Resection rate for patients with tissue confirmation of NSCLC (2004-2008:England)

First seen in centre

with thoracic surgery?

NumberWith a tissue

diagnosisof NSCLC

Number who had surgical

resection

%having surgery

Adjusted Odds Ratio

for surgery*P value

No 25,248 2,947 12% 1.00Yes 9,265

(27%)1,538 17% 1.51 (1.16-

1.97)<0.001

*adjusted for sex, age, PS, stage, deprivation indexand Charlson co-morbidity index

Resection rate by PCT 2004-6*

0

2

4

6

8

10

12

14

16

18

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

101

102

103

104

105

106

107

108

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110

111

112

113

114

115

116

117

118

119

120

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122

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126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

PCT of residence

Pro

po

rtio

n o

f lu

ng

ca

ses

havin

g a

pn

eu

mo

necto

my

(%

)

Q1

Q2

Q3

Q4

Q5

*Source: National Cancer Data Repository

EMEE

L

NENW

SE

SW

WM

Y&H

0.85

0.90

0.95

1.00

1.05

Ha

zard

ra

tio

5 6 7 8 9 10 11Radical surgery (%)

Hazard ratio 95% CIRadical surgery 95% CI

N = 77,349

Mortality Hazard Ratios for Lung Cancer Patients in England 2004-6 related to resectionrate by government office region

Mortality hazard ratios for resected patients; England 2004-6 by Government Regional Office

EM

EE

L NE NW

SE

SW

WM

Y&H

0.50

0.60

0.70

0.80

0.90

1.00

1.101.201.301.401.501.601.70

Ha

zard

ra

tio

5 6 7 8 9 10 11Radical surgery (%)

Hazard ratio 95% CI

Radical sugery 95% CI

N = 6,900

Mortality hazard ratios for resected patients; England 2004-6 by Government Regional Office

EM

EE

L NE NW

SE

SW

WM

Y&H

0.50

0.60

0.70

0.80

0.90

1.00

1.101.201.301.401.501.601.70

Ha

zard

ra

tio

5 6 7 8 9 10 11Radical surgery (%)

Hazard ratio 95% CI

Radical sugery 95% CI

N = 6,900

Implications: comparing the top quintile PCT withLower 4: 5420 deaths ‘postponed’ by surgery 146 deaths related to higher resection rates

Kelvin LauDavid Waller

Sridhar RathinamMichael Peake

Glenfield Hospital, Leicester, UK UK National Lung Cancer Audit Programme

The effects of investing in thoracic surgery on

lung cancer resection rates

Lung cancer in UK is under treated

There is a wide variation in lung cancer surgery in England

5.2% – 10.1%10.9% – 13.2%13.6% – 14.5%14.6% – 16.5%16.9% – 31.8%

Hypothesis

the variability in Resection Rate is determined by the provision of

specialist thoracic surgery

Method

We correlated results of the NATIONAL LUNG CANCER AUDIT

with manpower data for cardiothoracic surgery

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

N15

N23

N22

N20

N31

N03

N14

N08

N11

N29

N06

N21

N01

N02

N07

N38

N27

N30

N35

N33

N36

N37

N26

N12

N13

N24

SWW

N28

N25

N32

NW

W

N34

SEW

Adj

uste

d O

R (

95%

CI)

Network

Adjusted OR for Resection in NSCLC by Network (2008)

National Lung Cancer Audit results

• 33 English Cancer Networks, comprising 174 Hospital Trusts

• 31 Trusts had Thoracic Surgery in house (Base Hospitals)

• 18 (58%) Trusts had less than 2 Pure Thoracic Surgeons

• 13 (42%) Trusts had 2 or more Pure Thoracic Surgeons

• In 2008, 15,774 cases of histologically confirmed NSCLC

– 18.4% cStage I and II

– 14.2% underwent resection

Resection rates are higher in centres who treat more cases

R = 0.155p = 0.06

Resection rates are higher in base than in referring centres

0%

5%

10%

15%

20%

25%

Base Peripheral

p < 0.001

Res

ecti

on

Rat

e

0%

5%

10%

15%

20%

Base Peripheral

p < 0.001

Across the UK Within each Cancer Network

0%

5%

10%

15%

20%

25%

Less than 2 2 or More

Resection rates are higher in centres with 2 or more specialist thoracic surgeons

p = 0.02

Res

ecti

on

Rat

e

0

2

4

6

8

10

12

14

16

Less than two-thirds More than two-thirds

Resection rates are higher when surgeons attend preoperative MDTs

p = 0.012

0

5

10

15

20

Static Expanded (5 Units)

The increase in resection rate was greatest in those units who employed new thoracic surgeons

p = 0.04

19%66%

2008

2009Growth

Res

ectio

n R

ate

Conclusion

• Lung cancer resection rates in UK can be increased by

• Increasing the number of specialist thoracic surgeons at preoperative MDTs in referring hospitals

• Increasing the number of specialist thoracic surgeons in operating centres

• Thereby increasing the individual caseload in any unit

• Individual Units must invest in more pure Thoracic Surgical appointments

• The number of specialist thoracic surgeons in training must be increased

Resection Rate - Leicester

Surgical Numbers

Resection Rate for confirmedNSCLC

Resection Rate for all Lung Cancers

1994-1996* 65 12.2 4.5

1997-1999* 175 23.4 12.0

2002 45 19.9 12.7

2003 58 21.0 13.8

2004 60 20.8 13.5

2005 89 30.4 20.6

2006 94 31.1 19.3

* A Martin-Ucar et al. Lung Cancer. 2004; 46:227-232 (specialist thoracic surgeon appointed 1997)