The National Optimum Lung Cancer Pathway David Baldwin Consultant Respiratory Physician Nottingham University Hospitals Hon. Professor, School of Medicine, University of Nottingham Chair, CEG for Lung Cancer, NHSE

Objectives Key features of NOLCP Selected detail of pathways and supplements Discuss implementation

Pathway development: A National Consultation

Lung Cancer Commissioning Guidance Guidance for commissioners of specialised and non-specialised services Including: Priorities for healthcare improvement What to commission What to measure Approved by the Programme of Care Board (NHSE) 2015 Approved by the Clinical Panel (NHSE) 2016 Updated for 2017/18 – signed-off NHSE August 2017 Sent to Alliances for implementation Available at: https://www.roycastle.org/how-we-help/lung-cancer-information/information-for-healthcare-professionals/commissioning-guidance

Nationally agreed pathways Requested by Clinical Panel NHSE Draft by 8 clinicians Modified by CRG Consultation with all networks and professional bodies (supported by CRUK) Draft updated following comments Finalised by CRG Sent to stakeholders for endorsement Update vs. 2.0 June 2017 Signed off by NHSE August 2017 Oct 15 Jan 16 June 17

Pathways developed Standard – current practice Optimal pathway (previously termed “aspirational” Triage Curative intent Direct to CT Update 2017 – release ? May

Detail of Optimal Pathway

Non lung cancer pathway TRIAGE Respiratory physician triages with reported CT according to clinical and radiological features. Lung cancer likely? Yes Respiratory condition requiring urgent appointment including other cancer? No Non lung cancer pathway Yes Urgent respiratory clinic or other fast track cancer referral Lung cancer pathway Fast track lung cancer clinic. Meet LCNS. Diagnostic process plan / diagnostic planning meeting prior to clinic. Treatment of co-morbidity and palliation / treatment of symptoms. Urgent non-respiratory condition? No Urgent communication with GP or direct admission depending on condition found or suspected Yes No Ongoing symptoms / need for non-urgent respiratory OPA? Write to GP and patient Yes Non-urgent respiratory OPA Including management of pulmonary nodules GP meets/communicates with patient. Still requires respiratory OPA? GP manages patient No Yes

Direct to biopsy – neck US, lung, EBUS Day 0-3 TRIAGE By radiology or respiratory medicine according to local protocol Lung Cancer Likely? No Manage Yes Suitable for potentially curative treatment? Yes No Will pathological diagnosis influence treatment and is potential treatment appropriate to patient’s wishes? Yes No Clinical diagnosis or patient preference means no biopsy required. Staging investigation not required to guide management Direct to biopsy; same day or within 3 days Yes No No Yes Day 1-5 Fast track lung cancer clinic. Meet LCNS. Diagnostic process plan / diagnostic planning meeting prior to clinic Treatment of co-morbidity and palliation / treatment of symptoms National Optimal Pathway

Full MDT Discussion of treatment options or further investigation National Optimum Curative Intent Management Pathway (part) Day 1-5 Maximum times NOLCP Day 21 Fast track lung cancer clinic ± diagnostic planning meeting / Diagnostic MDT Meet lung cancer nurse specialist Usual diagnosis and staging pathway Stage: Potentially T1-3 N0-2 M0 (N2 non-bulky; i.e. <3cm) Or locally advanced; potential for radical RT? May include selected patients with oligometastatic disease Full MDT Discussion of treatment options or further investigation No Potentially fit enough for treatment with curative intent and willing to consider this? (Ensure low threshold for proceeding with work up for curative treatment) No Yes Simultaneous fast track: Yes All patients: Medical optimisation (incl. smoking cessation) PET-CT (within 5 days) Diagnostic and staging tests Spirometry ±TLCO Complete all tests within 14 days Alert surgeons / clinical oncology Patients with borderline fitness$ add: Preoperative rehabilitation Shuttle walk test / CPEX / ECHO Perfusion scan if required Early cardiology assessment for cardiac co-morbidity

Chest x-rays prior to a diagnosis of lung cancer in general practice Frequency distribution of chest x-rays among cases in general practice, 12 months prior to lung cancer diagnoses. The plot for frequency of chest x-rays in controls is not shown but the pattern was consistent over the 12-month period and overall only 4% of controls had chest x-rays performed within the 12 months. This figure is only reproduced in colour in the online version. Barbara Iyen-Omofoman et al. Thorax 2013;68:451-459

NCIN Routes to Diagnosis

PS and overall survival NLCA linked to HES Total Died % HR Adj HR* 5839 3804 64 1.0   1 9267 7226 78 1.49 (1.43 to 1.55) 1.28 (1.22 to 1.33) 2 5300 4737 89 2.50 (2.40 to 2.61) 1.87 (1.76 to 1.99) 3 3230 3103 96 4.51 (4.30 to 4.74) 3.12 (2.91 to 3.35) 4 737 722 98 7.62 (7.03 to 8.25) 5.21 (4.39 to 6.17) Missing 9992 8168 82 1.82 (1.75 to 1.89) 1.54 (1.45 to 1.62) * Adjusted for age, sex, ethnicity, deprivation, comorbidity, stage, surgical centre, radiotherapy centre and trial entry centre Rich AL et al Thorax 2011;66:1078-1084

8 Dec 2015

24 Feb 2016

12 March 2016

National Optimum Lung Cancer Pathway

Implementation All elements working now at some hospitals Liverpool Nottingham Manchester and London Successful bids for Alliance Transformation funding Toolkit in preparation https://www.roycastle.org/how-we-help/lung-cancer-information/information-for-healthcare-professionals/commissioning-guidance

The Future Implementation of Service Guidance and NOLCP Supported by CRUK, RCF, NHSE, Alliances Big, challenging ideas are needed for big, challenging problems

Thanks Roy Castle Lung Cancer Foundation Members of CRG: Stakeholders (for comments) Ian Woolhouse, Martin Ledson, Paul Beckett, Sadia Anwar, Mick Peake, Mat Callister, Robert Rintoul. Ruth Bridgeman, Louise Wilson Diana Borthwick Julie Hendry David Gilligan Andrew Bates Neil Bayman Anand Devaraj Sue Maughan Amelia Randle Yvonne Summers Andrew Wilcock Michele McMahon Martin Grange John White Denis Talbot Sanjay Popat Paul Cane David Baldwin Sam Janes Robert Rintoul Yvtis Dudzevicius Imran Hussain Sion Barnard Doug West

Mid pathway

First treatment pathway