Predictors of Lung Cancer multidisciplinary review and the impact on survival for HNELHD residents treated in the public sector Cancer Innovations ConferenceDate: Thursday, 15 October, 2015Location: Aerial Function CentreAddress: Building 10, Level 7/235 Jones Street, Sydney, New South Wales 2007, Australia

Dr Elizabeth TraceyResearch Fellow University of NewcastleConsultant Epidemiologist HNE Cancer Network Directorate The Lodge John Hunter Hospital Campus

Acknowledgments• Professor Anthony Proietto – review and discussion• Dr Sanjiv Gupta – Chair of the HNELHD Lung MDT• Denise Kaminski – MDT survey extraction• Peter Troke and staff of the Clinical Cancer Registry- extraction of ClinCR data, data

quality and death checking– Jodie Pride– Gina O’Hearn– Lisa Shaw

Feedback from the• Cancer Clinical Network Leadership Committee, • Lung MDT • Respiratory Meeting

Outline

• Background• Method• Results• Summary• Implications and Recommendations

Background

• Lung cancer is a poor survival cancer that usually presents at a late stage1,2 but if detected early and staged appropriately surgical resection alone or with adjuvant chemotherapy is currently the recommended treatment.

• The primary reason for a Multidisciplinary Team (MDT) review – is to ensure that all appropriate diagnostic test and treatment options have been

considered; 3 – for the development of standardised patient protocols; as well as – a forum for the continuing education of the clinical staff.

1. Walters S, Maringe C, Butler J, Brierley JD, Rachet B, Coleman MP. Comparability of stage data in cancer registries in six countries: lessons from the International Cancer Benchmarking Partnership. Int J Cancer 2013; 132(3): 676-85.2. Walters S, Maringe C, Coleman MP, et al. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004-2007. Thorax 2013.3. Multidisciplinary cancer conferences: A systematic review and development of practice standards. 2007; 43(6): 1002–10.

Background (continued)• Review by an MDT has been shown to lead to increased rates of surgical

resection, radiotherapy, chemotherapy and timeliness of care.4,5 Most recently, the Victorian lung cancer patterns of care study have found that MDT review is an independent predictor of lung cancer survival. 6

• Cancer Australia 2012 Guidelines recommend that all patients suspected of lung cancer be referred to a lung cancer MDT. 7

• Previous patterns of care studies have compared lung cancer survival and treatment patterns in South Western Sydney and Northern Sydney Area Health with the Hunter New England Local Health District (HNELHD) region and reported that Hunter New England residents had significantly poorer lung cancer survival and proportionally less surgical and chemotherapy treatment than the other regions.8

4.Coory M, Gkolia P, Yang IA, Bowman RV, Fong KM. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer 2008; 60(1): 14-21.5.Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer 2011; 117(22): 5112-20.6.Mitchell PL, Thursfield VJ, Ball DL, et al. Lung cancer in Victoria: are we making progress? Med J Aust 2013; 199(10): 674-9.7.Cancer Australia. Investigating symptoms of lung cancer: a guide for GPs. 2012. http://canceraustralia.gov.au/publications-and-resources/cancer-australia-publications/investigating-symptoms-lung-cancer-guide-gps (accessed 30th July 2014).10.Vinod S, Hui A, Esmaili N, Hensley M, Barton M. Comparison of patterns of care in lung cancer in three area health services in New South Wales, Australia. Intern Med J 2004; 34(12): 677-83

Aims

1. To examine predictors of lung cancer MDT review in the HNELHD Public sector patients after adjusting for patient, tumour, treatment and system factors

2. To determine whether MDT is independent predictor of survival

3. To review the quality and usefulness of data collected at the MDT review

Method• Data linkage study:

– Hunter New England residents diagnosed with lung cancer between January 1st 2009 and June 30th 2013 identified HNE Clinical Cancer Registry

– MDT patient - lung cancer patients treated at some time in the public sector

• A protocol was developed and ethical approval was obtained from the Hunter New England Ethics Committee (LNR/15/HNE/10).

