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Clinical Focus on Lung Cancer
A snapshot of lung cancer for Ontario health care providers and managers
Driving quality, accountability and innovation
throughout Ontario’s cancer system
TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 1
Incidence of Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 1
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 2
Mortality from Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 2
Lung Cancer Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 3
Assessing Consistency of Practice Against Evidence-Based Recommendations . . . . . . . . . . page 3
Practice Guidelines and the Treatment of Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 4
Observations on the Treatment of Locally Advanced NSCLC at RCCs . . . . . . . . . . . . . . . . . . page 5
Management of Metastatic Non-Small Cell Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 9
Management of Small Cell Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 10
Role of Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 11
Access to Cancer Treatment — Wait Times . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 11
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 14
Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . page 15
Practice Guideline Publications of the Lung Disease Site Group . . . . . . . . . . . . . . . . . . . . . . page 16
CLINICAL FOCUS ON LUNG CANCER
Prepared by:
Dr. W.K. (Bill) Evans
Chief Medical Officer and
Provincial Vice-President
Cancer Care Ontario
and
Chair, Lung Disease Site Group
With the Assistance of:
Dr. Terrence Sullivan Deborah Fitzsimmons
Dr. Eric Holowaty Alex Drossos
Dr. Anthony Whitton Mark Gregus
Dr. Brent Zanke Diane Nishri
Dr. Loraine D. Marrett Saira Bahl
Ian Brunskill Sherman Quan
Beth Theis Bev Hess May 2004
CLINICAL FOCUS
ON LUNG CANCER
Introduction Ontario’s Program in Evidence- Incidence of Lung Cancer
based Care. In addition to
This monograph on lung information on patterns of Lung cancer is the most
cancer has been prepared practice, this monograph common cause of death due
to provide information on provides information on the to cancer in Canada. In 2003,
patterns of practice to those timeliness of access to care, it is estimated that there will
directly involved in the as well as a brief overview of be 21,100 new cases and 18,800
provision of care to lung the incidence and mortality deaths from lung cancer. In
cancer patients. As well, it of lung cancer, and the trends Ontario, it is estimated that
should be helpful to those in the main risk factor for there will be 7,500 new cases
who are responsible for developing lung cancer, namely and 6,300 deaths from lung
managing aspects of the smoking. In brief, it provides cancer. Figure 1 shows the
cancer system that impact a snapshot of the quality of incidence of lung cancer by
on the care that lung cancer care for lung cancer patients gender over the past 10 years.
patients receive across the in the province of Ontario. Although the overall incidence
province of Ontario. The It is hoped that this monograph is higher in men, there has been
practice patterns are shown will assist those responsible a steady decrease in the inci-
against the backdrop of the for care delivery to achieve dence of lung cancer in men in
evidence-based guidelines the best possible results for the past 10 years. In contrast,
developed by the Lung Disease patients with a diagnosis of the incidence rate among women
Site Group of Cancer Care lung cancer. has been steadily increasing.
1
Risk Factors Figure 1 Lung Cancer Incidence Rates in Ontario, 1991–2001
Lung cancer is the most
preventable of all human cancers. 100
Age-standardized rate per 100,000
Cigarette smoking is the main 90
cause of lung cancer and it
(3-year moving averages)
80
should be no surprise to anyone
70
that changes in the incidence
60
of lung cancer run parallel to
changes in smoking habits. 50
Individuals who have been 40
smoking for the past several 30
decades are the ones now being 20
diagnosed with lung cancer.
10
Twenty years ago there were
0
record numbers of women, 1991 1993 1995 1997 1999 2001
including teenagers, who were
smoking regularly. The number Year of diagnosis or death
of men smoking at that time,
M a le inc ide nc e F e m a le inc ide nc e
in all age groups, had begun to
decline. The trends in smoking Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
rates among men and women
over the past decade are shown
in Figure 2 and Figure 3. As
fewer people are smoking today, Figure 2 Smoking Rates for Lung Cancer by Age — Male
it is anticipated that lung cancer
rates will be lower in the future.
