Lung Cancer Presentation

Dr Richard Sullivan and Ms Anne Fraser

6th November 2014

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Overview

• Background

• Risk Profile of Lung Cancer

• The Lung Cancer Pathway

• Treatment and Management

• DHB Contacts

• Q & A

6 September 2013 3

Background• Lung cancer is the leading cause of cancer

deaths in New Zealand– 1942 people diagnosed in 2010– 1650 people died in 2010

• Survival in NZ is poorer than Australia, Canada, the USA & some European countries

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Background• Poor survival in lung cancer is because the majority of lung cancer

patients present with advanced incurable disease

5yr survival (NSCLC) : Stage I/II 50%, III 15%, IV <3%

• Differences in survival between countries relate to management

• Earlier diagnosis of people with lung cancer has the potential to improve survival, when combined with appropriate and timely investigation and treatment

• Initial Presentation–76% Patients presented to primary care–24% Patients presented to secondary care

• 14% self-presented to the Emergency Department (ED) • 10% were already under secondary care when they developed symptoms or had

an incidental finding

( Stevens, W et al - Final Report - Identification of barriers to the early diagnosis of people with lung cancer and description of best practice solutions July 2012)

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BackgroundSignificant health inequalities exist:•Maori & Pacific have poorer lung cancer survival outcomes

– Maori patients are approximately 3 times more likely to die from their lung cancer than non-Maori patients

•Known differences in stage of disease at diagnosis– Maori patients were 2.5 times more likely to have locally

advanced disease

•Known differences in management of disease– Maori patients had longer timelines from diagnosis to

treatment

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Background• Prevention and Awareness

– Social marketing – “Cough, Cough, Cough”– Tobacco Control/Smoking Cessation– NRT, buproprion (Zyban), varenicline

(Champix)– Access to support and counselling

• NZ National efforts– Aspire 2025, plain packaging

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BackgroundWhy don’t we screen for lung cancer?• "screening with annual CT has been shown to reduce

lung cancer deaths compared to chest Xray” ……. BUT

• high number needed to screen• best selection criteria for screening not yet known• cost effectiveness uncertain• risk of over diagnosis and invasive tests for benign

disease• need for lots of follow up CTs• Also smoking cessation and tobacco control are likely to

be much more (cost) effective

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Risk Profile

Cigarettes

Lung Cancer

Emphysema/COPD

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Profile of a Patient that should be Referred urgently for a chest x-ray

• Unexplained haemoptysis OR• Any of the following unexplained, persistent (lasting more than 3

weeks or less than 3 weeks in people with known risk factors) symptoms and signs: – Chest and/or shoulder pain – Shortness of breath – Weight loss/loss of appetite – Abnormal chest signs – Hoarseness – Finger clubbing – Cervical and/or supraclavicular lymphadenopathy – Cough – Features suggestive of metastasis from a lung cancer (e.g., in

brain, bone, liver or skin)

(NZ Guidelines Group)

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Profile of a Patient that should be Referred Urgently to a Specialist

• Persistent haemoptysis and are smokers or ex-smokers aged 40 years or older

• A chest x-ray suggestive of lung cancer (including pleural effusion and slowly resolving consolidation)

• Finger clubbing• Severe weight loss• SVC Obstruction• Neck nodes – in smokers(NZ Guidelines Group)

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Urgent referral with high-

suspicion of cancer

First cancer treatment

First specialist assessment

Decision-to-treat

Indicator one (best practise – 62 days)

Indicator two (best practise – 14 days) Indicator three (best practise – 31 days)

Includes diagnostics, surgical & non-surgical treatments

All cancers by tumour stream

Lung Cancer Pathway

CT

Lung cancer

PrimaryCare

6 September 2013 12

Identification of Barriers to the Early Diagnosis of Lung Cancer and

Description of Best Practice Solutions

Principal Investigator: Dr Wendy Stevens

Cancer Trials New Zealand, the University of Auckland

Funded by a Health Research Council of New Zealand & District Health Boards New Zealand Grant