• Exclusions: Private patients reviewed by the MDT that had not also been treated in the public sector and patients who were treated outside the LHD were excluded to ensure consistent numerator and denominator information.

Statistical Analyses • SAS 9.4 was used for data cleaning and linkage. STATA12.115 was used for the statistical analysis.

Descriptive statistics using chi square and multinomial Logistic regression analysis (no MDT participation (referent category) relative to MDT participation.

• We described all cause survival from lung cancer and its predictors using Kaplan–Meier curves and univariable and multivariable Cox proportional hazards regression models. Patients without a date if death ( N=564) were checked to see if they had died up to December 31st 2014 by the Clinical Cancer Registry staff looking up the NSW death register. Patients who had died after that date were censored.

ResultsClinical Cancer Registry 2009-2013

8679 records for people with lung cancer and mesothelioma.

ExclusionsExclude 461 records with

mesothelioma. This leaves 8,218 records of lung cancer for 2,167 individuals with the number of episodes per person ranging

from 2-22

Tamworth – 18 Rural and 22

Calvary Mater Lung MDT

Of the 2,167 individuals with lung cancer 411 matched the clinical cancer

their MDT attendance. 1788 did not attend an

MDT

95 people reviewed in an MDT but were not in the Clinical

Cancer Registry –

MDT reviewed 2009-2013 644 records 558 once,72 twice,12 three times, 2 four times

Descriptive characteristics – key points• 20% of total HNELHD lung cancer patients are reviewed annually at an MDT

• On average 450 lung cancer patients a year are registered in the ClinCR. Given that there are 500 recorded cases of lung cancer annually in HNELHD (based on CCR data) it would appear most lung cancer patients have some access with the public health system. Although according to the Cancer Institute only 37% of patients receive their lung cancer surgery in HNELHD. This was confirmed using FLOWINFO which showed that most respiratory surgery was conducted in the private sector

• There were a similar proportion of patients reviewed and not reviewed by age, sex, indigenous status, laterality, histological grade.

• More patients with localised and regional stage and less distant stage reviewed at the MDT.

• More squamous and adenocarcinoma reviewed at the MDT.

Descriptive characteristics – key points• 43.4% patients treated at Calvary Mater (61.8% of all MDT patients were treated at

Calvary Mater)• Approximately 6% had surgery (11.2% if attending an MDT). • 29% chemotherapy, (41% MDT)• 44.7% radiotherapy (72% MDT)• 54% not referred to palliative care (62% MDT)• 35.5% seen by a specialist nurse relative (57% MDT)• If referred to an MDT are reviewed 70% of patients are reviewed within a month of their

diagnosis• 29% of patients do not have treatment (16.8% if attending an MDT)• For patients who do undergo treatment most (92%) have their treatment within 6 months

of their date of diagnosis.

