Lung Cancer Presentation

Dr Richard Sullivan and

Ms Anne Fraser

6th November 2014

 Overview
• Background
• Risk Profile of Lung Cancer
• The Lung Cancer Pathway
• Treatment and Management
• DHB Contacts
• Q&A

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 Background
• Lung cancer is the leading cause of cancer
deaths in New Zealand
– 1942 people diagnosed in 2010
– 1650 people died in 2010

• Survival in NZ is poorer than Australia,

Canada, the USA & some European
countries
6 September 2013 3
 Background
• Poor survival in lung cancer is because the majority of lung cancer
patients present with advanced incurable disease
5yr survival (NSCLC) : Stage I/II 50%, III 15%, IV <3%

• Differences in survival between countries relate to management

• Earlier diagnosis of people with lung cancer has the potential to
improve survival, when combined with appropriate and timely
investigation and treatment

• Initial Presentation
–76% Patients presented to primary care
–24% Patients presented to secondary care
• 14% self-presented to the Emergency Department (ED)
• 10% were already under secondary care when they developed symptoms or
had an incidental finding

( Stevens, W et al - Final Report - Identification of barriers to the early diagnosis of people with
lung cancer and description of best practice solutions July 2012)

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 Background
Significant health inequalities exist:
•Maori & Pacific have poorer lung cancer survival outcomes
– Maori patients are approximately 3 times more likely to die
from their lung cancer than non-Maori patients

•Known differences in stage of disease at diagnosis

– Maori patients were 2.5 times more likely to have locally
advanced disease

•Known differences in management of disease

– Maori patients had longer timelines from diagnosis to
treatment

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 Background
• Prevention and Awareness
– Social marketing – “Cough, Cough, Cough”
– Tobacco Control/Smoking Cessation
– NRT, buproprion (Zyban), varenicline
(Champix)
– Access to support and counselling
• NZ National efforts
– Aspire 2025, plain packaging

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 Background
Why don’t we screen for lung cancer?
• "screening with annual CT has been shown to reduce
lung cancer deaths compared to chest Xray” …….
BUT
• high number needed to screen
• best selection criteria for screening not yet known
• cost effectiveness uncertain
• risk of over diagnosis and invasive tests for benign
disease
• need for lots of follow up CTs
• Also smoking cessation and tobacco control are likely to
be much more (cost) effective
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 Risk Profile

Cigarettes

Lung Cancer

Emphysema/COPD

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 Profile of a Patient that should be
Referred urgently for a chest x-ray
• Unexplained haemoptysis
OR
• Any of the following unexplained, persistent (lasting more than 3
weeks or less than 3 weeks in people with known risk factors)
symptoms and signs:
– Chest and/or shoulder pain
– Shortness of breath
– Weight loss/loss of appetite
– Abnormal chest signs
– Hoarseness
– Finger clubbing
– Cervical and/or supraclavicular lymphadenopathy
– Cough
– Features suggestive of metastasis from a lung cancer (e.g., in
brain, bone, liver or skin)

(NZ Guidelines Group) 9

 Profile of a Patient that should be
Referred Urgently to a Specialist
• Persistent haemoptysis and are smokers or ex-
smokers aged 40 years or older
• A chest x-ray suggestive of lung cancer
(including pleural effusion and slowly resolving
consolidation)
• Finger clubbing
• Severe weight loss
• SVC Obstruction
• Neck nodes – in smokers
(NZ Guidelines Group)
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 Lung Cancer Pathway
Lung cancer

Indicator two (best practise – 14 days) Indicator three (best practise – 31 days)

CT
Urgent referral
Primary with high- First specialist
Decision-to-treat
First cancer
Care suspicion of assessment treatment
cancer

Indicator one (best practise – 62 days)

Includes diagnostics, surgical & non-

surgical treatments
All cancers by tumour stream
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 Identification of Barriers to the
Early Diagnosis of Lung Cancer and
Description of Best Practice Solutions

