The complex diagnosing and treatment of lung cancer needs the reins of policy tightening. By David Baldwin
Lung cancer is the leading cause of cancer mortality in the UK accounting for a fifth of cancer deaths. Five year survival rates have doubled over the last 15 years but are nevertheless only 15 per cent and this is below other countries such as Australia, Canada, Denmark, Norway and Ireland (19-21 per cent). The majority of patients present with late-stage cancer and many are too unwell to receive systemic treatment despite the availability of more effective targeted therapy.
Performances status predicts both receipt of treatment and extent of benefit and it often deteriorates prior to diagnosis. Delays in timely diagnosis and associated patient receipt of treatment and care have been identified as contributing to the UK’s comparatively poor lung cancer outcomes. Furthermore, patients consistently identify delay in diagnosis as a source of distress and therefore methods to improve the speed of diagnosis are a priority to improve outcomes and patient satisfaction.
The National Optimal Lung Cancer Pathway (NOLCP) was introduced in August 2017 with the aim of helping to cut delays in the diagnostic and treatment pathway. The guidance was developed to provide commissioners and service providers with a roadmap for optimising lung cancer services – and with the potential to reduce the time from referral to treatment from 62 to 49 days. The pathway details the optimal logistics to achieve diagnosis, staging and treatment and has become a major national priority for implementation. Clinical teams are working hard to achieve the ambitious timeframes.
Now, two years after the introduction of the NOLCP, and with the commitment in the NHS Long Term Plan to increase the number of early stage cancer diagnoses through faster diagnosis standards, there is an opportunity to take stock of the progress that has been achieved.
An excellent new report by the UK Lung Cancer Coalition, called Pathways Matter, highlights the progress achieved with the pathway to date and I am astonished by the excellent level of uptake so far. However, there are still a number of major challenges which need to be addressed to ensure wider roll-out.
The four most important are probably: rapid access to CT scans (and the reports!) at the very start of the pathway, access to high quality endobronchial ultrasound (EBUS), rapid turn round of molecular pathology tests and rapid access to PET-CT scanning.
One key area which needs consideration is the commissioning guidance for PET-CT. It is imperative that NHS England should review the national PET-CT commissioning guidance to align PET-CT scan reporting turnaround timelines with that set out in the NOLCP; the current contract deviating significantly from those stipulated in the pathway. With the contract commissioned nationally, trusts currently do not have much influence locally over accelerating the turnaround times of an external PET-CT scan provider.
Currently, the UK has only 78 PET-CT scanners – less than half the number of those available in other comparable EU countries. Consequently, timely access to PET-CT scans remains challenging for UK lung cancer patients. This is exacerbated by the increasing use of PET-CT in the diagnosis in a range of non-cancer diseases. We are just not keeping up with the clinical need for this technology.
A central PET-CT booking system, which enables the clinical team to coordinate PET-CT scan availability in a specific area, may provide an organisational approach towards unlocking efficiencies in this part of the pathway. Some trusts in London have already begun to develop a register through which capacity and waiting times for the available PET-CT scan facilities is managed via a single booking system, though this is still not in place. This will enable comparison of waiting times across the PET-CT scanners in the area and the patient to be sent to next available.
The UK has only 78 PET-CT scanners – less than half the number of those available in other comparable EU countries
Whilst this approach will enable PET-CT scan capacity to be more efficiently managed (particularly in urban areas), Cancer Alliances in rural parts of the country have warned that such a system would potentially require lung cancer patients having to travel long distances to the next available PET-CT scanner - rather than going to the one nearest to them.
In this case, a network of radiologists within a Cancer Alliances could provide an alternative organisational approach. This would involve PET-CT images being sent to and interpreted by the radiologist with the greatest capacity in that area. PET-CT images can be easily shared electronically and therefore do not require the patient to travel.
Trusts in South Cumbria Cancer Alliance are already implementing such as a system, whereby the administrator in the radiology department provides daily email updates to the oncology team on the available PET images. This has helped reduced PET scan turnaround times by five days, from 12 to 7 days.
Welcome with open-arms
The diagnosis, staging and treatment of lung cancer has become very much more complex in the last 10 years making the optimum care both more specialised and potentially more time consuming, posing challenges to all of us responsible for the provision, delivery and commissioning of care.
We all recognise these challenges and are fully supportive of the efforts to meet them, it is important that we continue to press for them to be implemented as rapidly and widely as possible to improve the quality of care and outcomes for lung cancer patients in this country.
The NHS long-term plan, rightly, contains some ambitious targets for cancer. It states that it wants to see 55,000 more people surviving five years or more by 2028. I welcome this ambition. But the hard reality is that, as the UK’s biggest cancer killer, unless there is a radical and impactful intervention in lung cancer that shared goal will not be achieved.