Predictors of MDT review – multivariate modelTotal MDT

2187 411

Age at diagnosis n n % OR LCI UCI

15-49 70 14 3.4 1

50-59 276 67 16 1.34 0.66 2.73

60-69 645 148 36 1.28 0.65 2.52

70-79 740 137 33 1.09 0.55 2.16

80+ 455 45 11 0.66 0.31 1.39 P=0.0319

TNM stagestage 1

303 74 18 1

Stage II 136 55 13 2.26 1.37 3.75

Stage III 415 129 31 1.09 0.71 1.69

Stage IV

1,100 133 32 0.42 0.27 0.66

Not Applicable 56 9 2.2 0.37 0.15 0.90

Unknown 97 4 1 0.23 0.07 0.70

Unstaged 73 5 1.2 0.57 0.19 1.69 <.0001

Best basis of diagnosisOther

537 54 13 1

Cytology

1,145 265 65 1.55 1.06 2.26

Histology 504 92 22 1.39 0.91 2.12 P=0.077

Hospital of treatment

Other 121 5 1.2 1

Armidale and New England 96 1 0.2 0.11 0.01 1.02

Belmont Hospital 70 4 1.0 1.05 0.26 4.33

Calvery Mater Hospital 950 254 61.8 3.28 1.27 8.50

Cessnock District Hospital 34 3 0.7 1.55 0.32 7.55

John Hunter Hospital 451 113 27.5 3.51 1.33 9.32

Maitland Hospital 62 4 1.0 1.74 0.41 7.45

Manning River Base Hospital 154 17 4.1 2.43 0.82 7.15

Total MDT

2187 411

n n % OR LCI UCI

Moree Hospital 19 1 0.2 1.28 0.13 13.21

Muswellbrook Hospital 18 2 0.5 2.40 0.36 16.20

Singleton Hospital 13 3 0.7 6.63 1.09 40.49

Tamworth base hospital 199 4 1.0 0.15 0.04 0.61 p<.0001

Surgery

No surgery 1,502 278 67.6 1

Biopsy 576 101 24.6 1.52 0.96 2.40

Pneumonectomies 4 2 0.5 0.84 0.38 1.87

Lobectomy 48 12 2.9 1.62 0.22 11.97

Wedge resection 85 32 7.8 1.67 0.91 3.06 P=0.2605

ChemotherapyNo Chemotherapy

1,100 148 36 1

Chemotherapy consultation

447 95 23 1.35 0.96 1.90

Chemotherapy

639 168 41 1.11 0.79 1.57 P=0.2145

RadiotherapyNo radiotherapy 1162 107 26.0 1

Radiotherapy consultation 47 8 1.9 2.25 0.86 5.93

Radiotherapy 978 296 72.0 2.98 2.16 4.13 p<.0001

Referred to palliative careNot referred

1,173 254 62 1

Referred

1,013 157 38 0.65 0.49 0.87 P=0.0032

Referral to psychosocial careNo stated

1,157 140 34 1

Other

254 35 9 1.31 0.83 2.05Specialist nurse

775 236 57 2.61 1.94 3.51 <.0001

Kaplan Meier – unadjusted survival from lung cancer by MDT review

Kaplan Meier – unadjusted lung cancer survival by MDT review by TNM Stage

Kaplan Meier – unadjusted survival from lung cancer by MDT review stratified for patients with Stage III lung cancer

Kaplan Meier – unadjusted survival from lung cancer by MDT review stratified for patients with Stage IV lung cancer

Final Multivariate survival model

MDT review Total N Died %Died HR LCI UCI P-valueNo MDT review 1,775 1,562 83.2 1

MDT review 411 315 16.8 0.79 0.70 0.91 p<0.0001

SexMale 1,318 1,178 62.8 1

Female 868

699 37.2 0.83 0.75 0.91 p<0.0001Age group15-49

70 56 3.0 1

50-59 276

218 11.6 1.06 0.79 1.43

60-69 645

542 28.9 1.15 0.87 1.52

70-79 740

641 34.2 1.18 0.89 1.56

80+ 455

420 22.4 1.23 0.92 1.64 p=0.4314Aboriginal statusNon-Aboriginal or Torres Strait

71 63 3.4 1

Abtsi 7

6 0.3 1.30 1.00 1.68Not stated unknown 2,108 1,808 96.3 0.93 0.41 2.10 p=0.1401TNM Stage at diagnosisI

303 172 9.2 1

II 139

105 5.6 1.86 1.46 2.39

III 418

353 18.8 2.39 1.96 2.90IV 1,100 1,044 55.6 4.49 3.75 5.37

Not Applicable 73

67 3.6 3.15 2.22 4.48

Unknown 56

53 2.8 1.70 1.30 2.24

Unstaged 97

83 4.4 2.94 2.19 3.94 p<0.0001Histological subtypeCarcinoma NOS

422 364 19.4 1

Adenocarcinoma 799

651 34.7 0.80 0.70 0.90

Large-cell carcinoma 246

224 11.9 1.02 0.84 1.23

Small-cell carcinoma 168

144 7.7 1.00 0.83 1.20

Squamous cell carcinoma 551

494 26.3 1.09 0.94 1.26 p<0.0001

Surgery Total N Died %Died HR LCI UCI P-value

Biopsy 547 490 23.3 1

Lobectomy 48 14 0.75 0.36 0.20 0.63

Wedge resection 85 38 2.02 0.52 0.36 0.76

Pneumonectomies 5 1 0.05 0.17 0.02 1.23No surgery 1,502 1,335 73.9 1.02 0.86 1.22 p=0.0002