Principal Investigator: Dr Wendy Stevens

Cancer Trials New Zealand, the University of Auckland

6 September 2013 12
Funded by a Health Research Council of New Zealand & District Health Boards New Zealand Grant
Our Barriers to Early Diagnosis
1. Presentation/Attendance Barriers
2. Identification Barriers
3. Waiting Time Barriers
4. Information Barriers

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 Best Practice Solutions
TO REDUCE BARRIERS WITHIN PRIMARY CARE

1. Increase awareness of lung cancer in primary care

2. Smoking status routinely recorded
3. Improve GP utilisation of CXRs
4. Follow up systems in place for patients
5. Regionally consistent investigation & referral pathways
6. A standardised template for e-referral system
7. Audit tool for the assessment of GP lung cancer referral

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 Northern Region Radiological
Referral Processes
• ADHB and CMDHB
– Access to Diagnostics Tool using community and hospital
service providers
– Utilising e-referrals process
– Some practices utilising Fax refferal system
• NDHB
– GP refers to hospital respiratory services with suspected cancer
– Respiratory service has to refer for CT scan
– Future planned implementation of macro e-referral template
• WDHB
– Utilising e-referrals in some practices
– Utilise current Fax referral system

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 Radiology Access
• Chest x-rays
– E-referral or Fax
• CXR or CT
– All DHBs have radiology liaisons that can be called to
discuss needs and gain access
– Patients can been seen same/next day
– GP practices will receive a report with next steps
• All Significant findings will include a phone call to GP
• If CT required this should be sent at the same time as FSA
– GPs should be confident in ability to access good
DHB radiology capacity

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 Lung cancer Pathway
High Suspicion
Lung Cancer

Referral
CT

CT report
Respiratory FSA
(< 14 days)

Bronchoscopy CT-FNA Biopsy extra thoracic

lesion
Bronchoscopy
~35%
report
non diagnostic
(< 3 days)
CT-FNA report Biopsy report
(<1-3 days) (< 3 days)
~65%
diagnostic

TMDM
(< 14 days after FSA)

When there is a high suspicion of cancer – ensure that you complete

• Referral to Respiratory
• Referral to CT
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 Advances in
Treatment/Management
• Management
– Minimally invasive staging and surgery
• Endobronchial ultrasound
• Thoracoscopic resections
– Stereotactic radiotherapy
• Less toxic to normal lung
– Targeted chemotherapy
• More effective if +ve for mutations; oral tablets
– Advanced Care Planning and Palliative care
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 Key Take Home Messages (1)
• Prevent lung cancer
– Ask about smoking status; offer support to quit
• Recognition of lung cancer
– Smokers with emphysema/COPD at highest risk
– Persistent cough (longer than 3 weeks) not
responding to treatment – most common symptom
– Low threshold for ordering Chest Xray
– Consider ordering CT chest at same time as
specialist referral
– DHBs are now required to see and treat your patient
quickly; most are already doing so

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 Key Take Home Messages (2)
• Help treat lung cancer
– Advanced Care Planning
– Help to give excellent quality palliative care – it can
improve quality of life and even survival
• Lung cancer is not hopeless
– Co-morbid patients may still be able to have minimally
invasive surgery or modern radiotherapy
– Targeted chemotherapy is effective, less toxic and
easier to take in suitable patients
– Palliative radiotherapy is effective for symptom control

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 ADHB Key Contacts
• Central Referrals Office – fax (09) 638 0400
• Respiratory
– (09) 367 0000 (Physician roster in place)
• Radiology - Auckland DHB GP Advice/ Contacts
– Hot Desk 8.30am to 4.30pm Monday to Friday
• (09) 3074949 Ext 24571#
– Fax (09) 375 7033 (Auckland City Hospital)
– Fax (09) 623 6444 (Greenlane)
– Emergency Phone (09) 3074949 (GP hotline)
• Oncology – If under Regional Cancer Service
– CNS Anne Fraser – 021950168
– Medical Ongologist Dr Richard Sullivan – 021493915
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Appendix
When you click on Help  Referral Guidelines

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 Useful Website Guide
• www.lungfoundation.com.au
• www.macmillan.org
• www.cancersociety.co.nz
• www.lunghealth.org.nz

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