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Objectives Healthcare systems increasingly recognise the importance of service users’ perspectives for improving care organisation and delivery. The English Cancer Patient Experience Survey (CPES) is carried out annually, however, its representativeness within cancer types is unknown. We have explored if the CPES results are representative of people with lung cancer. Materials and methods We linked cancer registry data across multiple sources to assess how CPES represents sociodemographic and clinical characteristics of the National Lung Cancer Audit population, accounting for post-sampling mortality bias. Multivariable logistic regression was used to compare people included and not included in CPES. Results Of 240,375 people diagnosed (2009–2015), 15,967 (7 %) were included in CPES. Gender and ethnicity were reasonably represented, as were sociodemographic and clinical groupings, although more received anti-cancer treatment (96 % of CPES respondents vs. 56 % of patients nationally; adjusted odds ratio = 10.3, 95 % confidence interval 9.4–11.2 for any anti-cancer treatment) with chemotherapy most over-represented, followed by surgery and then radiotherapy. CPES under-represented older, more socioeconomically deprived, and certain clinical groups, including those with worse performance status, multiple comorbidities, and diagnosis via emergency presentation. Conclusion CPES includes patients across the sociodemographic and clinical spectrum indicating its value for research and service planning. Unbalanced representation of incident lung cancer cases is a limitation that must be considered in context of using CPES findings to implement service changes. Although half the national lung cancer population who received no anti-cancer treatment do not have their experiences represented, the strength of this dataset is in providing detailed comparisons of patient experiences across different treatment groups.

Purpose Identification of unmet needs in person centred and supportive care could be limited by differences in experience across specific cancer populations. Using the experiences of people with lung cancer, we assess distinctions according to demographic and clinical characteristics. Methods The English Cancer Patient Experience Survey was linked to the national cancer registry. The primary outcome was experience of the lung cancer pathway when assessed in multi-question models developed with item response theory. Secondary outcomes were experience by treatment received and in separate dimensions of the care pathway: up to diagnosis, treatment information, and staff support. Results Responses from 15,967 adults with a lung cancer diagnosis between 2009 and 2015 were included. Positive experiences were more likely to be reported by people aged between 65 and 80 (adjusted coefficient 0.08, 95%CI 0.05;0.11), those living in the most deprived areas (adjusted coefficient 0.10, 95%CI 0.05;0.14), diagnosed at lung cancer stage IIA–B (adjusted coefficient 0.09, 95%CI 0.04;0.14), and those diagnosed through inpatient elective admissions (adjusted coefficient 0.17, 95%CI 0.07;0.28). Specific experiences differed across dimensions of care and within lung cancer treatment groups. Conclusions Experiences differed according to gender and ethnicity, supporting previous observations in cancer. In contrast to previous studies, people with lung cancer were more likely to report positive pathway experiences at older ages, living in more deprived areas, or diagnosed after stage I, all frequently associated with worse clinical outcomes. The distinct observations in lung cancer specific analyses suggest potential unmet needs, such as in early stage disease and younger age groups.

Introduction: More than 2,700 people are diagnosed with mesothelioma each year in the UK. We assessed whether the English Cancer Patient Experience Survey (CPES) respondents with mesothelioma were representative of all people diagnosed with mesothelioma in England in terms of their sociodemographic, clinical and healthcare characteristics. Method: We used national cancer registry data with individual patient record linkages to multiple sources (CPES, mortality, hospital and socioeconomic data). We included all people with a diagnosis of mesothelioma in the registry from 2009-2015 and identified the proportion of CPES respondents. Results: We identified 15,587 people diagnosed with mesothelioma, of which 1,597 (10.3%) were included in CPES. Those in CPES had similar survival to those not included. The adjusted odds of being included in CPES decreased with older age, stage at diagnosis, worsening performance status and increasing comorbidities, but was not associated with gender or socioeconomic deprivation. People with recorded non-white ethnicity were also less likely to be included in CPES. People were more likely to be included in CPES if a lung cancer nurse was present at diagnosis (odds ratio 1.22, 95% confidence interval 1.03-1.45) and were much more likely to have received anti-cancer treatment. Conclusions: CPES provides information across treatement groups, however, policy makers and healthcare providers should be aware of the under-representation of some people with mesothelioma, particularly the half who do not received treatment; feedback on their care should be sought in patient experience surveys.

BackgroundApproximately 15%–20% of all non-small cell lung cancer (NSCLC) cases present with stage I disease. Surgical resection traditionally offers the best chance of a cure but some patients will not have this treatment due to older age, comorbidities or personal choice. Stereotactic ablative radiotherapy (SABR) has become an established curative intent treatment option for patients who are not selected for or do not choose surgery. The aim of this study is to compare survival at 90 days, 6 months, 1 year and 2 years for patients who received either lobectomy or SABR.MethodsWe used data from the 2015 National Lung Cancer Audit database and linked with Hospital Episode Statistics and the radiotherapy dataset to identify patients with NSCLC stage IA-IB and performance status (PS) 0–2 who underwent surgery or SABR treatment. We assessed the likelihood of death at 90 days, 6 months, 1 year and 2 year after diagnosis and procedure date to observe survival between two patient groups.ResultsWe identified 2373 patients in our cohort, 476 of whom had SABR. The median difference between date of diagnosis and date of treatment for surgery patients was 17 days while for SABR patients it was 73 days. Increasing age and worsening PS were associated with having SABR rather than surgery. Survival between the two treatment modalities was similar early on but by 1-year people who had surgery did better than those who had SABR (adjusted ORs 2.12, 95% CI 1.35 to 2.31). This difference persisted at 2 years and when the analysis was restricted to patients aged ConclusionOur analysis suggests that patients who have lobectomy have a better survival compared with SABR patients; however, we found considerable delays in patients receiving SABR which may contribute to poorer long-term outcomes with this treatment option. Reducing these delays should be a key focus in development and reorganisation of services.

