Multidisciplinary Lung Cancer Clinic Research Articles

Multidisciplinary lung cancer clinic: An emerging model of care

Dear Editor, Lung cancer management is progressively complex and multidisciplinary input is often needed. The recent publication of CheckMate 816 heralds a paradigm shift in the treatment of resectable non-small cell lung cancer (NSCLC),1 with many other perioperative trials soon to follow.2 Oligometastasis and oligoprogression in stage IV NSCLC are now recognised as distinct entities.

Barriers and facilitators to early-stage lung cancer care in the USA: a qualitative study.

Improved outcomes in lung cancer treatment are seen in high-volume academic centers, making it important to understand barriers to accessing care at such institutions. Few qualitative studies examine the barriers and facilitators to early-stage lung cancer care at US academic institutions. Adult patients with suspected or diagnosed early-stage non-small cell lung cancer presenting to a multidisciplinary lung cancer clinic at a US academic institution over a 6-month period beginning in 2019 were purposively sampled for semi-structured interviews. Semi-structured interviews were conducted and a qualitative content analysis was performed using the framework method. Themes relating to barriers and facilitators to lung cancer care were identified through iterative team-based coding. The 26 participants had a mean age of 62years (SD: 8.4years) and were majority female (62%), white (77%), and urban (85%). We identified 6 major themes: trust with providers and health systems are valued by patients; financial toxicity negatively influenced the diagnostic and treatment experience; social constraints magnified other barriers; patient self-advocacy as a facilitator of care access; provider advocacy could overcome other barriers; care coordination and good communication were important to patients. We have identified several barriers and facilitators to lung cancer care at an academic center in the US. These factors need to be addressed to improve quality of care among lung cancer patients. Further work will examine our findings in a community setting to understand if our findings are generalizable to patients who do not access a tertiary cancer care center.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System.

Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Health Resource and Cost Savings Achieved in a Multidisciplinary Lung Cancer Clinic.

Background: Lung cancer (LC) care is resource and cost intensive. We launched a Multidisciplinary LC Clinic (MDC), where patients with a new LC diagnosis received concurrent oncology consultation, resulting in improved time to LC assessment and treatment. Here, we evaluate the impact of MDC on health resource utilization, patient and caregiver costs, and secondary patient benefits. Methods: We retrospectively analyzed patients in a rapid assessment clinic with a new LC diagnosis pre-MDC (September 2016–February 2017) and post-MDC implementation (February 2017–December 2018). Data are reported as means; unpaired t-tests and ANOVA were used to assess for significance. We also conducted a cost analysis. Resource utilization, out-of-pocket costs, procedure-related costs, and indirect costs were evaluated from the societal perspective and presented in 2019 Canadian dollars (CAD); multi-way worst/best case and threshold sensitivity analyses were conducted. Results: We reviewed 428 patients (78 traditional model, 350 MDC). Patients in the MDC model required significantly fewer oncology visits from LC diagnosis to first LC treatment (1.62 vs. 2.68, p < 0.001), which was significant for patients with stage 1, 3, and 4 disease. Compared with the traditional model, there was no change in mean biopsies/patient (1.32 traditional vs. 1.17 MDC, p = 0.18) or staging investigations/patient (2.24 traditional vs. 2.02 MDC, p = 0.20). Post-MDC, there was an increase in invasive mediastinal staging for patients with stage 2/3 LC (15.0% vs. 60.0%, p < 0.001). Over 22 months, MDC resulted in savings of CAD 48,389 including CAD 24,167 CAD in direct patient out-of-pocket expenses. For the threshold analyses, MDC was estimated to cost CAD 25,708 per quality-adjusted life year (QALY), considered to be below current willingness to pay thresholds (at CAD 80,000 per QALY). MDC also facilitated oncology assessment for 29 non-LC patients. Conclusions: An MDC led to a reduction in patient visits and direct patient and caregiver costs.