ChemotherapyNo chemotherapy 1,100 955 50.9 1

Chemo consultation 447 377 20.1 0.72 0.64 0.82Chemotherapy 639 545 29.0 0.52 0.46 0.59 p<0.0001

RadiotherapyNo radiotherapy 1162 979 52.2 1Radio consult 47 44 2.3 0.97 0.71 1.32Radiotherapy 978 855 45.6 0.85 0.76 0.96 P=0.0216

Palliative care

Not referred

1,173 892 47.5 1.00

Referred

1,013 985 52.5 1.35 1.22 1.48 p<0.0001

Hospital of treatmentJohn Hunter Hospital 451 332 17.7 1.00

Armidale Hospital 96 84 4.5 1.13 0.87 1.46

Belmont Hospital 70 68 3.6 1.43 1.10 1.88

Calvary Mater Hospital 950 828 44.1 1.10 0.96 1.27

Cessnock District Hospital 34 33 1.8 1.26 0.88 1.82

Maitland Hospital 62 60 3.2 1.42 1.07 1.88

Manning River Base Hospital 154 144 7.7 1.20 0.97 1.47

Moree Hospital 19 15 0.8 0.60 0.35 1.02

Muswellbrook 18 17 0.9 1.25 0.76 2.05Singleton 13 12 0.6 1.55 0.87 2.78

Tamworth base hospital 199 173 9.2 1.27 1.04 1.54Other 121 112 6.0 1.27 1.01 1.59 P=0.0245

Final Multivariate survival model stratified by TNM stageStage I and II Stage III Stage IV Unknown Stage

MDT review HR 95% CI Hazard95% Hazard Ratio Confidence Hazard

95% Hazard Ratio Confidence Hazard

95% Hazard Ratio Confidence

No_MDT review 1 1 1 1MDT review 1.11 0.84 1.48p=0.4561 0.59 0.45 0.77P<0.0001 0.80 0.66 0.97 p=0.0244 0.63 0.34 1.15p=0.1309SexMale 1 1 1 1Female 0.82 0.64 1.050=0.1128 0.87 0.69 1.09p=0.2137 0.87 0.76 0.98 p=0.0272 0.56 0.41 0.76p=0.0002Age group15-49 1 1 1 150-59 0.70 0.24 2.03 0.83 0.32 2.14 1.04 0.73 1.48 1.45 0.52 4.0460-69 1.41 0.55 3.60 0.71 0.29 1.77 1.11 0.80 1.55 1.55 0.61 3.9670-79 1.62 0.64 4.11 0.69 0.28 1.73 1.11 0.80 1.54 1.38 0.54 3.5680+ 1.95 0.75 5.05p=0.032 0.66 0.26 1.67p=0.8032 1.07 0.76 1.52 p=0.9406 2.06 0.80 5.33p=0.3042Histological subtypeCarcinoma NOS 1 1 1 1Adenocarcinoma 0.66 0.48 0.92 0.90 0.66 1.24 0.77 0.65 0.90 1.15 0.76 1.76Large-cell carcinoma 0.83 0.49 1.42 0.93 0.61 1.41 1.13 0.88 1.45 1.36 0.64 2.90Small-cell carcinoma 1.07 0.45 2.58 1.35 0.88 2.07 0.89 0.71 1.12 1.56 1.03 2.38Squamous cell carcinoma 1.34 0.98 1.85p=0.001 1.06 0.77 1.45p=0.4144 0.96 0.78 1.17 p=0.0018 1.95 1.14 3.33p=0.001SurgeryNo surgery 1 1 1 1Biopsy 1.04 0.58 1.85 0.86 0.60 1.23 1.04 0.83 1.32 0.96 0.55 1.66p=0.0989Wedge_resection 0.45 0.29 0.68 1.63 0.50 5.30 1.22 0.58 2.59Lobectomy 0.36 0.19 0.68 0.26 0.04 1.90p=0.365 0.53 0.07 3.77 p=0.8467Pneumanectomy 0.14 0.02 1.01p<.0001ChemotherapyNo chemotherapy 1 1 1 1Chemo consult 0.71 0.53 0.95 0.60 0.45 0.80 0.77 0.65 0.90 0.80 0.52 1.24Chemotherapy 0.78 0.54 1.12p=0.0537 0.39 0.30 0.51p<.0001 0.52 0.45 0.61 p <.0001 0.82 0.50 1.35p=0.5109RadiotherapyNo radiotherapy 1 1 1 1Radio consult 0.99 0.49 2.00 0.99 0.52 1.86 0.93 0.61 1.43 1.44 0.34 6.18Radiotherapy 0.86 0.65 1.13p=0.5378 0.71 0.56 0.90p=0.019 0.82 0.72 0.94 p=0.0128 0.71 0.44 1.15p=0.3094Palliative careNot referred 1 1 1 1Referred 2.21 1.70 2.87p<.0001 1.19 1.05 1.35 p=0.001 1.45 1.16 1.82 p=0.0007 1.06 0.79 1.41p=0.7142