Aims We present the first analysis of the management and outcomes of stage III non-small cell lung cancer (NSCLC) conducted in England using National Lung Cancer Audit data. Materials and methods Patients diagnosed with stage III NSCLC in 2016 were identified. Linked datasets (including Hospital Episode Statistics, the National Radiotherapy Dataset, the Systemic Anti-Cancer Dataset, pathology reports and death certificate data) were used to categorise the treatment received. Kaplan–Meier survival curves were obtained, with survival defined from the date of diagnosis to the date of death. Results In total, 6276 cases of stage III NSCLC were analysed: 3827 stage IIIA and 2449 stage IIIB; 1047 (17%) patients were treated with radical radiotherapy with 676 (11%) of these also receiving chemotherapy. Twenty per cent of patients with stage IIIA disease underwent surgery, with half of these also receiving chemotherapy, predominantly delivered in the adjuvant setting. Of note, 2148 (34%) patients received palliative-intent treatment and 2265 (36%) received no active anti-cancer treatment. The 1-year survival was 32.9% (37.4% for stage IIIA), with the highest survival seen for those patients receiving chemotherapy and surgery. Conclusions We highlight important gaps in the optimal care of patients with stage III NSCLC in England. Multimodality treatment with either surgery or radical radiotherapy combined with chemotherapy was delivered to less than one-fifth of patients, even though these regimens are considered optimal. Timely access to specialist resources and staff, the practice of effective shared decision making and challenging preconceptions have the potential to optimise management.

IntroductionData from the National Lung Cancer Audit (NLCA) often show variation in outcomes between lung cancer units which are not entirely explained by case mix. We explore the association between the organisation of services and patient outcome.MethodsDetails of service provision were collected via an electronic survey in June 2017. An overall organisational score derived from eleven key service factors from national lung cancer commissioning guidance was calculated for each organisation. The results for each hospital were linked to their patient outcome results from the 2015 NLCA cases. Multivariate logistic regression analysis was used to link the organisational score to patient outcomes.ResultsLung cancer unit organisational audit scores varied from 0 to 11. Thirty-eight (29%) units had a score of 0–4, 64 (50%) had a score of 5–7 and 27 (21%) had a score of 8–11. Multivariate regression analysis revealed that, compared with an organisational score of 0–4, patients seen at units with a score of 8–11 had higher 1-year survival (adjusted OR (95% CI)=2.30 (1.04 to 5.08), pConclusionNational variation in the provision of services and workforce remain. We provide evidence that adherence to the national lung commissioning guidance has the potential to improve patient outcomes within the current service structure.

Background\ud \ud Cancer nurse specialists are advanced practitioners who offer continuity of care and expert support for people diagnosed with specific cancers. Health Education England's Cancer Workforce Plan prioritises expansion of cancer nurse specialist numbers by 2021 as part of the Cancer Taskforce Strategy for England.\ud \ud \ud \ud Objective\ud \ud To assess whether working practices of advanced practice specialist nurses are associated with clinical outcomes for people with lung cancer.\ud \ud \ud \ud Methods\ud \ud Adults with non-small cell lung cancer followed from 30 days post-diagnosis in English secondary care were obtained from the English National Lung Cancer Audit, 2007 to 2011. A national survey of lung cancer nurse specialists provided information on self-reported working practices. Mortality and unplanned admissions from 30 days to 12 months post diagnosis were respectively analysed using Cox and Poisson regression. Outcomes were assessed according to patients’ receipt of initial assessments by a lung cancer nurse specialist and according to trust-level reported working practices. Regression models were adjusted for individual sociodemographic and clinical characteristics, error adjusted for intracorrelations within regional cancer networks, and presented separately according to patients’ treatment pathways (surgery, chemotherapy, radiotherapy, or no anti-cancer therapy).\ud \ud \ud \ud Results\ud \ud Data for 108,115 people with lung cancer were analysed and associations with mortality and unplanned admissions were infrequent. Among people receiving only radiotherapy, however, the hazard for death was 17% lower among those who received an assessment by a lung cancer nurse specialist, compared with no assessment (hazard ratio = 0.83, 95% confidence interval 0.73–0.94; p = 0.003). The hazard was also lower among those receiving surgery (hazard ratio = 0.91, 0.84–0.99; p = 0.028). Among those receiving radiotherapy, nurse specialists’ reported confidence within multidisciplinary team settings was associated with a lower risk of death (hazard ratio = 0.88, 0.78–1.00; p = 0.049) and a lower rate of unplanned cancer-related admissions (incidence rate ratio = 0.83, 0.73–0.95; p = 0.007). Lung cancer nurse specialist assessments before/at diagnosis, were associated with a 5% lower rate of unplanned admissions, compared to when assessments occurred after diagnosis.\ud \ud \ud \ud Conclusion\ud \ud The contribution of nurse specialist working practices was occasionally associated with better outcomes for people with lung cancer. These were not limited to a single treatment pathway, but do indicate discrete relationships within pathways. Our study provides initial measures of overall lung cancer nurse specialist working practices at trusts, however, more detailed studies with longitudinal measurement of lung cancer nurse specialist-patient interaction are needed to better ascertain impacts on long-term patient outcomes. The findings highlight opportunities for potential improvement in effectiveness of service and care management.

