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Improving surgical resection rates in lung cancer without a two stop service
  1. E F Bowen,
  2. J R Anderson,
  3. M E Roddie
  1. Hammersmith & Charing Cross Hospitals NHS Trust, Du Cane Road, London W12 0HN, UK; fbowen{at}hhnt.org

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In 1998 the Papworth Thoracic Oncology Unit published their data from the first year of a two stop clinic. By this means they improved their surgical resection rates for patients with non-small cell lung cancer (NSCLC) from 10% to 25%.1 This paper is quoted as the benchmark for surgical resection in the UK. In 1998 the surgical resection rate for patients with NSCLC in Hammersmith Hospitals Trust was 4.7% (three of 64 patients). In March 2000 we set up rapid access clinics to assess both patients with abnormal chest radiographs and urgent GP referrals. In accordance with the National Service Framework (NSF),2 multidisciplinary team meetings (MDTM) between respiratory medicine, radiology, cardiothoracic surgery, oncology and palliative medicine were established.

From April 2000 inpatients and outpatients with a chest radiograph suspicious for lung cancer were referred directly from radiology to one of two rapid access clinics within the Trust. Local GPs, outpatient departments, and the emergency department also referred patients. There were no tertiary referrals. All patients were given appointments within the 2 week time period required by the NSF. Patients were told they were being investigated for an abnormal radiograph and would need further investigation with a CT scan and may require a bronchoscopy (FOB) and/or fine needle aspiration/biopsy (FNAB). Written information was given at that point regarding CT scanning, FOB, and FNAB. Staging and tissue diagnosis was completed within 2 weeks.

All results were reviewed in the MDTM and management plans were made and recorded. Following the MDTM, patients were reviewed in a joint clinic with the Macmillan nurse and introduced to either the oncologist or the thoracic surgeon. All data on every aspect of the patient’s management were collected prospectively.

From 1 April 2000 to 31 March 2001 194 patients were seen (118 men). In 100 patients cancer was the most likely diagnosis (56 men and 44 women, mean age 67 years, range 26–95). Six patients declined further investigation. 94 (95%) patients had a finite histological diagnosis: 84 primary lung cancers, three secondary lung cancers, two carcinoid tumours, two Hodgkin’s disease, and three mesothelioma.

Of the 84 patients with lung cancer, 14 had small cell carcinoma and 70 had NSCLC. Of the 70 patients with NSCLC, 20 (28.5%) were referred for thoracotomy (11 men, mean age 64 years, range 48–81). Nineteen patients (27% of NSCLC; 23% of the whole cohort) had a successful resection, 17 lobectomies (stages 5Ia, 3Ib, 3IIa, 3IIb and 3IIIa) and two pneumonectomies (stages IIIb and Ia). One patient (5%) had a failed thoracotomy due to a cardiac event. In five cases (all Ia) the chest radiograph had been taken routinely before another operative procedure and three (Ia and IIIa) were routine outpatient radiographs in asymptomatic patients. There were no postoperative deaths. Two patients (pIIIa) subsequently died at 9 and 11 months, respectively. Currently, the 1 year survival rate for the whole cohort of patients with proven lung cancer is 46%.

With no additional resources we have successfully implemented the lung cancer NSF and have significantly improved our surgical resection rates from 4.7 % in 1998 to 27% of patients with NSCLC and 23% of our whole lung cancer cohort. This is equivalent to the benchmark series for surgical resection in the UK but, unlike that series, none of the patients were tertiary referrals.1 Our large increase in resection rate was not due to a more aggressive surgical approach as 80% of the cases were stage IIb or better, and our failed thoracotomy rate of 5% is similar to other series.1

We have shown that, without the resources to establish a two stop service we have still established a rapid and effective patient pathway culminating in an MDTM and joint clinic. This has produced resection rates considerably better than those previously achieved and a 1 year survival rate that compares very favourably with published UK survival figures.3

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