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The next steps in the battle against lung cancer

Averaging over 1,800 deaths annually, lung cancer is the leading cause of cancer deaths in both men and women. As part of the battle to fight the disease, at the end of last year, the Minister for Health Simon Harris launched a new National Clinical Effectiveness Guideline to help healthcare professionals with the identification, staging and treatment of patients with lung cancer. This new guideline was developed by a group led by the HSE’s National Cancer Control Programme (NCCP) and was quality assured by the Department’s National Clinical Effectiveness Committee (NCEC).

Purpose of the guideline

Speaking to the Medical Independent (MI), the Chair of the Guideline Development Group Dr Marcus Kennedy said the guideline is an attempt to reduce variation in practice regarding lung cancer treatment across the acute sector. 

“We didn’t have any national guidelines for lung cancer, or the other cancers until the NCCP was established,” according to Dr Kennedy.

“The guidelines were really about setting out a framework of how patients with lung cancer should be looked at in the public system in Ireland to essentially improve care for patients as regards their pathway through the system and standardise care through all the centres. In a large public hospital variation in practice occurs. Obviously practice is varying because of improvements in what we do. I suppose we were trying to standardise the practice and have a framework that people could look at. You are dealing with an area where there have been new technologies, so we’re trying to bring in those new technologies as well and look at how we should be using those.”

Dr Kennedy, who is Consultant in Respiratory Medicine in Cork University Hospital, said the group that developed the guideline paid close attention to new and emerging evidence in the field of lung cancer.

“We have gone from a situation where you would have had one standard chemotherapy for the majority of patients with lung cancer,” according to Dr Kennedy.

“Now you are into a scenario where there are multiple different treatments depending on the type of lung cancer. In 10 years’ time there would probably be another multitude, so you do need to review again and look at new emerging evidence and see where it fits in the Irish pathway.”

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Dr Marcus Kennedy

He added that there was a need to integrate clinical research evidence with clinical expertise. Another key consideration was reducing waste, especially within the context of tight hospital budgets.

“We wanted to put that down and reduce radiological investigations in patients where they are not necessary. And have them done in patients where they are necessary,” according to Dr Kennedy.

In terms of implementation, Dr Kennedy believes that the eight cancer centres have enough resources to adhere to the recommendations. At the upcoming meeting of the NCCP Annual Lung Cancer Forum in Farmleigh House, Dublin, in May, he said the various centres will review their data to see where there are areas for improvement.

In 2017 the NCCP completed an evaluation of the rapid access clinics for the prostate, breast and lung services resulting in the publication of a consolidated report and the collation of individual action plans for each service. In their correspondence, the NCCP outlined the plan for the next steps for the implementation of the recommendations, which were reviewed by CEOs and Group Clinical Directors at Hospital Group level, with support from the NCCP and relevant HSE divisions.

Dr Kennedy said it is important to consider how lung cancer cases present in hospitals. A report was recently compiled by the Irish Cancer Society and National Cancer Registry showing the number of cancer cases that present in emergency departments.

“There are about 1,800 new lung cancer cases a year in Ireland,” he said. “About 300 of them come through Cork University Hospital for instance. So we would be one of the larger hospitals to bring cancer patients through. A third of those come through the emergency department for us. So we have one-to-two patients coming in with symptoms per week. About a third come through our rapid access lung cancer clinic. And about a third of our patients come through our other hospitals [Mercy University Hospital, University Hospital Kerry etc].”

UK document

Also, Dr Kennedy said that many patients who present do not have lung cancer. Figures show that only one-third of patients who present in rapid access clinics have lung cancer, two-thirds don’t. In addition to his role with the guideline group Dr Kennedy is also current national HSE-NCCP Lung Tumour group chairperson. Speaking in this capacity, Dr Kennedy said that the Irish lung cancer pathway will potentially be revised in a similar manner what is being proposed in the UK. A National Optimal Clinical Pathway for suspected and confirmed lung cancer has been designed in the UK to meet targets as set out in the UK’s Independent Cancer Taskforce report. 

“They made a number of significant changes there, which we have been looking at,” according to Dr Kennedy.

“For instance, if someone has symptoms, and you do a CT scan, and the CT scan doesn’t show lung cancer, maybe that patient doesn’t need to be seen at all. That is a controversial area. And old practice would suggest that you still need to do a bronchoscopy to rule out lung cancer, but actually the current thought and hard data from Cork that we are publishing would suggest bronchoscopy may not be required. Maybe we could not bring that patient to clinic at all, so we can leave more slots for those patients who really need to come through. Another population that the UK document was looking at was patients with advanced disease with poor performance status. For lung cancer, if your performance status is ECOG 3 or 4, that really is a patient who really is not able to mobilise at all. The proposal in the UK pathway is that this patient does not need to be seen in a rapid access lung cancer clinic. The current practice is we would see all patients, but maybe those patients could somehow be sorted out in their local centre through their GP to allow more slots for those patients who need surgery in a timely fashion.”

Dr Kennedy said it is vital that people with lung cancer are seen and treated as quickly as possible.

“It has been shown that delays in their care are significant. For instance, in surgical patients and patients who we would treat with chemotherapy and radiation with intent to cure, any delay in getting those patients through is significant… We do need to revise the pathways and really it is all about shortening times for the patients we are going to treat with curative intent. So we are going to review our pathways at the moment with the aim of shortening the time between the presentation and a curative therapy. We have our data and we will look at our guidelines that we send out to our GPs and other healthcare professionals and we probably will revise those with that intent. And the UK has done some work on this, so this is clearly not about reinventing the wheel and we have more data here to look at to try and improve those pathways.”

Screening

Lung cancer screening is another issue that would help identify the disease at an earlier stage. A European position statement in The Lancet towards the end of last year called for all EU countries to consider lung cancer screening and start thinking about how such a programme would operate.

Dr Kennedy said work has begun on examining the evidence. It is planned for a recommendation on lung cancer screening, whether positive or negative, to be made to the Department of Health and potentially for a Health Technology Assessment or pilot study to be conducted at a later date.

“The ballpark is changing here,” according to Dr Kennedy.

“What screening hopefully, ultimately, will do is change the stage at which patients come in. But similar to BreastCheck, it is going to take significant resources, staff, CT scanners; it is going to be based around CT scanners. So I think we need to be thinking about not only getting the symptomatic patients through, which is what we are doing now, but I think we need to start thinking about screening as well.”

Centralisation

In terms of current treatment, Dr Kennedy said that the centralisation of cancer services and the development of rapid access clinics have improved outcomes for patients.

“Things just work smoother if you have a concentration of the multi-disciplinary team [MDT] in one centre,” according to Dr Kennedy.

“The MDTs are well run and they really improve the flow of the patient through the system. I think the patient experience is better. We do see patients in a timely fashion. The aim is to see patients at our rapid access clinics within 10 working days. You have a concentration of expertise in the centres, you also have the opportunities for research in parallel to the universities.

“We have had more surgeons employed and more radiation oncologists employed, and cures for these patients, and patients going through the curative route are getting through the pathway quicker. In my opinion, there is no doubt that centralising the cancer services into the specialist centres is the way to go.”

Dr Kennedy said that while it will take time for the improvements to be reflected in the mortality data published by the National Cancer Registry, it has already become evident that the incidence of lung cancer is starting to decrease.

“That is also related to the push for smoking cessation, which is a huge component of lung cancer,” Dr Kennedy said.

“So in general it has been a very positive step.”

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