Introduction Surgery is the preferred treatment for patients with early-stage non-small cell lung cancer (NSCLC) while stereotactic body radiation therapy (SBRT) may be applied in patients with major comorbidity or high age. We evaluated the association between age and treatment utilization for early-stage NSCLC in patients diagnosed in 2015–2016 in three European countries. Patients and methods Information was retrieved from population-based registries in England, Norway and the Netherlands. Treatment patterns and two-year overall survival rates for 105,124 patients with clinical stage I were analysed by age-group. Results Surgical resection rates were higher in Norway (55%) and England (53%) than in the Netherlands (47%), and decreased with increasing age. SBRT use was highest in the Netherlands (41%), followed by Norway (29%) and England (12%). In the Netherlands, SBRT was the prevailing treatment in patients aged 70 years or older. In octogenarians, the proportion not receiving curative intent treatment was 53% in England, versus 35% in Norway and 22% in the Netherlands. Two-year survival rates were better for surgery than for SBRT and slightly better in Norway. Conclusion In patients aged 70 years or older, the proportion not receiving any curative treatment remains substantial, and differs significantly between countries. Measures to address these disparities are needed.

Background The mainstay of treatment for small cell lung cancer (SCLC) involves platinum doublet chemotherapy but the optimal duration, 4 vs. 6 cycles, is not known. Concurrent thoracic radiotherapy followed by prophylactic cranial irradiation (PCI) is recommended for fit individuals with limited stage. However, outside of clinical trials, the efficacy of sequential thoracic radiotherapy and PCI for extensive stage is uncertain. Methods This retrospective, observational, cohort study used English national lung cancer data to determine the factors associated with survival for all people diagnosed with SCLC. More precisely, for individuals who received chemotherapy, we examined survival by the chemotherapy duration, thoracic radiotherapy dose and the use of PCI. Results In total 6,438 people were diagnosed with SCLC. We identified that male sex (OR 0.7; 95% CI: 0.62-0.80), increasing age (P=0.01) greater comorbidity (P≤0.01), extensive stage (OR 0.21; 95% CI: 0.19-0.25) and worse performance status (PS2 vs. PS0 adjusted OR 0.38 95% CI: 0.31-0.48) were associated with reduced 1-year survival. Receipt of chemotherapy augmented survival. We analysed data for 1,761 people who had received chemotherapy. Thoracic radiotherapy (≥30 Gy for extensive stage and ≥40 Gy for limited stage) and PCI were independently associated with better survival (P≤0.01 for each), but 6 cycles of chemotherapy instead of 4 was not (limited stage adjusted OR 0.97; 95% CI: 0.48-1.97) extensive stage adjusted OR 1.34; 95% CI: 0.81-2.21). Conclusions Extending chemotherapy beyond 4 cycles to 6 does not augment survival. Appropriately prescribed thoracic radiotherapy and PCI can prolong survival in both limited and extensive stage SCLC.

Background Thirty-day mortality after treatment for lung cancer is a measure of unsuccessful outcome and where treatment should have been avoided. Guidelines recommend offering chemotherapy to individuals with small-cell lung cancer (SCLC) who have poorer performance status (PS) because of its high initial response rate. However, this comes with an increased risk of toxicity and early death. We quantified real-world 30-day mortality in SCLC after chemotherapy, established the factors associated with this and compared these with the factors that influence receipt of chemotherapy. Methods We used linked national English data sets to define the factors associated with both receiving chemotherapy and 30-day mortality after chemotherapy. Results We identified 3715 people diagnosed with SCLC, of which 2235 (60.2%) received chemotherapy. There were 174 (7.8%) deaths within 30 days of chemotherapy. The adjusted odds of receiving chemotherapy decreased with older age, worsening PS and increasing comorbidities. Thirty-day mortality was independently associated with poor PS [PS 2 vs PS 0, adjusted odds ratio (OR) 3.75, 95% confidence interval (CI) 1.71–8.25] and stage (extensive vs limited adjusted OR 1.68, 95% CI 1.03–2.74) but in contrast was not associated with increasing age. Both chemotherapy administration and 30-day mortality varied by hospital network. Conclusions To reduce variation in chemotherapy administration, predictors of 30-day mortality could be used as an adjunct to improve suboptimal patient selection. We have quantified 30-day mortality risk by the two independently associated factors, PS and stage, so that patients and clinicians can make better informed decisions about the potential risk of early death after chemotherapy.

