The impact of surgical presence to MDT

Report
Resection rate for patients with tissue
confirmation of NSCLC (2004-2008:England)
First seen Number Number
%
Adjusted
in centre
With a
who had having Odds Ratio P value
with
tissue
surgical surgery for surgery*
thoracic diagnosis resection
surgery? of NSCLC
No
Yes
25,248
9,265
(27%)
2,947
1,538
12%
17%
1.00
1.51 (1.161.97)
<0.001
*adjusted for sex, age, PS, stage, deprivation index
and Charlson co-morbidity index
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
Proportion of lung cases having a pneumonectomy (%)
Resection rate by PCT
2004-6*
18
16
14
12
10
8
Q1
Q2
Q3
Q4
Q5
6
4
2
PCT of residence
*Source: National Cancer Data Repository
Mortality Hazard Ratios for Lung Cancer
Patients in England 2004-6 related to resection
rate by government office region
N = 77,349
1.05
SE
SW
EM
EE
1.00
NE
NWY&H
0.95
WM
L
0.90
0.85
5
6
7
8
9
Radical surgery (%)
Hazard ratio 95% CI
Radical surgery 95% CI
10
11
Mortality hazard ratios for resected
patients; England 2004-6 by
Government Regional Office
1.70
1.60
1.50
1.40
1.30
1.20
1.10
1.00
WM
EE
L
SW
0.90
Y&H
NW
NE
EM
0.80
SE
0.70
0.60
N = 6,900
0.50
5
6
7
8
9
Radical surgery (%)
Hazard ratio 95% CI
Radical sugery 95% CI
10
11
Mortality hazard ratios for resected
patients; England 2004-6 by
Government Regional Office
1.70
1.60
1.50
1.40
1.30
1.20
1.10
1.00
WM
Implications: comparing the top quintile PCT with
Lower 4:
0.90 deaths ‘postponed’ by surgery
5420
0.80
146
deaths related to higher resection rates
0.70
EE
L
SW
Y&H
NW
NE
EM
SE
0.60
N = 6,900
0.50
5
6
7
8
9
Radical surgery (%)
Hazard ratio 95% CI
Radical sugery 95% CI
10
11
The effects of investing in
thoracic surgery on
lung cancer resection rates
Kelvin Lau
David Waller
Sridhar Rathinam
Michael Peake
Glenfield Hospital, Leicester, UK
UK National Lung Cancer Audit Programme
Lung cancer in UK is under treated
There is a wide variation in
lung cancer surgery in England
5.2% – 10.1%
10.9% – 13.2%
13.6% – 14.5%
14.6% – 16.5%
16.9% – 31.8%
Hypothesis
the variability in Resection Rate
is determined by the provision of
specialist thoracic surgery
Method
We correlated results of the
NATIONAL LUNG CANCER AUDIT
with manpower data for cardiothoracic surgery
Network
SEW
N34
NWW
N32
N25
N28
SWW
N24
N13
N12
N26
N37
N36
N33
N35
N30
N27
N38
N07
N02
N01
N21
N06
N29
N11
N08
N14
N03
N31
N20
N22
N23
N15
Adjusted OR (95% CI)
Adjusted OR for Resection in NSCLC by Network (2008)
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
National Lung Cancer Audit results
• 33 English Cancer Networks, comprising 174 Hospital Trusts
• 31 Trusts had Thoracic Surgery in house (Base Hospitals)
• 18 (58%) Trusts had less than 2 Pure Thoracic Surgeons
• 13 (42%) Trusts had 2 or more Pure Thoracic Surgeons
• In 2008, 15,774 cases of histologically confirmed NSCLC
– 18.4% cStage I and II
– 14.2% underwent resection
Resection rates are higher in centres
who treat more cases
R = 0.155
p = 0.06
Resection rates are higher in base
than in referring centres
Across the UK
Within each Cancer Network
20%
25%
p < 0.001
Resection Rate
20%
p < 0.001
15%
15%
10%
10%
5%
5%
0%
0%
Base
Peripheral
Base
Peripheral
Resection rates are higher in centres with 2 or
more specialist thoracic surgeons
25%
p = 0.02
Resection Rate
20%
15%
10%
5%
0%
Less than 2
2 or More
Resection rates are higher when
surgeons attend preoperative MDTs
16
p = 0.012
14
12
10
8
6
4
2
0
Less than two-thirds
More than two-thirds
The increase in resection rate was greatest in those
units who employed new thoracic surgeons
20
p = 0.04
Resection Rate
15
19%
66%
2009
Growth
10
2008
5
0
Static
Expanded (5 Units)
Conclusion
• Lung cancer resection rates in UK can be
increased by
• Increasing the number of specialist thoracic
surgeons at preoperative MDTs in referring hospitals
• Increasing the number of specialist thoracic
surgeons in operating centres
• Thereby increasing the individual caseload in any
unit
• Individual Units must invest in more pure Thoracic
Surgical appointments
• The number of specialist thoracic surgeons in
training must be increased
Resection Rate - Leicester
Surgical
Numbers
Resection Rate
for confirmed
NSCLC
Resection Rate
for all Lung
Cancers
1994-1996*
65
12.2
4.5
1997-1999*
175
23.4
12.0
2002
45
19.9
12.7
2003
58
21.0
13.8
2004
60
20.8
13.5
2005
89
30.4
20.6
2006
94
31.1
19.3
* A Martin-Ucar et al. Lung Cancer. 2004; 46:227-232
(specialist thoracic surgeon appointed 1997)

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