Adjusted survival curves – overall and stage specificOverall TNM stage I and II

TNM stage IIITNM stage IV

Discussion

• Coory4 in a systematic review between 1984 and 2007 identified 16 studies only one was a randomised control trial (n=88). Only two of the 16 studies reported an improvement in survival.

Forrest 9 Chemotherapy increased (7-23%); Palliative care decreased (58-44%) and the proportion of patients formally staged increased. An improvement in median survival from 3.4 to 6.6 months for inoperable (stage III and stage IV patients) – no effect of age, sex or deprivation and a stage shift toward more advanced disease.

The second study10 showed an improvement in one year survival for patients aged 70 years and older from 18% to 23%.

4.Coory M, Gkolia P, Yang IA, Bowman RV, Fong KM. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer 2008; 60(1): 14-21.9.Forrest L, McMillan D, McArdle C, Dunlop D. An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-small-cell lung cancer. British journal of cancer 2005; 93(9): 977-8.10. Price A, Kerr G, Gregor A, Ironside J, Little F. The impact of multidisciplinary teams and site specialisation on the use of radiotherapy in elderly people with non-small cell lung cancer (NSCLC). Radiother Oncol 2002; 64(Suppl 1): 80.

Discussion (continued)

• In South Western Sydney Boxer et al5 examined 988 lung cancer patients of which 504 were reviewed at the lung MDT. This study found that for patients with significantly better performance status, the MDT group had significantly more radiotherapy and chemotherapy regardless of stage but it was found not to be an independent predictor of survival.

• More recently, St Vincent’s undertook a retrospective audit of 1,022 lung cancer patients11 between January 2006 and December 2012. Of these 29% were reviewed at the MDT. Similar to this study a unadjusted survival benefit was shown for stage IV patients at 1 and 2 years post diagnosis and for stage 1 patients at five years.

5. Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer 2011; 117(22): 5112-20.11. Bewes T, Zhang L, Djavdkhani Y, Nguyen T, Shaw T, Rankin N, Stone E. An evaluation of a multidisciplinary approach in the management of lung cancer (abstract)

. Aim 1– Predictors of lung cancer MDT review in HNELHD residents

Higher odds of MDT review• If stage 2 • If cytologically or histologically verified• Four times more likely if treated at Calvary Mater or John Hunter. • If undergoing radiotherapy treatment• If seen by a specialist nurse

Lower odds of MDT review• If referred to Palliative Care • If the person dies within a month of diagnosis or• If they are stages 3 and 4 or unknown or unstaged

Aim 2 MDT review and whether it is an independent predictor of survival

• There is an unadjusted median survival of 17 months (95% CI 13-21) for HNELHD residents who undergo an MDT review. Compared to six months (95%CI 6-7 months).

• MDT review was an independent predictor of survival with a 21% lower hazard of death (HR 0.79 95% CI 0.20-0.90). After adjustment for sex, age, aboriginal status, TNM stage, histological subtype, surgery, chemotherapy, radiotherapy, palliative care and hospital of treatment.