Introduction Optimal management of people with advanced NSCLC depends on accurate identification of predictive markers. Yet, real-world data in this setting are limited. We describe the impact, timeliness, and outcomes of molecular testing for patients with advanced NSCLC and good performance status in England. Methods In collaboration with Public Health England, patients with stages IIIB to IV NSCLC, with an Eastern Cooperative Oncology Group performance status of 0 to 2, in England, between June 2017 and December 2017, were identified. All English hospitals were invited to record information. Results A total of 60 of 142 invited hospitals in England participated in this study and submitted data on 1157 patients. During the study period, 83% of patients with advanced adenocarcinoma underwent molecular testing for three recommended predictive biomarkers (EGFR, ALK, and programmed death-ligand 1). A total of 80% of patients with nonsquamous carcinomas on whom biomarker testing was performed had adequate tissue for analysis on initial sampling. First-line treatment with a tyrosine kinase inhibitor was received by 71% of patients with adenocarcinoma and a sensitizing EGFR mutation and by 59% of those with an ALK translocation. Of patients with no driver mutation and a programmed death-ligand 1 expression of greater than or equal to 50%, 47% received immunotherapy. Conclusions We present a comprehensive data set for molecular testing in England. Although molecular testing is well established in England, timeliness and uptake of targeted therapies should be improved.

Background One possible explanation for poor survival in lung cancer patients in the UK is under-utilisation of curative-intent treatment. We carried out a spotlight audit to understand why eligible patients do not receive surgical treatment and whether national guidelines for assessment of early-stage lung cancer were being adhered to. Methods Details of patients in England with stage I/II NSCLC and a performance status of 0–1 who did not undergo surgical treatment were extracted from the NLCA dataset and used to populate a web-based portal developed in conjunction with the National Cancer Registration and Analysis Service (NCRAS). Trusts were invited to populate their cases with additional data. Results 82 of 142 trusts in England took part in the audit and data on 775 patients was suitable for analysis (67% stage I and 33% stage II). 46% of patients did receive treatment with curative intent in the form of SABR or radical radiotherapy (including CHART). 8% received other anti-cancer therapy, and 46% received best supportive care. As expected, age over 75 independently predicted best supportive care, even after other factors associated with age (such as co-morbidity and PS) are taken into account. 31% of patients did not have surgery owing to patient choice and, of these, 66% preferred SABR or other radical radiotherapy, while the remainder elected for no treatment. Only 2% of patients had a second surgical opinion, 14% had a CPEX, 34% had an echocardiogram and 11% had a V/Q scan. Very few patients had a shuttle walk test, or had thoracoscore or a formal cardiac risk assessed. 1 year survival for patients having best supportive care was 37%, for SABR it was 67%, for radical radiotherapy it was 45% and for those undergoing palliative radiotherapy was 27%. After adjustment for age, PS, stage, deprivation index and comorbidity index (ACE-27), both SABR and radical radiotherapy improved survival compared with best supportive care. Conclusions Although nearly half the patients did receive an alternative treatment with curative intent, patient choice is a common reason for not receiving surgery. It is crucial that patients are assessed according to best practice and that information about their options is delivered and discussed appropriately.

Objectives: Treatment choices for people with lung cancer may be influenced by contact and engagement with lung cancer nurse specialists (LCNSs). We investigated how service factors, LCNS workload, and LCNS working practices may influence the receipt of anticancer treatment. Materials and methods: English National Lung Cancer Audit data and inpatient Hospital Episode Statistics for 109,079 people with lung cancer surviving 30 days from diagnosis were linked along with LCNS workforce census data and a bespoke nationwide LCNS survey. Multinomial logistic regression was used to determine adjusted relative risk ratios (RRRs) for receipt of anticancer therapies associated with LCNS assessment, LCNS workforce composition, caseload, LCNS reported working practices, treatment facilities at the patients’ attending hospitals, and the size of the lung cancer service. Results: Assessment by an LCNS was the strongest independent predictor for receipt of anticancer therapy, with early LCNS assessments being particularly associated with greater receipt of surgery (RRR 1.85, 95%CI 1.63–2.11). For people we considered clinically suitable for surgery, receipt was 55%. Large LCNS caseloads were associated with decreased receipt of surgery among suitable patients (RRR 0.71, 95%CI 0.51–0.97) for caseloads >250 compared to ≤150. Reported LCNS working practices were associated with receipt of surgery, particularly provision of psychological support (RRR 1.60, 95%CI 1.02–2.51) and social support (RRR 1.56, 95%CI 1.07–2.28). Conclusion: LCNS assessment, workload, and working practices are associated with the likelihood of patients receiving anticancer therapy. Enabling and supporting LCNSs to undertake key case management interventions offers an opportunity to improve treatment uptake and reduce the apparent gap in receipt of surgery for those suitable. Keywords: Lung cancer; Nurse specialists; Treatment; Workload; Case management; Clinical Audit

