Elsevier

Lung Cancer

Volume 83, Issue 3, March 2014, Pages 396-400
Lung Cancer

Risk factors and survival outcome for non-elective referral in non-small cell lung cancer patients – Analysis based on the National Lung Cancer Audit

https://doi.org/10.1016/j.lungcan.2013.10.010Get rights and content

Abstract

Introduction

Survival after diagnosis of lung cancer is poor and seemingly lower in the UK than other Western countries, due in large part to late presentation with advanced disease precluding curative treatment. Recent research suggests that around one-third of lung cancer patients reach specialist care after emergency presentation and have a worse survival outcome. Confirmation of these data and understanding which patients are affected may allow a targeted approach to improving outcomes.

Methods

We used data from the UK National Lung Cancer Audit in a multivariate logistic regression model to quantify the association of non-elective referral in non-small cell lung cancer patients with covariates including age, sex, stage, performance status, co-morbidity and socioeconomic status and used the Kaplan–Meier method and Cox proportional hazards model to quantify survival by source of referral.

Results

In an analysis of 133,530 cases of NSCLC who presented 2006–2011, 19% of patients were referred non-electively (following an emergency admission to hospital or following an emergency presentation to A&E). This route of referral was strongly associated with more advanced disease stage (e.g. in Stage IV – OR: 2.34, 95% CI: 2.14–2.57, p < 0.001) and worse performance status (e.g. in PS 4 – OR: 7.28, 95% CI: 6.75–7.86, p < 0.001), but was also independently associated with worse socioeconomic status, and extremes of age. These patients were more likely to have died within 1 year of diagnosis (hazard ratio of 1.51 (95% CI: 1.49–1.54) after adjustment for key clinical variables.

Conclusion

Our data confirm and quantify poorer survival in lung cancer patients who are referred non-electively to specialist care, which is more common in patients with poorer performance status, higher disease stage and less advantaged socioeconomic status. Work to tackle this late presentation should be urgently accelerated, since its realisation holds the promise of improved outcomes and better healthcare resource utilisation.

Introduction

Survival after a diagnosis of cancer appears to be lower in the UK compared to similar healthcare systems [1] with late presentation to specialist care providing the major explanation for the differences [2]. The National Cancer Intelligence Network recently published an analysis of 739,667 cases of cancer diagnosed between 2006 and 2008 from the National Cancer Data Repository, where Administrative Hospital Episode Statistics data are linked with Cancer Waiting Times data, data from the cancer screening programmes and cancer registration data and showed that 24% of all cancers had an emergency presentation to secondary care as their “route to diagnosis” [3]. This figure was higher for lung cancer at 39% with early indications that 1 year survival is particularly poor for these patients. Understanding the demographics and clinical features of patients who present as an emergency is important as it potentially facilitates targeted earlier intervention. Such interventions might be expected to improve survival outcomes, patient experience and utilisation of healthcare resources.

The National Lung Cancer Audit is an audit of lung cancer and mesothelioma commissioned by the Healthcare Quality Improvement Partnership (HQIP) and has collected data on people with lung cancer of progressively improving completeness since 2005 [4]. The audit records the route of referral of the patient to the lung cancer team as well as other key clinical information such as stage and performance status that is not available in other datasets. We have used these data to quantify the extent to which a non-elective mode of referral occurs in people with lung cancer, to identify the demographics of the people most affected, and to determine the impact upon survival.

Section snippets

Methods

We obtained data on all cases of non-small cell lung cancer (NSCLC) submitted to the National Lung Cancer Audit in England between 2006 and 2011. This cohort includes those with histologically confirmed NSCLC and those with presumed NSCLC (i.e. not histologically confirmed small cell lung cancer, and not clinically or histologically diagnosed mesothelioma). We excluded patients with small cell lung cancer since their staging has until recently been recorded as limited/extensive which cannot be

Results

There were 133,546 cases of non-small cell lung cancer submitted to the National Lung Cancer Audit in England between 2006 and 2011, of which we excluded 16 patients with a calculated survival of less than zero (diagnosed post-mortem), leaving 133,530 cases of histologically confirmed or presumed NSCLC which we used as our study population. The median age was 72 years and 57% of patients were male. Approximately 50% of patients were diagnosed with metastatic or locally advanced (Stage IIIB/IV)

Conclusions

We have shown that around one-fifth of patients with NSCLC in England have a non-elective referral to the specialist lung cancer team, with poor performance status and advanced disease stage being the strongest predictors. Even after adjustment for the main clinical variables, these patients were 51% more likely to die within the first year than patients referred through other routes. Whilst performance status appears to be the strongest predictor, it cannot be determined from the dataset

Conflicts of interest statement

No conflicts of interest declared.

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