Nonetheless, aggressive 40
anti-smoking measures must
35
continue, as the proportion of
the population smoking is still
Smoking Rate per 100,000
30 15-19
approximately 19%. Factors 20-24
25-29
helping to reduce smoking 25 30-34
35-39
include strict anti-smoking 40-44
45-49
bylaws, cigarette taxation, 20 50-54
55-59
smoking cessation programs, 60-64
and school and public education 15 65-69
70-74
programs. 75-79
10
Mortality from Lung Cancer 5
Figure 4 shows the mortality 0
rate (death rate per 100,000 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
population) from lung cancer Year
for both men and women over Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
the past decade. The graph for
mortality is similar to that for
incidence, in that men show
a decline in mortality, whereas
women show an increasing
mortality rate.
2
CLINICAL FOCUS ON LUNG CANCER
Lung Cancer Survival Figure 3 Smoking Rates for Lung Cancer by Age — Female
The overall survival rate for lung
cancer is poor, in part because 35
it is most often diagnosed at an
advanced and incurable stage. 30
Only about 25% of all lung
Smoking Rate per 100,000
cancers are, potentially, surgically 25 15-19
20-24
resectable. Approximately 35% 25-29
30-34
of patients have extension of 20 35-39
40-44
cancer to involve lymph nodes 45-49
50-54
centrally in the chest (mediastinal 15 55-59
60-64
lymph nodes) and about 40% 65-69
70-74
have cancer spread outside of 10 75-79
the chest. Figure 5 shows that
the two-year survival does not 5
vary much between regions,
although the survival in the south 0
is significantly worse than the 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
rest of Ontario, while survival Year
in the east is significantly better. Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
Survival for all of Ontario is
indicated by the blue horizontal
line.
Figure 4 Lung Cancer Mortality Rates in Ontario, 1991–2001
Assessing Consistency of
Practice Against Evidence-
100
based Recommendations
Age-standardized rate per 100,000
90
(3-year moving averages)
The recent development of a 80
software called DS-Web has 70
made it possible to rapidly 60
interrogate a number of admin- 50
istrative databases, including 40
the Ontario Cancer Registry, the
30
Oncology Patient Information
20
System (OPIS) and the New
Drug Funding Program (NDFP) 10
database. Amongst other things, 0
DS-Web can rapidly determine 1991 1993 1995 1997 1999 2001
the volume of clinical activity Year of diagnosis or death
in any cancer centre across
Male mortality Female mortality
the province and analyze radio-
therapy and systemic therapy Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
clinical practice patterns. Where
stage information is available, it
is now possible to describe the
stage-specific treatment practices.
In the future it should be possible
to assess stage-specific survival.
3
In the paragraphs that follow, Figure 5 Lung Cancer Estimated* Two-Year Relative Survival †
the recommendations for treat- by Region, Age-Adjusted, 2000–2001
ment by type and stage of lung
100
cancer are described and then
90
the actual clinical practices
Relative survival (%)
are displayed for each of the 80
regional cancer centres. 70
60
For more information on
DS-Web, send inquiries to 50
DS-Web@cancercare.on.ca. 40
30
Practice Guidelines and the 20
Treatment of Lung Cancer 10
0
The Provincial Lung Disease Site NW NE S SW CW CE SE E
Group (DSG) is one of 14 DSGs
Centre
that develop evidence-based * Estimated with Brenner’s period method, which estimates survival of all cases under
practice guidelines and evidence follow-up during 2000-2001, adjusted for age
† Bars = survival estimates, I = 95% confidence intervals
summaries as part of Cancer
Care Ontario’s Program in Source: Cancer Care Ontario (Ontario Cancer Registry, 2003)
Evidence-Based Care. The Lung
DSG has 31 members from
across the province representing co-morbidities that prevent The data on the use of adjuvant
the disciplines of thoracic pulmonary resection, local chemotherapy is conflicting, but
surgery, radiation therapy and radiotherapy may be used to recent studies suggest that there
systemic therapy. As well, the control the tumour. For those may be a small survival benefit.
