1. Lung Cancer Elin Roddy, Lead Clinician for Lung Cancer at SaTH Elin.roddy@sath.nhs.uk @elinlowri

2. Overview Some depressing statistics Some possible reasons for the depressing statistics Brief overview of diagnosis and treatment of lung cancer, explaining why we sometimes take so long Discussion around potential improvements

3. Age-Standardised Ten-Year Survival for Common Cancers in Males and Females, England and Wales, 2010-2011

6. Mesothelioma 2008 - 2012

7. Reasons why lung cancer survival is still variable and poor? Late presentation Deprivation (not just smoking, but mainly) Lack of advocacy & research Stigma Access to staff,diagnostics and treatment

8. Late presentation Late symptoms due to anatomy Poor differentiation of symptoms by patients Primary care gate-keeping? Early diagnosis campaigns not a panacea

9. Symptoms in patients who turn out to have lung cancer

10. Red flags are not always reliable but……NICE says Any haemoptysis Three weeks of unexplained clubbing or….. Cough Breathlessness Chest or shoulder pain Weight loss Hoarseness Chest signs Or just because smokes and tired? Unclear. But probably. Don’t wait for antibiotics to work

11. What about the radiation?

13. What about the cost?

15. We (you) do well in terms of routes of referral for lung cancer – very few ‘emergencies’

17. Is there an ideal percentage?

18. Lung cancer rates by deprivation quintile

19. Smoking prevalence 22.8% vs. 19.5% national average vs. 30% highest

20. Advocacy, stigma, research Linked to deprivation and smoking ‘It’s all my own fault’ Deserving vs. undeserving cancers Research spend per annum in the UK: Breast - £41million (£3500 per death) Leukaemia - £32million (£7000 per death) Lung - £15million (£400 per death)

24. Diagnosis and Staging Accurate diagnosis AND staging is important CT should be before bronchoscopy Most patients should have histology obtained Nodal staging with EBUS is becoming important ‘Radical’ treatment should be preceded by PET ‘Open and close rates’ should be <5%

25. TNM staging – T1 NO MO good, T4 N3 M1b bad At diagnosis 20% 10% 25% 45% 1 yr survival 80% 70% 50% <20%

26. Diagnostics

29. Treatment Surgery is preferred radical option ‘Resectable’ versus ‘operable’ Radical RT (or SBRT) should be considered even if patient not fit for surgery (‘operable’) Performance status at diagnosis is crucial: Grade Explanation of activity 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair 5 Dead

31. Things that affect PS Nutrition Pain Continued smoking Low mood Physical activity

32. Surgery

33. Radiotherapy Radiotherapy – can be curative, good for pain, brain mets or in combination with chemo Radical, long course palliative, single fraction Side effects – skin redness, hair loss, fatigue Spinal cord and lung damage concerns with higher doses but IMRT reduces risk Previous RT (eg for breast) may affect current dose

34. Chemotherapy Neo-adjuvant Adjuvant Palliative – first-line, second-line, maintenance Biologic treatments – gefitinib, erlotinib – oral, fewer side-effects – need receptor testing Incremental gains Histological diagnosis more & more important In the future – a panel of receptors tested? Treatment more likely with CNS support

35. -

37. Comparison LUCADA headline data 2013 (2012) Number of pts % MDT discussi on %CT before bronch % seen by CNS CNS present at diagnosis Histo diagnosis % Active treatment Surgery (all cases) % receiving radiother apy % small cell receiving chemo RXW256 (245) 96.1 (96.3) 80.9 (85.8) 74.2 (81.2) 44.5 (75.9) 73.8 (77.1) 59 (60) 18.8 (20) 33.2 (35) 64.2 (58.6) RL4237 (228) 100 (100) 100 (91.5) 97 (96.5) 94.1 (95.6) 74 (70.6) 56.1 (57) 15.6 (23.2) 23.2 (18.9) 74.2 (68.4) RTH31798.110085.882.690.971.629.718.676.0 RVR18176.292.576.240.973.559.78.319.356.8

38. Learning points Smoking and deprivation influence incidence, treatment and outcomes Improving early diagnosis is complex X ray early Aim to maintain PS - including smoking cessation Surgery preferred treatment option Accurate staging can be complex and time-consuming Chemo is improving, individualised Improving specialist nurse support improves outcomes Inverse care law – perhaps equal resource not the answer?

40. References British Journal of Cancer (2015) 112, 207–216. doi:10.1038/bjc.2014.596 – evaluation of the early diagnosis campaign http://www.bbc.co.uk/news/business-22310825 - Robert Peston on fundinghttp://www.bbc.co.uk/news/business-22310825 http://www.rcgp.org.uk/clinical/clinical- resources/~/media/Files/CIRC/Cancer/ImprovingCancerDiag nosishttp://www.rcgp.org.uk/clinical/clinical- resources/~/media/Files/CIRC/Cancer/ImprovingCancerDiag nosis The Patient Paradox by Margaret McCartney http://www.apho.org.uk/resource/item.aspx?RID=142221 – Health Profile for T&Whttp://www.apho.org.uk/resource/item.aspx?RID=142221 http://www.hscic.gov.uk/catalogue/PUB12719/clin-audi-supp- prog-lung-nlca-2013-rep.pdf