The latest report of the National Lung Cancer Audit has the potential to significantly reduce variations in care, writes Mick Peake

The publication this week of the report of the National Lung Cancer Audit (NLCA) for patients first seen in 2009 is a milestone in many respects. The comprehensive nature of the coverage across the UK, the quality of the data and the evidence of its impact on patient outcomes is probably unique in the cancer world and very rare in other clinical disciplines.

After a long period of gestation, the NLCA had its first full year of data collection in England and Wales in 2005, with the first report being published in 2006. At the outset, population coverage was limited and data completeness relatively poor. Since then, the project team - a partnership between the NHS Information Centre and the Royal College of Physicians of London - has worked very hard with trusts and cancer networks across the country - to the point where in this report we have data submitted from every trust in England, Wales, Scotland, Northern Ireland (bar one) and Jersey.

Data has been collected on very nearly 100 per cent of the expected incident cases and data completeness for the key fields is 80 per cent or more. Strong, multi-disciplinary clinical engagement from the beginning has been a crucial element of this success.

Headline indicators

Treatment and survival rates for lung cancer are known to be low in the UK compared with many parts of the Western world and so we chose to concentrate on auditing elements of care that, if addressed, would be likely to have the greatest impact on patient outcomes. We have called these the “headline indicators”.

From the start, the audit demonstrated very wide variations between trusts and cancer networks in these indicators and while some of this was initially related to data quality, it has become clear that even when data are near-complete and are corrected for case-mix variables such as age, sex, stage of disease, performance status (a measure of overall fitness) and deprivation, a large part of the variation remains.

Results of the audit are available to trusts and networks online in near “real-time”, but it has been the use of local action plans, produced in parallel with each annual report, that we believe has had most impact on clinical practice. The NLCA team are regularly invited to trusts and networks to help work through the data and try to define what the nature of the local issues are. We have also worked with NHS Cancer Improvement to support service redesign. Several headline indicators are now included as “clinical lines of enquiry” in cancer peer review, which has also stimulated many multi-disciplinary teams to examine their practice in more detail.

Variations remain

In the table below is shown the progression of data quality and some of the headline indicators over the six year life of the audit for England. It is clear that there have been significant improvements in all the indicators and we are confident that these will be translated into better survival over time.

However, serious variation remains, despite the fact that the range of this variation has also reduced over the period of the audit.

For example, in 2009, the proportion of lung cancer patients in England receiving any active anti-cancer treatment (viz. surgery, radiotherapy of chemotherapy) varied from 40.9 per cent to 68.9 per cent by network and 33.3 per cent to 88 per cent by trust. The proportion of patients with non-small cell lung cancer who underwent potentially curative surgery ranged from 10.7 per cent to 20.3 per cent by network and 5.3 per cent to 33 per cent by trust - a six-fold difference.

We have observed examples of areas where the recruitment of a specialist thoracic surgeon has led to a significant increase in resection rates, indicating that there is significant scope for further improvement. The fact that trusts and networks are named in our reports and that they are publicly available is an important element of the work.

These data are now being linked to other data sources (such as HES and radiotherapy data) by the National Cancer Intelligence Network and it is our aim to make an increasing range of such activity, performance and outcome information available to commissioners, providers and indeed patients. As comparative data of this sort becomes more widely available, the potential to support much higher quality commissioning and informed patient choice is obvious.

 

 20052006200720082009
% of trusts submitting data779396.598.1100
Case ascertainment (%)4066759297
Number of cases10,92016,92220,63927,81830,155
% discussed at MDT7984878993
% cases confirmed by biopsy6866656775
Resection rate: confirmed NSCLC (%)1414151618.4
Active treatment rate (%)4550525459
Small Cell chemotherapy rate (%)586265636

 

'Better quality data will help to reduce variations in care'