DSG has a medical sociologist, patients undergoing surgical
two research coordinators and resection, roughly half survive Management of Locally
two patient representatives. five years. The survival rate Advanced NSCLC
The DSG has completed and depends on factors such as the Patients are most commonly
published 14 guidelines on size of the tumour, the extent referred to a cancer treatment
various aspects of treatment of lymph node involvement by facility with a diagnosis of cancer
for different forms and stages cancer found at surgery and the when the disease is considered
of lung cancer. These guidelines tumour histology. In the most to be inoperable. Lung cancer is
can be found on Cancer favourable situation — a tumour inoperable but locally advanced
Care Ontario’s Web site, less than three centimeters in when it has extended beyond
www.cancercare.on.ca/ maximum diameter, without what a surgeon can resect for
access_PEBC.htm. The details spread to intrapulmonary lymph cure, but is still confined to
found in these guidelines are nodes and with squamous the chest (Stage III). For those
briefly summarized below. histology — the survival is patients who have mediastinal
approximately 70%–80% at five lymph nodes involved by tumour
Management of Early Stage Non years. Some patients are sent
Small Cell Lung Cancer (NSCLC) (lymph nodes located around
for consideration of adjuvant the central structures in the
For those patients presenting chemotherapy or radiotherapy chest), but who have a good
with early stage lung cancer after complete resection of performance status and have
(Stages I and II), the usual a lung cancer. The Lung DSG, not lost more than 5% of their
treatment is surgical removal which has reviewed the evidence usual body weight in the
(resection), assuming the patient for adjuvant therapies, has preceding three months, the
can tolerate an appropriate concluded that there are no data evidence supports the use of
operation. For those individuals to support the use of radiotherapy a combination of chemotherapy
who have very poor pulmonary in patients who have had a com- and radical radiotherapy.
function or other major plete resection of their tumour.
4
CLINICAL FOCUS ON LUNG CANCER
Observations on the of stage information has improved could be given. While most
Treatment of Locally at all cancer centres but is still centres employ this approach,
incomplete. This accounts for some use fewer fractions. This
Advanced NSCLC at the modest number of cases seen may reflect the fact that there
Regional Cancer Centres in some analyses. are other radical dose schedules
in use including 50Gy in
The data displayed below Radiation Therapy 20 fractions and even 48Gy in
was extracted from several
Figure 6 provides information on 12 fractions. The lower fraction
of Cancer Care Ontario’s
the radiotherapeutic management number may also be due to
administrative databases — the
of Stage III non-small cell lung errors of coding the intent of
Oncology Patient Information
cancer (NSCLC) patients treated treatment, failure to complete
System and the New Drug
with curative intent at each the prescribed course of
Funding Program’s databases —
regional cancer centre. The radiation therapy, a belief that
using DS-Web. In order to
recommended amount of lesser amounts of radiotherapy
evaluate practice relative to
radiotherapy (60 Gray) requires may be sufficient, or a case mix
evidence-based recommenda-
six weeks of therapy and 30 with a greater proportion of
tions, it was necessary to select
fractions (treatments). A boost poor performance status patients
only those cases for whom stage
of radiation may be given so who would not be candidates
information was recorded in the
that more than 30 fractions for radical radiotherapy.
chart electronically. The capture
Legend for Figures 6–10
Ham = Hamilton, KNG = Kingston, LND = London, NEO = Northeastern Ontario, NOW = Northwestern Ontario,
OTT = Ottawa, TSB = Toronto Sunnybrook, WND = Windsor, RCC = Regional Cancer Centre
Figure 6 Percentage of Stage III NSCLC Treated with Curative Intent Showing Number of
Radiation Treatments, Jan – Dec 2002
100%
90%
80%
Percentage of Treated Cases
70%
>=30
60%
21-29
50%
<= 20
40%
30%
20%
10%
0%
HAM KNG LND NEO NWO OTT TSB WND ALL RCC
# of Cases: 75 31 56 33 5 55 43 19 317
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
5
Chemotherapy modality therapy, used the the NCIC. Based on these trial
two-drug combination vinblastine results, oncologists are using
The chemotherapy used in the and cisplatin (CISPVINB). A trial one of these regimens in
combined modality approach performed by the Southwest combination with radiotherapy.
