1. 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

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

3. Pathway development: A National Consultation

4. 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:

5. 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

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

7. Detail of Optimal Pathway

9. 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

10. 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

11. 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

12. 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:

13. NCIN Routes to Diagnosis

14. 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:

15. 8 Dec 2015

16. 24 Feb 2016

17. 12 March 2016

18. National Optimum Lung Cancer Pathway

19. Implementation All elements working now at some hospitals
Liverpool
Nottingham
Manchester and London
Successful bids for Alliance Transformation funding
Toolkit in preparation

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

21. 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

22. Mid pathway

23. First treatment pathway