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We read with interest the study of Larocheet al.1 Clearly the system they describe with a multidisciplinary clinic and specialist surgical input will enhance the investigative process and so probably improve the quality of the care of patients presenting to a respiratory service with possible lung cancer. We commend the authors on this.
We do, however, have serious questions as to whether the resection rate of 25% quoted is actually a true reflection on the resection rate for the whole population of patients with lung cancer within the area. In other words, it is essential to know what the absolute denominator was.
A review of registry data in the former Yorkshire region shows that only half the patients with lung cancer present in the “classical” way to a respiratory physician with a prior diagnosis of possible lung cancer. Virtually all patients who do prove operable are found in the half who present in the classical way. If experience is similar in East Anglia, then the denominator should be doubled.
In addition, we are concerned that some patients with advanced chronic obstructive disease or metastatic lung cancer would not have been referred to the clinic by the nine screening chest physicians. Moreover, the reason that small cell lung cancers were excluded from the denominator is unclear, and again will improve the apparent resection rate. We note that a number of patients were referred direct specifically for surgery from outwith the area, so increasing the numerator.
The authors describe an innovative process for the management of the patient with presumed lung cancer. However, it would be inappropriate to regard the 25% resection rate quoted as a benchmark and a possible audit standard for other lung cancer services, particularly where comorbidity is likely to be higher than in East Anglia.
authors’ reply We agree with the above signatories that our surgical resection rate of 25% may not reflect the resection rate for the whole population of lung cancer patients within the area. What is certain is that our investigation process immediately led to a significant increase in the overall number of patients being referred for surgical resection from within the referral region, and that the number has continued to rise with the increased number of referrals into the system. We have found problems ourselves in attempting to obtain a true figure for overall resection rates.
Cancer registry data include patients who have not undergone histological confirmation and, as we have found from our service, many patients with presumed lung cancer have in reality alternative diagnoses. However, recognising that virtually all patients who do prove operable present in the classical way to chest physicians, it is important to note that, as mentioned in our paper, resection rates of patients with histologically confirmed lung cancer are still less than 10% in some units.
We would therefore propose that, while continually trying to increase the proportion of patients undergoing histological confirmation, the surgical resection rate of patients with confirmed non-small celllung cancer would be the most useful benchmark audit indicator for lung cancer services.