to locally advanced lung cancer Oncology Group (SWOG), in As can be seen in Figure 7a,
can be one of several different concert with the National Cancer two centres use predominantly
regimens, but should include Institute of Canada (NCIC), vinblastine-cisplatin (CISPVINB),
the drug cisplatin. It has been used etoposide-cisplatin two use predominantly etoposide-
demonstrated that a survival (CISPET) for the treatment of cisplatin or etoposide-carboplatin
advantage can be achieved Pancoast tumours (tumours (CISPETOP/CISPET-RT/
when both chemotherapy and at the apex of the lung), and ETOPCARBO), and two use
radiotherapy are used together. demonstrated enhanced local predominantly vinorelbine-
The Provincial Lung DSG does control and improved survival. cisplatin (VINOCISP). Figure 7b
not recommend a specific Vinorelbine-cisplatin (VINOCISP) shows that 83% of the
chemotherapy regimen, but there has been shown to be one of the chemotherapy usage for Stage III
are a number of chemotherapy most effective regimens available disease is consistent with one
regimens that are acceptable. for the treatment of advanced of these approaches and this is
The initial trials, demonstrating disease, and it has been tested consistent with the practice
increased survival with combined in an adjuvant trial through guideline recommendations.
Figure 7a Percentage of Stage IIIb NSCLC Patients Treated by Specific Chemotherapy
Regimen, Jan – Dec 2002
100%
80%
VINOREL
VINOCISP
Number of Treated Cases
60% VINO/CARBO
OTHER
GEMCIT
40%
CISPVINB
CISPETOP/CISPET
20% -RT/ETOPCARBO
0%
HAM KNG LND NEO NWO OTT TSB WND ALL RCC
# of Cases: 21 13 23 6 7 41 11 10 132
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
6
CLINICAL FOCUS ON LUNG CANCER
Figure 7b Percentage of Stage IIIb NSCLC Patients Treated by Specific Chemotherapy
Regimen Consistent with Provincial Guidelines, Jan – Dec 2002
100%
80%
Number of Treated Cases
VINOREL
VINO/CARBO
60%
OTHER
GEMCIT
40%
CONSISTENT
WITH
GUIDELINES
20%
Consistent with
Guidelines:
0% - VINOCISP
HAM KNG LND NEO NWO OTT TSB WND ALL RCC - CISPVINB
# of Cases: 21 13 23 6 7 41 11 10 132 - CISPETOP
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
Stage III can be divided into IIIa (neoadjuvant chemotherapy). carboplatin is being used in a
and IIIb disease. One group of The most commonly used small percentage of these cases.
Stage IIIa patients (those with regimens for neoadjuvant Although it is well tolerated,
a relatively low volume of chemotherapy include it is a more expensive regimen
lymph node disease in the etoposide-cisplatin, vinorelbine- and has not been well studied
mediastinum on the same side cisplatin, and vinblastine- in Stage III disease.