PATIENT AND HEALTH SYSTEM COST SAVINGS IN A MULTIDISCIPLINARY LUNG CANCER CLINIC

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Lung cancer (LC) care is resource and cost intensive. A previous evaluation of a Multidisciplinary LC Clinic (MDC) at Kingston Health Sciences Centre in Kingston, Ontario, Canada, demonstrated that patients with a new LC diagnosis seen in a multidisciplinary model, with concurrent Pulmonology and Oncology consultations, experienced faster oncology assessment, shorter times to treatment, and a reduced number of clinic visits from diagnosis to treatment. In this economic evaluation, we report cost savings from the implementation of the MDC. METHODS: Standard methods of cost analysis were used. Resource use and costs were evaluated retrospectively for MDC implementation. Analyses were conducted from the societal perspective, with costs presented in 2019 Canadian dollars (CDN). We estimated total cost savings due to the reduction in clinic visits resulting from MDC implementation based on the analysis of all patients seen in the MDC from Feb 2017–Dec 2018. Productivity loss, travel-related costs, and administrative costs associated with booking clinic visits were evaluated. Multi-way sensitivity analyses were conducted to examine the impact of uncertainty on study results. RESULTS: In a sample of 350 patients seen in MDC, 271 (77%) were >65 years of age. MDC patients required 1.06 fewer oncology visits from LC diagnosis to first treatment, resulting in 371 fewer oncology visits over the study period. Travel costs were estimated using the Government of Canada automobile allowance rate ($0.58/km) and the mean round trip distance between patients’ homes and KHSC (101.96 km/visit), amounting to $21,940.94 in savings. Savings related to parking expenses ($3/hr) resulted in total cost savings of $2,226.00. The total out-of-pocket savings for n=350 patients were $24,166.94, or ˜$70/patient. Savings related to patient and caregiver productivity loss were calculated using the average wage for Canadians over the age of 25 ($29.55/hr), and all patients <65 years of age (23%) were included in the analysis. Additional parameters such as travel time (61.2 mins), clinic visit time (75.6 mins), parking/time spent locating the clinic (15 mins) and an average of 1.25 caregivers/patient helped inform our calculations. Patient and caregiver productivity-loss cost savings totalled $6,379.40 and $17,335.32, respectively. Clinic administrative level savings amounted to $508.27 (3 mins/booking; average wage $27.33/hr). The cost analysis was moderately sensitive to changes in productivity loss. CONCLUSIONS: A lung cancer MDC led to patient and health system economic benefits, with a total cost reduction of $48,389.93 over approximately 2 years (range: $37,173.37 - $122,896.42). CLINICAL IMPLICATIONS: This study identifies patient and health system economic benefits that add further evidence in support of multidisciplinary lung cancer care. DISCLOSURES: No relevant relationships by Genevieve Digby, source=Web Response No relevant relationships by Ana Johnson, source=Web Response No relevant relationships by Andriy Katyukha, source=Web Response No relevant relationships by Chris Parker, source=Web Response Advisory Committee Member relationship with Merck Please note: $1001 - $5000 Added 05/26/2020 by Andrew Robinson, source=Web Response, value=Honoraria Advisory Committee Member relationship with Astra Zeneca Please note: $1001 - $5000 Added 05/26/2020 by Andrew Robinson, source=Web Response, value=Consulting fee No relevant relationships by Christopher Stone, source=Web Response

Use of clinical quality indicators to improve lung cancer care in a regional/rural network of health services.

Optimal lung cancer care requires multidisciplinary team input, with access to specialised diagnostic and therapeutic services that may be limited in rural or regional areas and impact clinical outcomes. Clinical quality indicators can be used to measure the quality of care delivered to patients with lung cancer in a region and identify areas for improvement. We describe the implementation of internationally recognised clinical quality indicators for lung cancer care in the Barwon South Western region. The consensus of an expert panel was used for the selection of clinical quality indicators. The data were retrospectively collected from the Evaluation of Cancer Outcomes Barwon South West Registry, which systematically records detailed information on all new patients with cancer in the region. Region-based health service. Adherence to clinical quality indicator targets. Clinical quality indicators, which fall short of the expected targets, highlight areas for improvement in the service provided to patients with lung cancer. These results have prompted changes in the service offered to these patients, such as the introduction of a multidisciplinary lung cancer clinic. The multidisciplinary lung cancer clinic has streamlined the access to lung cancer services, including specialist consultations, diagnostics and therapeutic services, in a regional setting. Ongoing data collection is required to determine the effect of such changes on adherence to clinical quality indicator targets. The regular monitoring of clinical quality indicators serves as a useful method of quality assurance in the care of patients with lung cancer. We expect these clinical quality indicators to also be used by other health services to analyse and improve services provided to patients with lung cancer.