Introduction: Pleural mesothelioma has a dismal prognosis and is refractory to local treatment. Combination chemotherapy can increase median survival by several months and was gradually introduced in the period 2003-2006. Elderly patients may be unfit for chemotherapy but little is known about age-related treatment practice. To determine treatment patterns and current survival outcome, three large population-based registries were queried in a uniform manner. Methods: Data from the Belgian Cancer Registry, the Netherlands Cancer Registry and the UK National Lung Cancer Audit were analyzed for patients diagnosed with pleural mesothelioma since 2007. Treatment patterns and survival rates were compared between countries and age-groups. Results: The study included 900, 2306 and 5808 patients from Belgium, the Netherlands and England, respectively. Fifty-nine percent of patients were 70 years or older and 84% were men. Chemotherapy use decreased with advancing age and was used more often in Belgium (60%) than in the Netherlands (41%) and England (37%). For patients aged 70-79 years, chemotherapy use was 55%, 36% and 34% in the respective countries. Median survival was 10.7 months in Belgium versus 9.2 months for the Netherlands and 9.5 months for England. Survival rates decreased with advancing age. On average, median survival was 5.6 months longer for patients treated with chemotherapy, irrespective of age. Conclusions: Combined analysis of data from three countries with high mesothelioma rates demonstrates that chemotherapy has become standard treatment for younger patients. Elderly patients currently account for more than half of all cases and less toxic treatment options will be required to improve their prospects. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Introduction The National Lung Cancer Audit has collected data for over 10 years demonstrating gradually rising resection rates in the UK. The Clinical Outcomes Programme (COP) uses national audit data to publish quality measures at the level of individual consultants. The lung cancer COP focusses on activity at individual surgeon level, and on survival at unit level. Previous rounds of this audit demonstrated overall 30 and 90 day survival of 97.8% and 95.5% (2013) and 97.9% and 96.2% (2014). Methods Data submitted to the NLCA for patients having curative-intent surgery who underwent surgery in 2015 was sent to the clinical lead at each surgical unit for validation and addition of responsible surgeon GMC number, with the option to add surgical cases if they were not included in the supplied dataset. Date of death was derived by a link to the Office of National Statistics. Units reporting unadjusted survival proportions more than three standard errors outside the national mean (“alarm” level) at 30 or 90 days were identified as statistical outliers. Results All of the 28 surgical units in England participated in the audit, submitting a total of 5843 cases, of which 93% were NSCLC, 2% SCLC and 6% carcinoid. Median annual unit activity was 186 resections (IQR 141–264, range 49–507), an increase over the median 156 in the previous year. Median annual activity for individual surgeons was 44 (IQR 18–67, range 1–171). Median LOS 8.1 days (median 6, IQR 4–9). Overall 30 day survival was 98.2% and 90 day survival was 96.3%. There were no units with statistical outliers at the alarm level at 30 days and 90 days (see figure 1). Overall 1 year survival 87.9%. Conclusion Volume of activity varies widely by unit and individual surgeon. Survival after lung cancer surgery is very high, is improving, and is not statistically significantly different across the surgical units in England. New measures are needed to properly reflect features that are important to patients.

In 2014, the method of data collection from NHS trusts in England for the National Lung Cancer Audit (NLCA) was changed from a bespoke dataset called LUCADA (Lung Cancer Data). Under the new contract, data are submitted via the Cancer Outcome and Service Dataset (COSD) system and linked additional cancer registry datasets. In 2014, trusts were given opportunity to submit LUCADA data as well as registry data. 132 NHS trusts submitted LUCADA data, and all 151 trusts submitted COSD data. This transitional year therefore provided the opportunity to compare both datasets for data completeness and reliability. We linked the two datasets at the patient level to assess the completeness of key patient and treatment variables. We also assessed the interdata agreement of these variables using Cohen's kappa statistic, κ. We identified 26 001 patients in both datasets. Overall, the recording of sex, age, performance status and stage had more than 90% agreement between datasets, but there were more patients with missing performance status in the registry dataset. Although levels of agreement for surgery, chemotherapy and external-beam radiotherapy were high between datasets, the new COSD system identified more instances of active treatment. There seems to be a high agreement of data between the datasets, and the findings suggest that the registry dataset coupled with COSD provides a richer dataset than LUCADA. However, it lagged behind LUCADA in performance status recording, which needs to improve over time., New lung cancer data submission method provides a richer dataset http://ow.ly/zE5r30ceaUU

Objectives: To determine the influence of where a patient is first seen (either surgical or non-surgical centre) and patient features on having surgery for non-small cell lung cancer (NSCLC). Design: Cross-sectional study from individual patients, between 1January 2008 and 31March 2012. Setting: Linked National Lung Cancer Audit and Hospital Episode Statistics datasets. Participants: 95 818 English patients with a diagnosis of NSCLC, of whom 12 759 (13%) underwent surgical resection. Main outcome measure: Odds of having surgery based on the empirical catchment population of the 30 thoracic surgical centres in England and whether the patient is first seen in a surgical centre or a non-surgical centre. Results: Patients were more likely to be operated on if they were first seen at a surgical centre (OR 1.37; 95% CI 1.29 to 1.45). This was most marked for surgical centres with the largest catchment populations. In these surgical centres with large catchment populations, the resection rate for local patients was 18% and for patients first seen in a non-surgical centre within catchment was 12%. Conclusions: Surgical centres that serve the largest catchment populations have high resection rates for patients first seen in their own centre but, in contrast, low resection rates for patients first seen at the surrounding centres they serve. Our findings demonstrate the importance of going further than relating resection rates to hospital volume or surgeon number, and show that there is a pressing need to design lung cancer services which enable all patients, including those first seen at non-surgical centres, to have equal access to lung cancer surgery.

