Introduction The National Lung Cancer Audit stipulates a minimum 75% tissue diagnosis rate in order to meet the standard required for Peer Review. Whilst this is imperative in patients suitable for potentially curative treatment (PS=1–2), in those with a poorer performance state (PS=3–4) it has been suggested that investigations aimed at obtaining a tissue diagnosis lengthen the diagnostic process without improving the patient journey, thereby wasting resource and diminishing the quality of care. To look at this further, we studied patients with PS=3–4 diagnosed at our large lung cancer unit (all-patients tissue diagnosis rate >80%), comparing their tissue diagnosis rate with treatment offered and ultimate outcome.

Methods All 108 patients (57 male) with PS=3–4 (18 PS=4) diagnosed at our unit during 2009 formed the study population (25% of total diagnoses). Eighty-eight diagnostic procedures were attempted in 72 patients (66%), and were successful in 59 of these (82%) (15 small cell, 40 non-small cell, 4 other malignancies).

Results Although a tissue diagnosis was more likely to be attempted in those with PS=3 than 4 (66/90 vs 6/18, χ²=10.8, p<0.01), it was no more likely to be successful (54/66 vs 5/6, χ²=0.1, p=NS). Those with a tissue diagnosis were more likely to be offered chemo or radiotherapy (active treatment) (28/59 vs 5/49, χ²=17.5, p<0.001), with the remaining patients benefiting from best supportive care (BSC). Furthermore, Kaplan–Meier plots (censored at 150 days) demonstrated that those who underwent active treatment had an improved clinical outcome (median survival: treated group 81 days [IQR 48–143] vs BSC group 16 days [6–56], p<0.001).

Conclusions This audit shows that patients with a poor performance state who undergo some form of active treatment gain a survival benefit. For clinical governance reasons, active treatment is unlikely to be offered to patients without a tissue diagnosis, underlining the need to appropriately investigate this patient group wherever possible. We achieved a tissue diagnosis rate of 55%, and exhort other lung cancer units to adopt a similar approach to improve the clinical journey of these unfortunate and sometimes under treated patients.