Introduction The majority of people with lung cancer should have pathological confirmation of their diagnosis. The National Lung Cancer Audit (NLCA) recommends that NHS 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.
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.
Methods Using the NLCA database, we calculated the proportion of patients with non-small cell and small cell lung cancer, first seen between 1st January 2004 and 31st December 2010, who had pathological confirmation of their diagnosis. Using bivariate analysis, we identified the features which were most strongly associated with having pathology. We stratified our cohort according to these features and developed 4 groups (Table 1) based on the percentage of pathology obtained by the majority of NHS trusts during the study period.
Results We analysed data on 136,993 individuals. The median age at diagnosis was 72 years (IQR 64–79 years). Performance status (PS) and age were the features most strongly associated with having a pathological diagnosis. Pathological confirmation was associated with a survival benefit at 6 months for patients in groups 1–3 and at 1 year for patients in group 1 & 2 having adjusted for confounders (HR 0.93 & 0.89 respectively). This survival benefit was removed when adjusted for treatment with chemotherapy (Table 2).
Discussion Stratifying by age and PS, is a simple means of benchmarking pathological confirmation rates which is more appropriate than current recommendations. We have shown better survival at six months and one year for patients who had pathological confirmation of lung cancer in groups 1 and 2 (younger patients with better PS), even after adjusting for confounders. Much of this survival advantage was accounted for by adjusting for the use of chemotherapy. We would suggest, therefore, that clinicians should aim to achieve a pathologically confirmed diagnosis in every patient in groups 1 & 2.
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