Improving Timeliness of Oncology Assessment and Cancer Treatment Through Implementation of a Multidisciplinary Lung Cancer Clinic.

Timely lung cancer care has been associated with improved clinical outcomes and patient satisfaction. We identified improvement opportunities in lung cancer management pathways at Kingston Health Sciences Centre. Quality improvement strategies led to the implementation of a multidisciplinary lung cancer clinic (MDC). We set an outcome measure of decreasing the time from diagnosis to first cancer treatment by 10 days within 6 months of clinic implementation. We implemented a weekly MDC that involved respirologists, medical oncologists, and radiation oncologists at which patients with new lung cancer diagnoses were offered concurrent oncology consultation. We used Plan-Do-Study-Act cycles to guide our improvement initiatives. A total of five Plan-Do-Study-Act cycles spanned 14 months and consisted of an MDC pilot clinic, large-scale MDC launching, debriefing meetings, and clinic expansion. Pre-MDC data were analyzed retrospectively to establish baseline and prospectively for improvement. Statistical Process Control XmR(i) charts were used to report data. Since MDC initiation, 128 patients have been seen in 34 MDC clinics (3.8 patients per clinic). Mean days from diagnosis to first oncology assessment decreased from 12.4 days to 3.9 days, and mean days from diagnosis to first cancer treatment decreased from 39.5 to 15.0 days, both of which demonstrated special cause variation. Time to assessment and treatment improved for patients with every stage of lung cancer and for both small-cell and non-small-cell subtypes. MDC shortens the time from lung cancer diagnosis to oncology assessment and treatment. Time to treatment improved more than time to oncology assessment, which suggests the improvement is related to benefits beyond faster oncology assessment.

MTE26.01 Onco-Pulmonologist

MTE26.01 Onco-Pulmonologist

Making the Evidentiary Case for Universal Multidisciplinary Thoracic Oncologic Care

The goal of this article is to provide an overview of the state of the evidence for, and challenges to, sustainable implementation of multidisciplinary thoracic oncology programs. Multidisciplinary care is much advocated by professional groups and makers of clinical guidelines, but little practiced. The gap between universal recommendation and scant evidence of practice suggests the existence of major barriers to program implementation. We examine 2 articles published in this issue of Clinical Lung Cancer to illustrate problems with the evidence base for multidisciplinary care. The inherent complexity of care delivery for the lung cancer patient drives near-universal advocacy for multidisciplinary care as a means of overcoming the heterogeneous quality and outcomes of patient care. However, the evidence to support this model of care delivery is poor. Challenges include the absence of a clear definition of “multidisciplinary care” in the literature, a consequent hodge-podge of poorly-defined examples of tested models, methodologically flawed studies, exemplified by the near-total absence of prospective studies examining this model of care delivery, and absence of scientifically sound dissemination and implementation studies, as well as cost-effectiveness studies. Against this background, we examined the results of a recent large single-institutional retrospective study suggesting the survival benefit of care within a colocated multidisciplinary lung cancer clinic, and an ambitious systematic review of existing literature on multidisciplinary cancer clinics. Better-quality evidence is still needed to establish the value of the multidisciplinary care concept. Such studies need to be prospective, use standardized definitions of multidisciplinary care, and provide clear information about program structure.