Aim 2 MDT review and whether it is an independent predictor of survival stratified by TNM stage

No MDT review MDT review

Median survival Months 95% CI Months 95% CI Log rank

Stage I and II 25 (21-31) 32 (25-35) p=.6578

Stage III 8 (7-10) 23 (16-30) p<.0001

Stage IV 4 (3-4) 7 (5-8) p=0.0003

Unknown 7 (5-9) 13 (9-36) p=0.0594

Unadjusted Fully adjusted *HR LCI UCI P value HR LCI UCI P value

No MDT review 1 1

MDT review Stage I and II 0.94 (0.73 -1.22) p=0.6424 1.11 (0.84 -1.48) p=0.4561

MDT review Stage III 0.45 (0.35 -0.57) p<.0001 0.59 (0.45 -0.77) p<0.0001

MDT review Stage IV 0.72 (0.60 -0.87) p=0.0007 0.80 (0.66 -0.97) p=0.0244

MDT review Unknown 0.62 (0.37 -1.04) p=0.0717 0.63 (0.34 -1.15) p=0.1309

* adjusted for sex, age at diagnosis, histology, surgery, chemotherapy, radiotherapy, palliative care

Aim 3 – descriptive overview of the 411 MDT patients

• 32% stage 1 and 2 63 % stage 3 or 4• 47% no weight loss• 47% had no performance status recorded• 43% had no local complications• 47% had tobacco consumption as the main comorbidity• 42% had a treatment intent of palliative• 80% are Medicare eligible

Implications and Recommendations

1. Present at the Lung MDT and review and discuss the usefulness of the data items

– It is not clear to me based on the terms of reference for the Lung MDT what the criteria are used for referral – who determines whether some patients are referred and others are not?

– Given that there is an independent survival advantage to an MDT review how do we increase the proportion attending from 20% of lung cancer patients?

– Is it possible to prioritise patients with a confirmed lung cancer to increase the proportion of primary lung cancer patients who have an MDT review?

– Investigate why there is a low proportion of patients having surgery with localised stage (stage 1 and stage 2)?

Implications and Recommendations– There are a large number of treatment categories are these necessary? Ideally it

should be possible to compare actual with expected treatment but this requires grouping of treatment categories.

– Why is the proportion missing for seemingly important data items like ECOG score high?

– Should smoking be included as a comorbidity or should it be a separate category?• Why are the number of pack years collected?

– Comorbidity categories need to be reviewed to determine why there are four columns?

– There is a reduced likelihood of review by an MDT if patients are referred to palliative care yet there is a large proportion of patients reviewed that are palliative instead of curative is this appropriate?

– Discuss how reporting of the findings of the Lung Cancer MDT can be improved to assist decision making and monitoring of patients.

Next steps

1. Obtain ECOG and comorbidity scores for stage III patients

• Allocate ECOG–two medical oncologist will review doctors letters to allocate the score where it is not recorded.

• The Charlson comorbidity index will be allocated on the basis of Admissions (IPM)• Sensitivity analysis - rerun the model for stage III patients to determine whether the reduction

in the hazard due to MDT review remains or is explained by a favourable ECOG or comorbidity profile.

2. Describe the referral pathways to diagnosis and treatment in HNELD residentsHunter Cancer Research Alliance Funding has been obtained to extend to current linkage to include Lung Clinic and Emergency Department data to determine whether these referral pathways affect the likelihood of MDT review.

Predictors of Lung Cancer multidisciplinary review and the impact on survival for HNELHD residents treated in the public sector Cancer Innovations ConferenceDate: Thursday, 15 October, 2015Location: Aerial Function CentreAddress: Building 10, Level 7/235 Jones Street, Sydney, New South Wales 2007, Australia

Dr Elizabeth TraceyResearch Fellow ,University of NewcastleConsultant Epidemiologist HNE Cancer Network Directorate The Lodge John Hunter Hospital Campus

