1%) and 2.9% participated in a clinical trial. Survival was poor with a median of 3.6 months; 21.1% (95% CI 19.8% to 22.4%) were alive at 1 year and 7.0% (95% CI 6.2% to 7.8%) at 3 years. Management by respiratory physician, oncologist, or thoracic surgeon was an independent predictor of access to potentially curative treatment and better survival.

CONCLUSION

This national population based study demonstrates low use of treatment, poor survival, and the influence of process of care on survival. Implementation of evidence-based guidelines will require substantial changes in practice. Increasing the number of patients who receive treatment may improve survival.

Quality of life in lung cancer patients: as an important prognostic factor

Given that lung cancer is one of the common cancers world-wide, the implications of focusing on quality of life as well as survival require to be understood. We have carried out a study of the relationship between survival and quality of life in patients with lung cancer comparing patients those who lived with those who died within 3 months. The design of the study allowed every patient in a defined geographical area with a potential diagnosis of lung cancer to be studied from first outpatient consultation till after a definitive treatment has been given. Quality of life was measured using three standard questionnaires: the Nottingham Health Profile (NHP), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer supplementary questionnaire (QLQ-LC13) in addition to a study specific questionnaire collecting data on demographic, social, clinical and performance status. The contribution of quality of life in relation to survival adjusted for known prognostic factors was determined using Cox's proportional hazard model. In all 129 lung cancer patients were interviewed, and 96 patients were alive at 3-months follow-up. Only 90 of 96 patients alive at 3-months follow-up were assessable. Descriptive analyses showed that those who were dead had more perceived health problems, greater level of symptoms and significant lower physical and role functioning and global quality of life at presentation. On the other hand, univariate analyses showed that patients' aggregate scores on the NHP, the functioning scores, and global quality of life scores alone were significant predictors of survival (P<0.03, P<0.04, P<0.04, respectively ). The multivariate analyses showed that pre-diagnosis global quality of life was the most significant predictor of the length of survival even after adjusting for known prognostic factors (age, P<0.04; extent of disease, P<0.03; global quality of life, P<0.02), while performance status, sex and weight loss were not. This study confirmed that pre-diagnosis quality of life was a significant predictor of survival. Indeed, pre-diagnosis quality of life should be considered as a clinical status which has to be established by physicians before treatment starts as it is such an important predictor of survival.

Gemcitabine plus best supportive care (BSC) vs BSC in inoperable non-small cell lung cancer--a randomized trial with quality of life as the primary outcome. UK NSCLC Gemcitabine Group. Non-Small Cell Lung Cancer

Three hundred patients with symptomatic, locally advanced or metastatic NSCLC not requiring immediate radiotherapy were enrolled into this randomized multicentre trial comparing gemcitabine + BSC vs BSC alone. Patients allocated gemcitabine received 1000 mg/m2 on days 1, 8 and 15 of a 28-day cycle, for a maximum of six cycles. The main aim of this trial was to compare patient assessment of a predefined subset of commonly reported symptoms (SS14) from the EORTC QLQ-C30 and LC13 scales. The primary end-points were defined as (1) the percentage change in mean SS14 score between baseline and 2 months and (2) the proportion of patients with a marked (> or = 25%) improvement in SS14 score between baseline and 2 months sustained for > or =4 weeks. The secondary objectives were to compare treatments with respect to overall survival, and multidimensional QL parameters. The treatment groups were balanced with regard to age, gender, Karnofsky performance status (KPS) and disease stage (40% had metastatic disease). The percentage change in mean SS14 score from baseline to 2 months was a 10% decrease (i.e. improvement) for gemcitabine plus BSC and a 1% increase (i.e. deterioration) for BSC alone (P = 0.113, two-sample t-test). A sustained (> or = 4 weeks) improvement (> or =25%) on SS14 was recorded in a significantly higher proportion of gemcitabine + BSC patients (22%) than in BSC alone patients (9%) (P = 0.0014, Pearson's chi-squared test). The QLQ-C30 and L13 subscales showed greater improvement in the gemcitabine plus BSC arm (in 11 domains) than in the BSC arm (one symptom item). There was greater deterioration in the BSC alone arm (six domains/items) than in the gemcitabine + BSC arm (three QL domains). Tumour response occurred in 19% (95% CI 13-27) of gemcitabine patients. There was no difference in overall survival: median 5.7 months (95% CI 4.6-7.6) for gemcitabine + BSC patients and 5.9 months (95% CI 5.0-7.9) (log-rank, P = 0.84) for BSC patients, and 1 -year survival was 25% for gemcitabine + BSC and 22% for BSC. Overall, 74 (49%) gemcitabine + BSC patients and 119 (79%) BSC patients received palliative radiotherapy. The median time to radiotherapy was 29 weeks for gemcitabine + BSC patients and 3.8 weeks for BSC. Patients treated with gemcitabine + BSC reported better QL and reduced disease-related symptoms compared with those receiving BSC alone. These improvements in patient-assessed QL were significant in magnitude and were sustained.