How, When and Where to Discuss Do Not Resuscitate: A Prospective Study to Compare the Perceptions and Preferences of Patients, Caregivers, and Health Care Providers in a Multidisciplinary Lung Cancer Clinic

Background: Do Not Resuscitate (DNR) is a significant but challenging part of end-of-life discussions when dealing with incurable lung cancer patients. We have explored the perceptions and preferences of patients, their caregivers (CGs), and health care providers (HCPs) and the current practice and opinions on DNR discussions in a multidisciplinary lung cancer clinic. Materials and Methods: This is a prospective descriptive study with a mixed quantitative and qualitative methodology to capture perceptions of the participants. To obtain a rich description of participant responses to questionnaire items, we employed a ‘think aloud’ process that prompted participants to immediately verbalize their thoughts when responding to questionnaire items. We used content analysis and constant comparison techniques to identify, code and categorize primary themes in the captured data. Results: Ten patients with advanced-stage lung cancer; nine CGs from the lung clinic and ten HCPs from the Thoracic Disease Site Group (DSG) were enrolled in the study. Most patients had only a limited understanding of DNR. Most CGs had a fair to good understanding of DNR. Most HCPs perceived their patients to have understood DNR most of the time. When patients were interviewed, a theme of “anticipated discussion” about DNR was identified. Patients and CGs expressed having faith in the system and responsible physicians as to when to discuss DNR. HCPs embraced a clinician preference-based decision-making approach to engaging in DNR discussions. They desired more resources, more knowledge, more structure and more time to discuss DNR. Most HCPs felt that it would be worth conducting a prospective clinical trial to determine the best time to discuss DNR. Conclusions: This pilot study provides a unique mixed quantitative and qualitative understanding of the perceptions of patients with lung cancer and their CGs and HCPs regarding DNR discussion. Our findings will help further the development of evidence-based guidelines and a broad prospective study that would have important implications for policies and practices around DNR discussions in order to reduce the emotional pain of dying patients, their CGs and HCPs.

How, When and Where to Discuss Do Not Resuscitate: A Prospective Study to Compare the Perceptions and Preferences of Patients, Caregivers, and Health Care Providers in a Multidisciplinary Lung Cancer Clinic.

Background: Do Not Resuscitate (DNR) is a significant but challenging part of end-of-life discussions when dealing with incurable lung cancer patients. We have explored the perceptions and preferences of patients, their caregivers (CGs), and health care providers (HCPs) and the current practice and opinions on DNR discussions in a multidisciplinary lung cancer clinic.Materials and Methods: This is a prospective descriptive study with a mixed quantitative and qualitative methodology to capture perceptions of the participants. To obtain a rich description of participant responses to questionnaire items, we employed a ‘think aloud’ process that prompted participants to immediately verbalize their thoughts when responding to questionnaire items. We used content analysis and constant comparison techniques to identify, code and categorize primary themes in the captured data.Results: Ten patients with advanced-stage lung cancer; nine CGs from the lung clinic and ten HCPs from the Thoracic Disease Site Group (DSG) were enrolled in the study. Most patients had only a limited understanding of DNR. Most CGs had a fair to good understanding of DNR. Most HCPs perceived their patients to have understood DNR most of the time. When patients were interviewed, a theme of “anticipated discussion” about DNR was identified. Patients and CGs expressed having faith in the system and responsible physicians as to when to discuss DNR. HCPs embraced a clinician preference-based decision-making approach to engaging in DNR discussions. They desired more resources, more knowledge, more structure and more time to discuss DNR. Most HCPs felt that it would be worth conducting a prospective clinical trial to determine the best time to discuss DNR.Conclusions: This pilot study provides a unique mixed quantitative and qualitative understanding of the perceptions of patients with lung cancer and their CGs and HCPs regarding DNR discussion. Our findings will help further the development of evidence-based guidelines and a broad prospective study that would have important implications for policies and practices around DNR discussions in order to reduce the emotional pain of dying patients, their CGs and HCPs.

Impact of a specialist clinical cancer pharmacist at a multidisciplinary lung cancer clinic.