Background: Chemotherapy improves survival for many patients with SCLC, and hence it is important to understand variations in practice and outcomes for this treatment strategy. Methods: We used the National Lung Cancer Audit and Hospital Episodes Statistics to determine the proportion of patients who received chemotherapy for SCLC, and assess the effects of patient and organisational factors on the odds of receiving chemotherapy and of completing four cycles. We calculated median survival and used Cox regression to determine factors that predicted survival. Results: Of 15 091 cases of SCLC, 70% received at least one cycle of chemotherapy. More deprived people were less likely to receive chemotherapy, but patients were more likely to receive chemotherapy, and to complete Xfour cycles, if they were referred to the lung cancer team by their GP. Median survival for those treated with chemotherapy was 12.9 months for limited and 7.3 months for extensive stage disease. Conclusions: The Linked NLCA and HES data provide real-life measures of survival in people treated with chemotherapy and show how this is influenced by patient and tumour characteristics. These data show the characteristics of patients who are less likely to complete a full course of treatment, an adverse predictor of survival.

Introduction For appropriately staged non-small cell lung cancer (NSCLC) surgical resection can dramatically improve survival, but some may not be offered this treatment because of concerns about perioperative mortality. Methods We used data from the National Lung Cancer Audit (NLCA) to determine the proportions of English patients who died within 30 and 90 days after surgery for NSCLC. We quantified the predictors of early postoperative death and using these results devised a score to predict risk of death within 90 days of surgery. Results We analysed data on 10 991 patients operated on between 2004 and 2010. Three per cent (334) of patients died within 30 days of their procedure and 5.9% (647) within 90 days. Age was strongly associated with early postoperative death (adjusted OR within 90 days for 80–84 years vs 70–74 years: 1.46, 95% CI 1.07 to 1.98); significant associations were also observed with performance status (PS) (adjusted OR within 90 days for PS 2 vs PS 0: 2.40, 95% CI 1.68 to 3.41), as well as lung function, stage and procedure type. Conclusions Our results show that age is the most important predictor of death within both of these early postoperative periods. We used the data in the NLCA to develop a predictive score, based on an English population and specific to lung cancer surgery, which estimates risk of death within 90 days; this score should be tested in future cohorts.

The National Lung Cancer Audit (NLCA) recommends that trusts obtain pathology (histology or cytology) for 75% of their lung cancer patients, however this figure was arbitrarily chosen and the optimal pathological confirmation rate is unknown, and many countries report somewhat higher rates. The aims of this study were to provide a simple means of benchmarking appropriate pathological confirmation rates by stratifying patients into groups, and whether obtaining pathology based on those groups is associated with a survival benefit.We calculated the proportion of patients with non-small cell or small cell lung cancer in the NLCA database, first seen between 1st January 2004 and 31st December 2010, who had pathological confirmation of their diagnosis. Using logistic we assessed the independent influence of patient factors on the likelihood of having histology or cytology, and the overall effect on survival. We also used bivariate analysis to identify the features which were most strongly associated with having pathology and performed Cox regression to identify any survival advantage.We analysed data on 136,993 individuals. Age and performance status (PS) were the strongest predictors of pathological confirmation: age ≥ 85 odds ratio (OR) 0.20 (95% confidence interval (CI) 0.19-0.22) compared with age55; PS 4 OR 0.11 (95%CI 0.10-0.12) compared with PS 0. Pathological confirmation of diagnosis was associated with a small early survival advantage for groups 12 which represented younger patients with good PS, even after adjusting for other patient features: hazard ratio (HR) 0.930.89 respectively.Stratifying patients by age and performance status is useful and appropriate when benchmarking standards for pathological confirmation of the diagnosis of lung cancer. We have shown better survival at six months and one year for younger patients with better PS, even after adjusting for confounders. Much of the survival advantage was accounted for by adjusting for the use of chemotherapy.

Introduction: The National Lung Cancer Audit (NLCA) was introduced in 2004 in the UK in order to collect data to improve the standard of care for patients. During this time, it has become important to refine the pathological phenotype of non-small cell lung cancer to determine optimum systemic anti-cancer therapy (SACT), clinical trial eligibility and decision to genotype. Methods: Using data submitted to the NLCA between 2009-14, we calculated the total number of cases submitted, the proportion of cases receiving a pathological diagnosis, and the proportion of cases of pathologically-confirmed NSCLC coded as NSCLC not otherwise specified (NOS). Results: The number of cases submitted and the pathological confirmation rate remained stable over the period of investigation. There has been a gradual fall in the NSCLC NOS rate, from 30.5% in 2009 to 12.4% in 2014 (Table 1). Analysis by cancer network however showed a significant variation in the rate from 9.1% to 22.5%, and there was even greater variation across individual hospital trusts (range 0% to 36%), with 45 of 133 trusts failing to achieve a 15% benchmark. Conclusion: There has been a marked improvement in the proportion of patients in England who have their NSCLC subtyped over the last 6 years. However, some organisations continue to report high NOS rates. These organisations should examine their results and implement mechanisms to ensure that best practice in pathological sampling, processing and reporting is being followed.

