Delivery of systemic therapy in Gloucestershire for NSCLC Nina Reeve Fiona Young Sam Guglani Lung Cancer Business Meeting Thursday 11th February 2016 Redwood Education Centre GRH

NICE Guidance 2011 1.4.40 Chemotherapy should be offered to patients with stage III or IV NSCLC and good performance status (WHO 0 or 1) 1.4.41 Chemotherapy for advanced NSCLC should be a combination of a single third-generation drug plus a platinum drug Docetaxel, gemcitabine, vinorelbine

10th National Lung Cancer Audit Report 2014 (2013 audit period)

10th National Lung Cancer Audit Report 2014 (2013 audit period) 39 000 patients/ 100% secondary care lung cancer Investigate chemo rates below England & Wales averages: SCLC 70% NSCLC 60% (PS 0/1 Stage IIIb/IV)

10th National Lung Cancer Audit Report 2014 (2013 audit period) 39 000 patients/ 100% secondary care lung cancer Investigate chemo rates below England & Wales averages: SCLC 70% 62% NSCLC 60% (PS 0/1 Stage IIIb/IV) 37%

10th National Lung Cancer Audit Report 2014 (2013 audit period) A self-assessment of the GH NHS FT lung cancer MDTs against the NICE lung cancer quality standards. QS12 People with stage IIIB or IV non-small-cell lung cancer and eligible performance status are offered systemic therapy (first- and second-line) in accordance with NICE guidance, that is tailored to the pathological sub-type of the tumour and individual predictive factors. Non-compliant – we have the lowest rate of this treatment of any trust in the South West, and the old 3-counties region had the lowest rate of any region in the whole country. Action: An audit is urgently required to examine the underlying reasons for this.

Delivery of systemic chemotherapy in NSCLC Audit February 2016

Aim Are we offering chemotherapy to stage 3b/4 NSCLC patients with a PS of 0/1 as per NICE guidance Are we reaching the standards set by the 10th lung cancer audit

Method GHT and CGH Lung cancer MDTs All NSCLC registered in 2014 Stage 3b/4 PS 0/1 as documented by MDT Opmas for registration clinic letters and chemotherapy regimes

Results GHT and CGH Lung cancer MDTs All NSCLC registered in 2014 Stage 3b/4 PS 0/1 as documented by MDT Opmas for registration clinic letters and chemotherapy regimes 59 patients

Demographics Sex 16% 40% Fits with national demographics

Stage and Intent Stage Intent How do these breakdown 3b. Why not concurrent/radical KD 1 x chemo offered, frail PS 1. Joint decision that SE would be too detrimental to QoL. RT for symptoms RS 1 x no chemo offered due to pain being predominant factor for referral so pallioative RT offered. No further documented meetings with onc as died 2 months later. 83 yrs weight loss DF 1 x RT for pain. Chemo offered at progression but pt declined RJ 1 x RT for pain. 80 yrs ?frail 1 x tarceva 3 x chemo (concurrent not discussed)

Performance status 6 pts were changed from PS 0/1 to a 2 or 3 and so were not eligible for further inclusion PS not stated in 3 pts so excluded 50 patients MDT PS highlighted 44 pts that were PS 0/1 Oncology found 50 at PS 0/1 MDT 1 to Onc 2 in 20 days (RT) MDT 1 to onc 2 13 days MDT 0 to Onc 3 in 8 days (WB) MDT 1 to onc 3 in 1 day (EB) MDT 1 to onc 3 and pt was seen 7 days before MDT discussion (AC)

Patient pathway Time from MDT discussion to seeing an oncologist; Mean 15 days 22% were seen before MDT Range 2-55 (2-26) Time to receiving chemotherapy from 1st oncologist appointment Mean 22 days Range 8-53 days (8-39) Time from MDT to receiving treatment Mean 37 days Range 2-55 days (2-39)

Chemotherapy and Systemic treatment 5 (10%) 26 (52%) 62% pts received systemic therapy

Documented reason for no chemotherapy 53% received RT upfront for local symptoms including pain (8 received thoracic RT (2 refuse chemo, 1 had chemo subsequently), 3 received WBRT) 26% had an egfr mutation and received a TKI 16% had a change in their PS deeming them unfit for chemotherapy 4% had comorbidities

Survival (months)

Summary 52% of patients who were PS 0 or 1 at diagnosis received a platinum based chemotherapy 10% had other systemic treatment – TKI etc 62% of patients with PS 0/1 received systemic therapy 16% of pts that were PS 0/1 at diagnosis had deteriorated by the time they were due to begin chemotherapy Those receiving primary RT for symptoms made up the largest group of patients not receiving immediate chemo (11) – 1 went on to receive chemo O

SACT 30 Day post-chemotherapy mortality Chemotherapy intelligence unit National cancer intelligence Network Systemic anti cancer therapy chemotherapy database NHS England and Public health England CIU of NCIN collecting NHS cancer chemo data since April 2012 (SACT) Mandatory for all NHS trusts April 2014 For NHSE and PHE - CIU produce 30-day breast and lung mortality data Short-term (30-day) mortality metric good clinical practice Data published/ outliers identified Publication January 2016

SACT 30 Day post-chemotherapy mortality Lung Palliative 1 death/ 1 patient [100% 30 day death rate]

SACT 30 Day post-chemotherapy mortality

SACT 30 Day post-chemotherapy mortality Lung Palliative 1 death/ 1 patient [100% 30 day death rate] 15 death/ 205 patients [7.3% 30 day death rate]

Discussion Could oncology see pts sooner to avoid delays in commencing definitive treatment Combined lung clinic Can we more accurately determine PS documented by MDT? Audit highlighted the importance of accurate prospective data collection Understand patterns of service provision Ultimately improve patient care The CIU will provide reports via this site, tailored to the requirements of trusts, commissioners, patients and other groups. These will provide a powerful new tool to understand patterns of service provision and support rational decision making to improve patient care. The programme provides a clear picture of patterns of chemotherapy being given across England by hospital and geographical area. Data collected within the SACT programme will show the immediate outcome of chemotherapy treatment and when linked to other data sources, can provide a complete picture of the management of cancer.

Thank you for listening Any questions?