Medication misadventure contributes to unplanned hospital admissions. General practitioners (GPs) may lack experience in managing problems involving complex cancer-related medication. A previous survey explored the unmet needs of lung cancer outpatients and highlighted their desire for more medication information. Inpatient clinical pharmacy services positively impact on patient care. This study evaluated the effects of extending this service to outpatients. A specialist cancer pharmacist joined the lung cancer clinic team for 6 months. Patients completed assessments of their medication adherence and their satisfaction with the provision of medicine information (at baseline and repeated within 30 days of initial pharmacist review). Following review, a medication list and plan (detailing recommendations/interventions) were provided to patients and their health care providers. Interventions were categorized and graded according to risk avoided. Unplanned admissions and clinic attendance rates were compared with the previous year. GPs' opinion of the service was also evaluated. Forty-eight patients participated in the study. Medication adherence (P = 0.007) and patient satisfaction (P < 0.001) significantly improved. A total of 154 pharmacist interventions were made: 4.5% extreme risk and 43.5% high risk. The mean number of unplanned admissions and clinic attendances per patient decreased from 0.3 to 0.26 (P = 0.265) and from 3.32 to 2.98 (P = 0.004), respectively. Seventy-four percent of surveyed GPs found the service useful. Adding a specialist cancer pharmacist to the outpatient lung cancer team led to significant improvements in patient medication adherence. Both patients and GPs were highly satisfied with the service. Medication misadventure and clinic attendances were reduced.

The effects of multidisciplinary clinics on the variability in timeliness of care for lung cancer patients.

e17533 Background: Implementation of multi-disciplinary clinics (MDC) has the potential to improve the care of cancer patients. Little data presently exists on the impact of MDC based care on cancer patient populations. Methods: A multi-disciplinary lung cancer clinic was implemented at a large, rural, multispecialty medical center in 2009. A retrospective analysis of the impact of MDC implementation on patient care was accomplished from 2009-2010 and was compared to care of patients from a reference period consisting of all patients treated in 2007. Patient survival, time to first appointment, time to treatment, use of clinical trials, and selection of palliative therapy only were analyzed using descriptive statistics. Two sided students t-test was performed to compare results from each cohort. Results: A new diagnosis of lung cancer was identified in 290 patients from 2009-2010. A total of 175 patients received care within the MDC and 115 patients were treated outside of the MDC. One hundred and forty-two patients were analyzed from the pre-MDC period of 2007. Seventy-seven percent of patients had NSCLC in 2007 and 81% of patients had NSCLC in 2009-2010. The time from referral to first appointment, and diagnosis to treatment are shown in the Table. There was a significant improvement in the mean time to initiation of cancer therapy with the introduction of the MDC clinic with patients starting therapy at a mean of 22 days instead of 28 days, however, the median time to treatment increased to 17 days from 5 days. MDC was associated with improvement in clinical trial accrual to 15% from 10%. Conclusions: The implementation of MDC was associated with greater homogeneity in timeliness of care, with fewer patients being outliers with long delays in time to care, hence improvements in mean time to care, with a detriment in median time to care owning to the increased complexity of scheduling. MDC also resulted in improvements in clinical trial accrual. [Table: see text]

Motivation to Quit Smoking among Relatives of Lung Cancer Patients

The purpose of this study was to determine the factors related to motivation to quit among smoking family members of lung cancer patients. Relatives of multidisciplinary lung cancer clinic patients were recruited during family members' treatment. Participants (N=29) were primarily female and Caucasian. The items assessed included the effect of their relative's disease on motivation to quit, intent to quit in the next 6 months, stage of change, perceived risk from smoking, and attitudes about being approached about cessation. Most indicated that their relative's disease had increased motivation to quit smoking (71%); 72% planned to quit within 6 months. One fourth (28%) were in precontemplation stage of change; 65% in contemplation; and 7% in preparation. The average perceived risk of developing lung cancer was 6.3. Two thirds were glad or very glad that someone had talked with them about quitting; 91% thought it was somewhat or very appropriate to talk about cessation with family members of lung cancer patients. Motivation to quit smoking was positively correlated with stage of change and perceived lung cancer risk. Public health nurses who interact with families of lung cancer patients may be able to promote cessation in an at-risk group that is motivated to quit smoking.

