2009 Cancer Committee

Transcription

1 2009 Cancer Committee Lung (non-small cell) Cancer Study Stage IIIA and IIIB John Clouse, M.D. Alicia Stark, RHIT Jeff Robinson

2 Table of Cont ent s Table of Contents... 1 Lung (non-small cell) Cancer Facts.2 CoxHealth Cancer Committee Study Criteria Item I Patients Diagnosed. 4 Item II Age Distribution Item III Diagnostic Exams Item IV Lymph Node Evaluation Item V Treatment Modalities...7 Item Vl Treatment Refusal or Contraindicated...7 Item Vll Clinical Trial Participation...7 Item VIll Survival Rates...8 Conclusion....9

3 Lung (non-small cell) Cancer Facts: Non-small Cell Lung Cancer (NSCLC) is the most common type of lung cancer. It usually grows and spreads more slowly than small cell lung cancer Smoking causes most cases of lung cancer. The risk depends upon the number of cigarettes smoked every day and for how long someone has smoked. Being around the smoke from others (secondhand smoke) also raises your risk for lung cancer. From , the median age at diagnosis for cancer of the lung and bronchus was 71 years of age. Lung cancer is rare in people under the age of 45. Most often, NSCLC develops slowly and causes few or no symptoms until very late stages. However, in some cases, it can be extremely aggressive and cause rapid death. Stage III tumors can be cured in some cases, but cure rates are much lower than earlier stage NSCLC Radon exposure is the second leading cause of lung cancer, and the leading cause of lung cancer among never-smokers. Lung cancer (both small cell and non-small cell) is the leading cause of cancer death for both men and women. More people die of lung cancer than of colon, breast, and prostate cancers combined Roughly 84 percent of people diagnosed with lung cancer die within five years of their diagnosis, compared to 11 percent of breast cancer and less than 1 percent of prostate cancer patients. Lung cancer is responsible for more than 28% of all cancer-related deaths every year. The American Cancer Society's most recent estimates for lung cancer in the United States are for 2009: o 219,440 new cases of lung cancer (both small cell and non-small cell) o Lung cancer kills more than 160,000 people annually 2

4 Lung (non-small cell) Cancer Study Criteria: CoxHealth Cancer Committee In 2009, the Hulston Cancer Committee elected to conduct an outcome and survival analysis of our stage IIIA and IIIB Lung (non-small cell) Cancer Patients. This study focused upon patients with an initial diagnosis between the time periods of (see criteria below). Members voted unanimously to approve the Lung Cancer study as outlined. Criteria: All patients diagnosed in the years with Lung (non-small cell) Cancer, stage IIIA and IIIB. Diagnostic exams performed prior to treatment, pathology lymph node evaluation, treatment options and five year survival. Study: I. Evaluate how many patients were diagnosed with Lung (non-small cell) Cancer. II. Evaluate at what age the patients were diagnosed. III. Identify what percentage of the patients had a pretreatment CT Needle Biopsy, PFT, Bronch (include intraoprative), PET and MRI of the brain. IV. Identify what percent of patients had a Pathology Lymph Node Evaluation for the mediastinal area. i. Age of those receiving LN eval V. Identify the percentage of patients having surgery, radiation or chemotherapy alone or combination Surg/Rad, Surg/Chemo, Rad/Chemo or Surg/Rad/Chemo. VI. Identify the percentage of patients who refused all or part of their treatment or if treatment was contraindicated. VII. Identify the percentage of patients that participated in a clinical trial. VIII. Evaluate the 5 year survival rate and benchmark to national data resources. 3

5 2009 Lung (non-small cell) Cancer Study Details: Item I -- Patients Diagnosed with NSCLC During the years 1999 through 2003, 261 patients were diagnosed with Lung (non-small cell) cancers in stage IIIA and IIIB. Of those 261 patients, 43 patients were excluded from our study due to other cancers in addition to Lung (non-small cell) cancer. This leaves 218 patients in our study, with: 76 patients diagnosed with stage IIIA 142 patients diagnosed with stage IIIB Item II Age Distribution at Time of Diagnosis Of the 218 patients studied, the most common age group at diagnosis was the group. In comparison with the national data, the age groups at the time of diagnosis were very similar. (See Figure 1 Below) Lung Stage III - Cox vs. National/CIRF Cox Stage III CIRF Stage III 40% 35% 34% 34% 30% 31% 30% 25% Percentage 20% 17% 17% 15% 10% 5% 0% 12% 11% 6% 6% 1% 0.80% 0.50% 0.70% 0.04% Age Groups Figure 1 Lung Stage III Age Distribution Cox vs. National/CIRF (Source: CoxHealth Cancer Registry Database) 4

6 Item III Pretreatment Diagnostic Procedures When looking at the pretreatment diagnostic studies, we chose to look at patients diagnosed in 2003 and then in 2007 as a comparison. (See Figure 2 Below) In 2003, 52 patients were diagnosed with stage IIIA and IIIB NSCLC. Of these 52 patients, all received a pretreatment diagnostic procedure % of patients had CT biopsy 35% of patients had PFT 65% of patients had Bronchoscopy 69% of patients had PET 42% of patients had Brain MRI In 2007, 28 patients were diagnosed with stage IIIA and IIIB NSCLC. Of these 28 patients, all received a pretreatment diagnostic procedure % of patients had CT biopsy 50% of patients had PFT 43% of patients had Bronchoscopy 61% of patients had PET 46% of patients had Brain MRI Pretreatment Diagnostic Exams- Stage III NSCLC 2003 vs Percentage 80% 70% 60% 50% 40% 30% 20% 10% 0% CT BIOPSY PFT BRONCH PET MRI BRAIN Exam Figure 2 Pretreatment Diagnostic Exams (Source: CoxHealth Cancer Registry Database) 5