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1.1. Presentation/Attendance BarriersPresentation/Attendance Barriers

2. Identification Barriers

3. Waiting Time Barriers

4. Information Barriers

Our Barriers to Early Diagnosis

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Best Practice SolutionsTO REDUCE BARRIERS WITHIN PRIMARY CARE

1. Increase awareness of lung cancer in primary care

2. Smoking status routinely recorded

3. Improve GP utilisation of CXRs

4. Follow up systems in place for patients

5. Regionally consistent investigation & referral pathways

6. A standardised template for e-referral system

7. Audit tool for the assessment of GP lung cancer referral

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Northern Region Radiological Referral Processes

• ADHB and CMDHB– Access to Diagnostics Tool using community and hospital

service providers – Utilising e-referrals process– Some practices utilising Fax refferal system

• NDHB – GP refers to hospital respiratory services with suspected cancer– Respiratory service has to refer for CT scan – Future planned implementation of macro e-referral template

• WDHB– Utilising e-referrals in some practices– Utilise current Fax referral system

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Radiology Access• Chest x-rays

– E-referral or Fax• CXR or CT

– All DHBs have radiology liaisons that can be called to discuss needs and gain access

– Patients can been seen same/next day– GP practices will receive a report with next steps

• All Significant findings will include a phone call to GP• If CT required this should be sent at the same time as FSA

– GPs should be confident in ability to access good DHB radiology capacity

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Lung cancer Pathway

Referral

FSA(< 14 days)

CT

CT report

Bronchoscopy

~35%non diagnostic

CT-FNA Biopsy extra thoracic lesion

TMDM(< 14 days after FSA)

CT-FNA report(<1-3 days)

Biopsy report(< 3 days)

Bronchoscopyreport

(< 3 days)

~65%diagnostic

Respiratory

High SuspicionLung Cancer

When there is a high suspicion of cancer – ensure that you complete• Referral to Respiratory• Referral to CT

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Advances in Treatment/Management

• Management– Minimally invasive staging and surgery

• Endobronchial ultrasound• Thoracoscopic resections

– Stereotactic radiotherapy• Less toxic to normal lung

– Targeted chemotherapy• More effective if +ve for mutations; oral tablets

– Advanced Care Planning and Palliative care

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Key Take Home Messages (1)

• Prevent lung cancer– Ask about smoking status; offer support to quit

• Recognition of lung cancer– Smokers with emphysema/COPD at highest risk– Persistent cough (longer than 3 weeks) not

responding to treatment – most common symptom– Low threshold for ordering Chest Xray– Consider ordering CT chest at same time as specialist

referral– DHBs are now required to see and treat your patient

quickly; most are already doing so

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Key Take Home Messages (2)

• Help treat lung cancer– Advanced Care Planning– Help to give excellent quality palliative care – it can

improve quality of life and even survival

• Lung cancer is not hopeless– Co-morbid patients may still be able to have minimally

invasive surgery or modern radiotherapy– Targeted chemotherapy is effective, less toxic and

easier to take in suitable patients– Palliative radiotherapy is effective for symptom control

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ADHB Key Contacts

• Central Referrals Office – fax (09) 638 0400• Respiratory

– (09) 367 0000 (Physician roster in place)• Radiology - Auckland DHB GP Advice/ Contacts

– Hot Desk 8.30am to 4.30pm Monday to Friday• (09) 3074949 Ext 24571#

– Fax (09) 375 7033 (Auckland City Hospital)– Fax (09) 623 6444 (Greenlane)– Emergency Phone (09) 3074949 (GP hotline)

• Oncology – If under Regional Cancer Service– CNS Anne Fraser – 021950168– Medical Ongologist Dr Richard Sullivan – 021493915

Appendix

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When you click on Help Referral Guidelines

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Useful Website Guide

• www.lungfoundation.com.au

• www.macmillan.org

• www.cancersociety.co.nz

• www.lunghealth.org.nz