Modeling a Better Way: Navigating the Healthcare System for Patients With Lung Cancer

The coordination of services for patients with suspected or newly diagnosed lung cancer produces improved patient outcomes, particularly in their quality of life. Evidence-based practice demonstrates improved outcomes from the multimodality therapies offered today, especially for patients with lung cancer; however, navigating through the healthcare system is especially challenging for patients. In developing the Multidisciplinary Lung Cancer Clinic at Frederick Memorial Hospital, navigation challenges in the healthcare system have been addressed. Patients are receptive and pleased with the approach, in which a nurse practitioner coordinates services and provides guidance and support for patients. The program offers benefits to patients with lung cancer in the community hospital setting. A similar program can be implemented in community cancer centers for patients with other diagnoses to improve outcomes and satisfaction with the healthcare system.

Distress screening in a multidisciplinary lung cancer clinic: Prevalence and predictors of clinically significant distress

Screening for distress in cancer patients is recommended by the National Comprehensive Cancer Network, and a Distress Thermometer has previously been developed and empirically validated for this purpose. The present study sought to determine the rates and predictors of distress in a sample of patients being seen in a multidisciplinary lung cancer clinic. Consecutive patients (N=333) were recruited from an outpatient multidisciplinary lung cancer clinic to complete the Distress Thermometer, an associated Problem Symptom List, and two questions about interest in receiving help for symptoms. Over half (61.6%) of patients reported distress at a clinically significant level, and 22.5% of patients indicated interest in receiving help with their distress and/or symptoms. Problems in the areas of family relationships, emotional functioning, lack of information about diagnosis/treatment, physical functioning, and cognitive functioning were associated with higher reports of distress. Specific symptoms of depression, anxiety, pain and fatigue were most predictive of distress. Younger age was also associated with higher levels of distress. Distress was not associated with other clinical variables, including stage of illness or medical treatment approach. Similar results were obtained when individuals who had not yet received a definitive diagnosis of lung cancer (n=134) were excluded from analyses; however, family problems and anxiety were no longer predictive of distress. Screening for distress in a multidisciplinary lung cancer clinic is feasible and a significant number of patients can be expected to meet clinical criteria for distress. Results also highlight younger age and specific physical and psychosocial symptoms as predictive of clinically significant distress. Identification of the presence and predictors of distress are the first steps toward appropriate referral and treatment of symptoms and problems that contribute to cancer patients' distress.

Validity of the Assessment of Quality of Life (AQoL) utility instrument in patients with operable and inoperable lung cancer

There have been few longitudinal studies of quality of life in patients with all stages of lung cancer, particularly those that have included measures of utility. The purpose of this study was to examine the psychometric properties of the Assessment of Quality of Life instrument (AQoL) in patients with lung cancer. The AQoL is a health-related quality of life questionnaire and provides a descriptive system for a multi-attribute utility instrument (MAU), so that scores can be used in cost-utility evaluations. In the present study the reliability (internal consistency) of the AQoL was examined and the concurrent validity was assessed using the Medical Outcomes 36-item Short Form Health Survey (SF-36) as the comparator instrument. The sensitivity to different health states of the AQoL and the responsiveness to change over time was also examined. A prospective, non-experimental cohort study was undertaken. Ninety-two participants with all stages of lung cancer were recruited from a tertiary multi-disciplinary lung cancer clinic. Ninety participants had non-small cell lung cancer (NSCLC) and two had limited stage small cell lung cancer. The AQOL and SF-36 surveys were administered concurrently at baseline. In patients with NSCLC the surveys were then repeated 3 and 6 months later. Correlations between the baseline AQoL summary scales and SF-36 summary scales support the divergent and convergent validity of the AQoL. Reliability was also found to be sufficient (Cronbach's Alpha=0.76). In addition, in patients with inoperable NSCLC, baseline AQoL scores were found to be predictive of survival at 6 months in Cox proportional hazards multivariate analysis. However, the physical components summary score of the SF-36 was more sensitive to differences in health states between patients with different stages of NSCLC at 6 months of follow-up and more responsive to change over time in both operable and inoperable patients with NSCLC than the AQoL. The findings support the construct validity and reliability of the AQoL in this population. However, there remains some uncertainty about whether the AQoL has sufficient sensitivity to different health states in this population. Further studies using other MAU instruments may determine whether alternative instruments are more sensitive to different health states in individuals with lung cancer.