Introduction: The National Lung Cancer Audit aims to record outcomes in lung cancer on a large scale and to highlight variation, adjusted for case-mix, as a driver to local service improvement. We have analysed all cases of NSCLC (both histologically-confirmed and clinically diagnosed) submitted to the audit from England and Wales to extract information on trends in management and outcome, focussing on changes in survival patterns. Results: Over 150,000 cases of NSCLC have been submitted since 2005. All secondary care organisations in England and Wales submit individual patient data on approximately 100% of incident cases. Data quality has progressively improved with over 90% of cases having stage and performance status recorded. Measures of quality of care (e.g. histological confirmation, resection and anti-cancer treatment rates) have gradually risen over the audit lifespan, and the aim to eliminate regional variation has been partially achieved (e.g. inter-quartile range for anti-cancer treatment rate by organisation: 43-62 in 2008, 56-64 in 2013). We analysed hazard ratio for mortality in NSCLC (England only) by year of diagnosis in a multivariate model adjusted for age, sex, stage and performance status and the results are shown in Table 1. Conclusions: A focus on local service improvement driven by highlighting variation has been successful in reducing variation and improving outcome. The development of similar initiatives in other European countries has the potential to prevent large numbers of lung cancer deaths.

Background: Non-small cell lung cancer (NSCLC) in young adults is a rare but devastating illness with significant socioeconomic implications, and studies of this patient subgroup are limited. Aim: This study employed the National Lung Cancer Audit to compare the clinical features and survival of young adults with NSCLC with the older age groups. Design: A retrospective cohort review using a validated national audit dataset. Methods: Data were analysed for the period between 1 January 2004 and 31 December 2011. Young adults were defined as between 18 and 39 years, and all others were divided into decade age groups, up to the 80 years and above group. We performed logistic and Cox regression analyses to assess clinical outcomes. Results: Of a total of 1 46 422 patients, 651 (0.5%) were young adults, of whom a higher proportion had adenocarcinoma (48%) than in any other age group. Stage distribution of NSCLC was similar across the age groups and 71% of young patients had stage IIIb/IV. Performance status (PS) was 0–1 for 85%. Young adults were more likely to have surgery and chemotherapy compared with the older age groups and had better overall and post-operative survival. The proportion with adenocarcinoma, better PS and that receiving surgery or chemotherapy diminished progressively with advancing decade age groups. Conclusion: In our cohort of young adults with NSCLC, the majority had good PS despite the same late-stage disease as older patients. They were more likely to have treatment and survive longer than older patients.

Background: The purpose of this study was to identify trends in survival and chemotherapy use for individuals with smallcell lung cancer (SCLC) in England using the National Lung Cancer Audit (NLCA). Methods: We used data from the NLCA database to identify people with histologically proven SCLC from 2004–2011. We calculated the median survival by stage and assessed whether patient characteristics changed over time. We also assessed whether the proportion of patients with records of chemotherapy and/or radiotherapy changed over time. Results: 18,513 patients were diagnosed with SCLC in our cohort. The median survival was 6 months for all patients, 1 year for those with limited stage and 4 months for extensive stage. 69% received chemotherapy and this proportion changed very slightly over time (test for trends p = 0.055). Age and performance status of patients remained stable over the study period, but the proportion of patients staged increased (p-value,0.001), mainly because of improved data completeness. There has been an increase in the proportion of patients that had a record of receiving both chemotherapy and radiotherapy each year (from 19% to 40% in limited and from 9% to 21% in extensive stage from 2004 to 2011). Patients who received chemotherapy with radiotherapy had better survival compared with any other treatment (HR 0.24, 95% CI 0.23–0.25). Conclusion: Since 2004, when the NLCA was established, the proportion of patients with SCLC having chemotherapy has remained static. We have found an upward trend in the proportion of patients receiving both chemotherapy and radiotherapy which corresponded to a better survival in this group, but as it only applied for a small proportion of patients, it was not enough to change the overall survival.

Background: In comparison with other European and North American countries, England has poor survival figures for lung cancer. Our aim was to evaluate the changes in survival since the introduction of the National Lung Cancer Audit (NLCA). Methods: We used data from the NLCA to identify people with non-small-cell lung cancer (NSCLC) and stratified people according to their performance status (PS) and clinical stage. Using Cox regression, we calculated hazard ratios (HRs) for death according to the year of diagnosis from 2004/2005 to 2010; adjusted for patient features including age, sex and co-morbidity. We also assessed whether any changes in survival were explained by the changes in surgical resection rates or histological subtype. Results: In this cohort of 120 745 patients, the overall median survival did not change; but there was a 1% annual improvement in survival over the study period (adjusted HR 0.99, 95% confidence interval (CI) 0.98–0.99). Survival improvement was only seen in patients with good PS and early stage (adjusted HR 0.97, 95% CI 0.95–0.99) and this was partly accounted for by changes in resection rates. Conclusion: Survival has only improved for a limited group of people with NSCLC and increasing surgical resection rates appeared to explain some of this improvement.

