Variation in surgical resection for lung cancer in relation to survival: Population-based study in England 2004–2006

https://doi.org/10.1016/j.ejca.2011.07.012Get rights and content

Abstract

Background

Compared with some European countries, England has low lung cancer survival and low use of surgical resection for lung cancer. The use of surgical resection varies within England. We assessed the relationship between surgical resection rate and the survival of lung cancer patients in England.

Methods

We extracted data on 77,349 non-small cell lung cancer (NSCLC) patients diagnosed between 2004 and 2006 from the English National Cancer Repository Dataset. We calculated the frequency of surgical resection by age, socio-economic deprivation and geographical area. We used Cox regression to compute mortality hazard ratios according to quintiles of frequency of surgical resection amongst all 77,349 lung cancer patients, and separately for the 6900 patients who underwent surgical resection.

Results

We found large geographical variation in the surgical resection rate for NSCLC in PCT areas (3–18%). A high frequency of resection was strongly inversely associated with overall mortality (HR 0.88, 95% CI 0.86–0.91 for the highest compared to the lowest resection quintile) and only moderately associated with mortality amongst the resected patients (HR 1.15, 95% CI 0.98–1.36). Compared to the highest resection quintile, 5420 deaths could be delayed in the overall NSCLC group, whereas about 146 more deaths could be expected amongst the resected patients.

Conclusion

The differences in the magnitudes of both the hazard ratios and the absolute excess deaths within resected patients and all NSCLC patients suggests that lung cancer survival in England could plausibly increase if a larger proportion of patients underwent surgical resection. Carefully designed research into the possible benefit of increasing resection rates is indicated.

Introduction

Around 40,000 incident cases of lung cancer are diagnosed in the United Kingdom every year, and five-year relative survival is less than 10%.1 Lung cancer survival is known to be lower in England than in other countries with similar health care systems2 and the mortality difference is largest early in the period of follow-up.3 Surgical resection for lung cancer can potentially lead to long-term survival and cure, and it is possible that the low survival in England can in part be ascribed to low resection rates.

Non-small cell lung cancer (NSCLC) comprises over 85% of all lung cancers. In patients with early stage NSCLC, pulmonary resection provides the best form of potentially curative treatment.4 The resection rate in England is reportedly around 10%,5 whereas elsewhere in Europe and the US resection rates of around 20% to 30% are reported.6, 7, 8 However, most internationally reported resection rates are quoted as a proportion of those patients with a confirmed tissue diagnosis of NSCLC whereas previous UK data has used the total lung cancer population (including those diagnosed on clinic-radiological grounds only) as the denominator. It has been shown that resection rates are variable by region.9, 10 Recent data from the English National Lung Cancer Audit showed that 14% of patients with a confirmed NSCLC diagnosis underwent resection, with some hospital trusts having rates of well over 20%.11 [http://www.ic.nhs.uk/webfiles/Services/NCASP/] A recent report from one UK hospital reported a resection rate of 25% for NSCLC.12 The resection rate in NSCLC patients declines above the age of 70 years,13 although there is strong evidence that they respond equally as well as younger patients.14 Higher levels of socio-economic deprivation have been associated with the low use of radical resection for lung cancer.15, 16

The present study was designed to explore the association between lung cancer resection and survival in different parts and subgroups of the English population. The ultimate question is whether it is likely that increasing the use of surgical resection would lead to an increase in lung cancer survival. A priori, we hypothesised that resection and survival would be positively associated in the total lung cancer population (resected patients expectedly living longer than non-resected patients), and negatively associated in the resected patient population (higher surgery rates being associated with surgery being carried out on higher risk patients). The relative magnitudes of these opposing associations could help indicate whether an increase in resection would lead to an increase in the overall lung cancer survival.

Section snippets

Lung cancer patients

We extracted data on 92,952 persons diagnosed with lung cancer (ICD-10 C33-C34) between 2004 and 2006 from the National Cancer Repository Dataset, collated from the regional cancer registries in England and linked with the hospital episode statistics (HES) records.17 Follow-up for death was until 31st December 2006.

We excluded small cell lung cancer (SCLC) (n = 11,428) patients from the analysis of survival in relation to surgical resection because the primary treatment for SCLC is generally

Variation in radical resection

Fig. 1 shows the proportions of lung cancer patients in the 152 PCTs in England who underwent surgical resection. The proportion ranged from 3% to 18% with a median of 9%.

A map of the resection quintiles in PCT areas in England indicated no obvious geographical pattern (data not shown).

Predictors of surgical resection

Initially we analysed the proportions of lung cancer patients who underwent surgical resection in relation to other known characteristics. Resection was highly dependent on age with the proportion of resected

Discussion

Within England, we found variation in the use of surgical resection as a treatment for NSCLC. Higher resection rates were strongly associated with better overall survival and only moderately inversely associated with survival within the resected sub-population. We found these associations both at the level of the 152 PCTs and nine Government Office Regions in England. These associations were independent of age, sex and socio-economic deprivation, but age, sex and socio-economic deprivation

Ethics

Cancer registries in England have approval from the National Information Governance Board to carry out surveillance using the data they collect on all cancer patients under section 251 of the NHS Act 2006. Therefore separate ethical approval was not required for this study.

Role of the funding source

The Thames Cancer Registry in King’s College London receives funding from the Department of Health for England. The views expressed in the article are those of the authors and not necessarily those of the Department of Health.

Conflict of interest statement

None declared.

Acknowledgements

This paper is a contribution from the National Cancer Intelligence Network and is based on the information collected and quality assured by the regional cancer registries in England. (www.ukacr.org; www.ncin.org.uk).

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