7 Item IV Lymph Node Evaluation With lymph node evaluation by pathology, we chose to look at patient age groups that had a lymph node evaluation. Again, we chose to look at patients in 2003 and then in 2007 as a comparison. (See Figure 3 Below) % of patients had lymph node evaluation 21% of patients had lymph node evaluation Lymph Node Evaluation 2003 vs % w/node Eval 2003 % w/node Eval % 50% 50% 50% 40% 30% 33% 33% 20% 17% 17% 10% 0% 0% 0% 0% 0% Age Groups Figure 3 Lymph Node Evaluation (Source: CoxHealth Cancer Registry Database) 6

8 Item V Treatment Options Of the 218 patients in our study, 9 patients had surgery only 64 had radiation only 21 had chemotherapy only 47 had radiation/chemo 18 had combination surgery/radiation 4 had surgery/chemo 10 had surgery/radiation/chemo 45 had no treatment A comparison of treatment options to the Cancer Information Reference File (CIRF) national data was performed. (See Figure 4 Below) Lung Stage III Treatment Type - Cox vs. CIRF Comparison CIRF Stage III COX Stage III 40% 35% 34% 30% 27% 25% 20% 20% 21% 15% 15% 15% 10% 7% 9% 9% 7% 10% 5% 4% 4% 3% 2% 4% 0% S R C R/C S/R S/C S/R/C NO TX Treatment Type Figure 4 Lung Stage III Treatment Type (Source: CoxHealth Cancer Registry Database) 7

9 Item VI Treatment Refusal or Contraindicated Of the 218 patients in our study, 45 patients did not receive treatment for the following reason: 15 had contraindications/co-morbidities 11 patients refused treatment 10 patients were referred to Hospice/Comfort care 5 patients expired before treatment could be started 3 had unknown reasons 1 patient s disease progressed before treatment began Item VIl Clinical Trial Participation Clinical trial participation was assessed for all five years of our study. (See Figure 5 Below) Clinical Trial Participation for Non-Small Cell Lung Cancer Stage III - Cox 14% 12% 10% 8% 6% 4% 2% 0% Years Figure 5 Clinical Trial Participation (Source: CoxHealth Cancer Registry Database) There was an overall average clinical trial participation rate for the study period of of 6.5%. 8

10 Item VIIl Survival Rates For comparison to the CIRF national data base, we were limited to the time period of 1999 to 2002 due to the unavailability of 2003 patient data by our software vendor. For this adjusted time period, at CoxHealth, 164 NSCLC patients, stage lll were diagnosed. These 164 patients have been followed and are now compared to the CIRF National Database which is comprised of 15,696 patients with stage lll NSCLC. (See Figure 6 Below) SURVIVAL PERCENTAGE NSCLC STAGE III SURVIVAL COX vs. CIRF CIRF STAGE III MONTHS COX STAGE III Figure 6 Survival Cox vs. CIRF (Source: CoxHealth Cancer Registry Database) Please note CIRF survival data is for CoxHealth s five-year survival rate shows outcomes slightly lower than the CIRF national database comparison. However, we were unable to compare CIRF survival by stage llla and lllb due to software limitations. Cox had a high proportion of stage lllb patients in our study who were unfit to receive combined radiation/chemo due to poor performance status. Also, when compared to CIRF data, Cox had a higher percentage of patients that had no treatment. Both of these factors would trend Cox patients lower. 9

11 For comparison to the National Cancer Data Base (NCDB) we were limited to the time period of 1998 to CoxHealth diagnosed 162 patients with stage lll NSCLC during this time period. These 162 patients have been followed and compared to the NCDB data comprised of 77,163 patients. (See Figure 7 Below) NSCLC Stage III Survival COX vs. NCDB Cox Stage III National Stage III SURVIVIAL PERCENTAGE Dx 1 Year 2 Years 3 Years 4 Years 5 Years Figure 7 Survival Cox vs. NCDB (Source: CoxHealth Cancer Registry Database and NCDB National Database) Please note that NCDB survival data is for CoxHealth s five-year survival rate shows outcomes similar to the previous conclusion with CIRF data. 10

12 Conclusion: I. During the years 1999 through 2003, 261 patients were diagnosed in our hospital with NSCLC Stages IIIA and IIIB. Of those 261 patients, 43 patients had other cancers in addition to NSCLC. II. Patients in our study with NSCLC were predominantly between the ages of 70 and 79 which correlate with a national median age of 71 for NSCLC. III. Of the patients in this study, 21% had no treatment due to refusal of treatment, Hospice/Comfort care, expired prior to start of treatment or were not a candidate for treatment. CoxHealth identified an opportunity for improvement in patient care with the creation of a Lung Cancer Coordinator who has worked diligently to help patients navigate through their treatment process IV. Our study demonstrated that 27% of our patients diagnosed during 1999 to 2003 had radiation alone compared to a national percentage of 15% for radiation only. For combination radiation/chemo Cox was 20% in comparison to a national average of 34%. It is probable that this reflects a lower performance status of our patient population. A unhealthy population is less capable of tolerating treatment and has been shown to have poorer survival outcomes V. CoxHealth s five year survival rate falls under the national rate for NSCLC stage III. This is most likely due to a higher percentage of stage IIIB patients, as well as a higher number of patients having no treatment in our study population. 11

13 Works Cited: a. American Cancer Society b. National Cancer Institute c. Medline Plus d. National Lung cancer Partnership 12

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