Lung Cancer in Patients < 50 Years of Age: The Experience of an Academic Multidisciplinary Program

To determine if the clinicopathologic features and survival of lung cancer patients < 50 years of age differ from those of older patients. Retrospective review of patients with primary bronchogenic carcinoma diagnosed at a single, multidisciplinary cancer center. A National Cancer Institute-designated comprehensive cancer center in urban Detroit, MI. All patients with primary bronchogenic carcinoma evaluated in the Multidisciplinary Lung Cancer Clinic at the Barbara Ann Karmanos Cancer Institute between 1990 and 1993. Of 1,012 patients with lung cancer, 126 (12.5%) were < 50 years old at diagnosis, with a median age of 44 years. The median age of the 886 patients > or = 50 years of age was 65 years. The gender (p = 0.08) and racial (p = 0.12) characteristics of the younger and older patient groups were not significantly different. More than 90% of patients in both groups were smokers. The incidence of adenocarcinoma was significantly higher in younger patients (48.4% vs 36.0%, p < 0.001), and early-stage disease was less frequently diagnosed in younger patients (4.8% vs 19.7%, p < 0.001). Younger patients were more likely than older patients to undergo treatment, including surgery and combined-modality therapy (p < 0.001). Median survival was 13 months in younger and 9 months in older patients, while overall survival was similar in younger and older patients (p = 0.13). Although younger patients with lung cancer present with more advanced-stage disease, their overall survival is similar to that of older patients, suggesting that lung cancer is not an inherently more aggressive disease in patients < 50 years of age.

Predicting Postoperative Pulmonary Function in Patients Undergoing Lung Resection

Our aim was to determine the effect of lung resection on spirometric lung function and to evaluate the accuracy of simple calculation in predicting postoperative pulmonary function in patients undergoing lung resection. We reviewed preoperative and postoperative pulmonary function test results on patients who were followed in the multidisciplinary lung cancer clinic between July 1991 and March 1994 and who underwent lung resection. The predicted postoperative FEV1 and FVC were calculated based on the number of segments resected and were compared with the actual postoperative FEV1 and FVC. This study was conducted at a university, tertiary referral hospital. All patients were evaluated at a multidisciplinary lung cancer clinic and underwent lung resection by one surgeon (L.A.L.). Sixty patients undergoing 62 pulmonary resections were reviewed. The predicted postoperative FEV1 and FVC were calculated using the following formula: predicted postoperative FEV1 (or FVC) = preoperative FEV1 (or FVC) x (1-(S x 0.0526)); where S = number of segments resected. The actual postoperative FEV1 and FVC correlated well with the predicted postoperative FEV1 and FVC for patients undergoing lobectomy (r = 0.867 and r = 0.832, respectively); however, the predicted postoperative FEV1 consistently underestimated the actual postoperative FEV1 by approximately 250 mL. For patients undergoing pneumonectomy, the actual postoperative FEV1 and FVC did not correlate as well with the predicted postoperative FEV1 and FVC (r = 0.677 and r = 0.741, respectively). Although there was considerable variability, the predicted postoperative FEV1 consistently underestimated the actual postoperative FEV1 by nearly 500 mL. Of the patients undergoing lobectomy, eight also received postoperative radiation therapy. When analyzed separately, patients receiving combined therapy lost an average of 5.47% of FEV1 per segment resected. This contrasts with a 2.84% per segment reduction in FEV1 for patients who did not receive radiation therapy. This simple calculation of predicted postoperative FEV1 and FVC correlates well with the actual postoperative FEV1 and FVC in patients undergoing lobectomy. The predicted postoperative FEV1 consistently underestimated the actual postoperative FEV1 by approximately 250 mL. The postoperative FEV1 and FVC for patients undergoing pneumonectomy is not accurately predicted using this equation. The predicted postoperative FEV1 for patients undergoing pneumonectomy was underestimated by an average of 500 mL and by greater than 250 mL in 12 of our 13 patients. Thus, by adding 250 mL to the above calculation of predicted postoperative FEV1, we improve our ability to we identify a minimal postoperative FEV1 for patients undergoing pneumonectomy. Finally, combined modality treatment with surgery followed by radiation therapy may result in additive lung function loss.