Risk Adjustment in Lung Cancer

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Risk Adjustment in Lung Cancer

• Dr Nicholas Chanarin
• Respiratory Physician

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Lung Cancer Selected Comparative 5 year
Survival males
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Lung Cancer Survival, England 1991-93
0 2 4 6 8 10
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Non-Small Cell LC Surgery by Age
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Non-Small Cell LC Surgery by Age
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Problem

• Why does the England appear to have worse
  survival figures for lung cancer?
• Greater Co-morbidity
• Patients have more advanced disease
• English Physicians are too cautious-Nihilistic
• How can we Improve outcomes for Lung cancer
  patients?
• Increase our uptake of radical treatments, surgery

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Fitness for Surgery
Co-Morbidity
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Co-Morbidity

• Kaplan-Feinstein Index
• J Chron Dis. 197427387-404
• Charlson Comorbidity Index
• J Chron Dis 198740(5)373-383
• The Index of Co-Existent Disease
• Med Care 199331(2)141-154.
• Adult Co-Morbidity Evaluation (ACE 27)

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Impact of Co-Morbidity on Lung CancerTammemagi
et al Int J Cancer 2003 1103(6)792-802

• 1155 patients with lung cancer
• 56 Co-Morbidities abstracted from records
• Outcome time to death
• Results
• Outcome predicted by stage, Co-Morbidity Count
  and Charlson Index
• These factors only explained a small proportion
  of the variability in outcome

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Co-Morbidity and Karnofksy performance score are
independent prognostic factors in stage III
Non-small cell lung cancer an institutional
analysis of patients treated on four RTOG
studies.
Byhart et al. Int J Radiat Biol Phys 2002 Oct
154(2)357-64

• 112 patients with stage III NSCLC
• Outcome Overall survival
• Results
• Performance status and Co-Morbidity score
  predictive of outcome

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Development/Validation of Cancer-Specific Models

• Colorectal
• Prostate
• Gynecological sites

• Lung
• Breast
• Head and Neck

• These models will be unique
• developed especially for cancer patients
• contain a wide range of comorbid ailments
• grade the severity of the individual ailments
• generate an overall severity score
• predict overall survival
• developed specifically to be used in conjunction
  with the standard ROADS-defined tumor
  registry data elements

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Fitness for Surgery

• Co-Morbidity models are not suitable

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Assessment of Fitness for surgery

• Opinion of Physician assessing patient
• Multi disciplinary team assessment
• British Thoracic Society Guidelines on the
  selection of patients with Lung cancer for
  Surgery
• Thorax 20015689-108

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Leicester Resection Rate
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British Thoracic Society Guidelines on the
selection of patients with Lung cancer for Surgery
Thorax 20015689-108

• Evidence based
• Recommendations on
• Age
• Cardiovascular disease
• Respiratory function
• Weight Loss and Performance Status
• Staging

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Conclusions

• No established scoring system in usage
• Different evaluations may be required for
  Co-Morbidity and Fitness for surgery
• Studies to explore the interaction between
  Co-Morbidity, fitness for surgery and radical
  treatments

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Time taken to Complete ACE 27
Max
Abstraction Time (mins)
Median
Min
With Comorbidity
Without Comorbidity
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