MDT data – descriptive overviewTotal

Age at diagnosis n %Total 411 100.015-49 14 3.450-59 67 16.360-69 148 36.070-79 137 33.380+ 45 10.9TNM StageI 74 18.0II 57 13.9III 129 31.4IV 133 32.4Unstaged 5 1.2Not Applicable 9 2.2Unknown 4 1.0Weight Loss5% 60 14.66-10% 37 9.0>10% 22 5.4No weight loss 192 46.7Unknown 79 19.2Total 390 94.9Performance statusFully active 56 13.6No strenuous but ambulatory 104 25.3Ambulatory but cannot work 48 11.7Limited self care 10 2.4Not stated 193 47.0Time from diagnosis to MDTPrior to diagnosis 12 2.9At diagnosis or within a month 290 70.6Two_six_months post diagnosis 91 22.1Seven to twelve months post diagnosis 8 1.9Greater than 12 months 10 2.4

ComplicationsBronchial obstruction 50 12.2Compression of the superior vena cava 3 0.7Infection (would include pneumonia aspergillosis) 9 2.2Lung collapse (segmental lobular or lung) 4 1.0Mediastinal invasion 16 3.9Nerve damage(eg brachial plexus spinal cord recurrent laryngeal nerve damage)

92.2

No local complications 179 43.6Other 15 3.6Pleural effusion 6 1.5Unknown 120 29.2ComorbidityCardiovascular co-morbidity 31 7.5Diabetes mellitus 21 5.1Neoplastic co-morbidity 19 4.6None 49 11.9Renal insufficency 9 2.2Respiratory co-morbidity 24 5.8Tobacco consumption 195 47.4Unknown 39 9.5none 24 5.8Treatment intentCurative 126 30.7Palliative 173 42.1Pending 53 12.9Unknown 59 14.4

Summary of actual and recommended treatmentSummary or recommended treatmentCancer surgery determined by procedure codesPneumanectomy 2 0.5Lobectomy 6 1.5Wedge resection 24 5.8Biopsy 101 24.6No_surgery 278 67.6Chemotherapy 411No chemotherapy 148 36.0Chemotherapy 168 40.9Chemo_consult 95 23.1Radiotherapy 411No_radiotherapy 295 71.8Radiotherapy 47 11.4Radio_consultation 69 16.8Referal to palliative careReferred 157 38.2not_referred 254 61.8Psycho social referralNot_stated 140 34.1Other 35 8.5Specialist_nurse 236 57.4Recorded treatment 0.0Radiotherapy 70 17.0Sequential radiotherapy 3 0.7Adjuvant radiotherapy 1 0.2Chemotherapy 66 16.1Chemotherapy , radiotherapy 61 14.8Concurrent chemotherapy followed by radiotherapy 43 10.5Sequential chemotherapy followed by radiotherapy 1 0.2Adjuvant chemotherapy 9 2.2Neo-adjuvant chemotherapy 3 0.7Neurosurgery 1 0.2Orthopaedic surgery 1 0.2Pneumonectomy 2 0.5Bronchoscopy 4 1.0VATS 3 0.7Mediastinoscopy 4 1.0Lobectomy 6 1.5Wedge resection 24 5.8Palliative care 5 1.2

Assessment 11 2.7Follow-up survey 4 1.0Not for treatment 3 0.7Treat when symptoms 2 0.5Unknown - not recorded 84 20.4Financial classMedicare Eligible 246 59.9Medicare card holder - nursing home 78 19.0Not Recorded 1 0.2Public Non Chargeable 18 4.4Veterans Affairs 2 0.5Total 346 84.2Months from diagnosis to MDTPrior_diag 12 2.9one_month 290 70.6Two_six_months 91 22.1seven_12_months 8 1.9more_than_12 10 2.4Time from diagnosis to death 0.0one_month 21 5.1Two_six_months 76 18.5seven_12_months 69 16.8more_than_12 94 22.9Alive 151 36.7Total 411 100.0

Patients that did not link - reasons

Other cancer sites 51

Blank in ClinCR 13

Mesothelioma 9

Coded since CLINCR close off 7

Not cancer 5

MDT only 3

Not in clinCr 3

Private 2

No admission in HIE 1

No treatment recorded 1

95