Introduction The National Lung Cancer Audit has collected data for over 10 years demonstrating gradually rising resection rates in the UK. The Clinical (formerly Consultant) Outcomes Programme (COP) is an NHS England initiative, managed by HQIP, using national audit data to publish quality measures at the level of individual consultants. The lung cancer COP focusses on activity at individual surgeon level, and on survival at unit level. The first lung cancer COP in 2014 demonstrated overall 30 and 90-day survival of 97.8% and 95.5%. Methods Data submitted to the NLCA for patients having curative-intent surgery who underwent surgery in 2013 was sent to the clinical lead at each surgical unit for validation and addition of responsible surgeon GMC number, with the option to add surgical cases if they were not included in the supplied dataset. Date of death was derived by a link to the Office of National Statistics. Units reporting unadjusted survival proportions more than three standard errors outside the national mean (“alarm” level) at 30 or 90 days were identified as statistical outliers. Results All of the 28 surgical units in England participated in the audit, submitting a total of 4892 cases. Median annual unit activity was 156 resections (IQR 99–221, range 39–481). Median annual activity for individual surgeons was 39 (IQR 20–52, range 1–152). Overall 30-day survival was 98% and 90-day survival was 96%. There were no units with statistical outliers at the alarm level at 30-days and 90-days (see Figure). Conclusion Volume of activity varies widely by unit and individual surgeon. Survival after lung cancer surgery is very high, is improving, and is not statistically significantly different across the surgical units in England. This suggests that lung cancer teams may still be risk averse when considering surgical treatment of their patients. Reasons why patients die between 30 and 90 days is worthy of further investigation. Case-mix adjustment will be needed to allow robust comparisons between units.

Introduction In 2014, the contract to deliver the National Lung Cancer Audit (NLCA) was awarded to the Royal College of Physicians. Data were previously submitted using a bespoke dataset (LUCADA), but will now be submitted via the nationally mandated Cancer Outcome and Services Dataset (COSD) and linked to additional cancer registry datasets. For patients diagnosed in 2014, NLCA data were submitted using LUCADA for 132 of 151 English trusts. Trusts also submitted data via COSD and registry data were produced by the National Cancer Registration Analysis Service (NCRAS), providing the opportunity to compare both datasets for data completeness and reliability. Methods We have linked the LUCADA and cancer registration datasets at patient level and assessed completeness of key patient variables including age, sex, stage, performance status and pathological confirmation, as well as recording/dates of treatment received. We assessed the inter-rater/data agreement of these variables using Cohen’s kappa statistics (k). Finally, we carried out a qualitative assessment on a subset of cases to explore reasons why patients were represented in one dataset but not the other. Results There were 26,001 patients in both datasets (94% of LUCADA data) with more in the registry dataset and not LUCADA than vice versa. Recorded sex and age were highly congruent, as was trust first seen which was the same in 96%. 56% of the patients had the same date of diagnosis, 74% were ± 7 days and 86% were ± 14 days of each other. The cancer registry data had a larger proportion of patients with missing PS (27% vs 11%) with agreement on PS (where available) being 97% (k = 0.91). Agreement on stage was 94% (k = 0.81). Agreement for surgery, chemotherapy and radiotherapy was 0.86, 0.88 and 0.77 respectively. Details of the qualitative work and trust first seen algorithms will be provided in the presentation. Conclusion Results suggest that cancer registry data accurately describe key patient features. Compared with LUCADA, the national cancer registry: identified more patients has a higher proportion pathological confirmation identified more patients with surgery, chemotherapy and radiotherapy has a higher proportion of missing data for PS which could be due to data entry transition

Much of the research in lung cancer is concerning survival or treatment rates and little is known about the rate of hospitalisation (emergency/elective) following the diagnosis of lung cancer. Newly diagnosed English patients from the National Lung Cancer Audit database (NLCA), 2007–2011, were linked with Hospital Episode Statistics (HES) data to provide details on their subsequent hospital admissions. Hospitalisations for receipt of chemotherapy or cardiothoracic surgery were excluded to ensure only non-treatment related admissions were included. We only included patients included who survived at least 30 days after their first presentation to a physician to exclude more advanced disease. We calculated rates and rate ratios (RR) of elective and emergency admissions per person-year (ppy) by patient features including sex, age, performance status and co-morbidity. Among 92,482 patients, there were 261,121 non-treatment related hospitalisations with rate of 2.92 admissions ppy (95% CI, 2.91–2.93). Emergency admissions constituted 57% of all admissions at a rate of 1.66 admissions ppy while the elective admission rate was lower at 1.26 admission ppy. Adjusted RRs in Table 1 show that males were approximately 20% more likely than females to be admitted through either route (RR 1.17, 95% CI 1.16 – 1.18 for emergency and 1.20 (1.18–1.21) for elective). Worsening performance status, co-morbidity and advanced stage were all associated with higher emergency admissions while there was no strong association with age. For elective admissions pattern were similar yet associations were weaker and performance status did not show a linear association with admissions. Increasing socioeconomic deprivation was associated with a moderate increase emergency admission rates but a decrease elective admission rates. The rate of emergency admissions was higher than the rate of elective admissions following diagnosis of lung cancer. Sex, worsening performance status, advanced stage and co-morbidity were all independently associated with admissions with similar patterns for emergency and elective admissions. However, being from a more deprived socioeconomic class was associated with more emergency admissions and fewer elective admissions. Reason for these findings could be related to variation in receiving treatment in these groups or treatment related side effects leading to more emergency admissions.