as the tumour) can be candidates cisplatin, which are all acceptable
for chemotherapy before surgery approaches. Vinorelbine-
7
Figure 8a Percentage of First-Line Systemic Treated Cases by Specific Chemotherapy Regimen
for Non-Small Cell Lung Cancer — Stage IIIa, Jan – Dec 2002
100%
80%
VINOREL
Number of Treated Cases
VINOCISP
60%
VINO/CARBO
OTHER
40%
GEMCIT
CISPVINB
20% CISPETOP/CISPET-
RT/ETOPCARBO
0%
HAM KNG LND NEO NWO OTT TSB WND ALL RCC
# of Cases: 16 11 17 14 7 20 9 6 100
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
Figure 8b Percentage of Stage IIIa NSCLC Patients Treated with Chemotherapy Consistent
with Provincial Guidelines, Jan – Dec 2002
100%
80%
VINOREL
Number of Treated Cases
VINO/CARBO
60%
OTHER
GEMCIT
40%
CONSISTENT
WITH
GUIDELINES
20%
Consistent with
Guidelines:
0% - VINOCISP
HAM KNG LND NEO NWO OTT TSB WND ALL RCC - CISPVINB
# of Cases: 16 11 17 14 7 20 9 6 100 - CISPETOP
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
8
CLINICAL FOCUS ON LUNG CANCER
Management of Metastatic superior to another. For example, taxotere-cisplatin and taxol-
Non-Small Cell Lung Cancer taxol-carboplatin and vinorelbine- cisplatin/carboplatin as potential
cisplatin are associated with first-line options. Previously,
The management of Stage IV nerve injury (neuropathy). taxotere was only available
NSCLC is dependent on the Neither regimen would be the as a second-line therapy after
performance status of the patient, preferred option in the setting first-line therapy with a regimen
as well as the willingness of the of a pre-existing neuropathy. such as vinorelbine-cisplatin.
patient to accept treatment with Unless there are clinical Specific clinical circumstances
its trade-offs of drug-induced reasons to use a different should dictate the choice of
toxicities and modest survival drug regimen, the Lung DSG regimen where vinorelbine-
and quality of life gains. recommends vinorelbine-cisplatin cisplatin is not possible and a
Four different combination as the first line treatment treatment decision algorithm
chemotherapy regimens have standard, in view of its proven has been developed to guide
been shown to have similar benefit in terms of response physician decision-making.
response rates and survival but rate, survival, and low cost.
they differ in their toxicities and Figure 9a shows the percentage
convenience of administration. For patients who have difficulty use of different chemotherapy
Some require multiple visits to with intra-venous access, pre- regimens for Stage IV NSCLC
a treatment centre each month, existing peripheral neuropathy patients by treatment centre.
whereas others are administered or severe constipation, the It can be seen that vinorelbine-
on a once every three week gemcitabine-cisplatin regimen is cisplatin, which is the
schedule. Depending on the recommended by the Lung DSG recommended standard, is
patient’s clinical situation, as a first-line choice. The Policy most commonly used in two
particularly other medical Advisory Committee for the centres (Ottawa, Northwestern
conditions, one regimen may be New Drug Funding Program Ontario), vinorelbine alone is
has recently approved both used predominantly in one
Figure 9a Percentage of First-Line Systemic Treated Cases by Specific Chemotherapy Regimen
for Non-Small Cell Lung Cancer — Stage 4, Jan – Dec 2002
100%
VINOREL
80%
VINOCISP
Number of Treated Cases
VINO/CARBO
60%
OTHER
GEMCIT
40%
DOCETAX
CISPVINB
20% CISPETOP/CISPET-
RT/ETOPCARBO
0%
HAM KNG LND NEO NWO OTT TSB WND ALL RCC
# of Cases: 25 11 39 24 22 65 8 11 205
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
9
centre (Hamilton), and several acceptable in this analysis, but regimen. Etoposide-carboplatin
centres use a variety of regimens, not vinorelbine-carboplatin (ETOPCARBO) is also considered
perhaps reflective of the case (VINO/CARBO). acceptable. Figure 10 shows that
mix seen. Vinorelbine alone for patients with both limited
is considered appropriate in Management of Small Cell and extensive lung cancer, these
elderly patients and those who are the dominant regimens
would not tolerate cisplatin- Lung Cancer used. An NCIC clinical trial has
related toxicities. It is not Small cell lung cancer makes shown that the use of CAV
recommended by the Lung DSG up about 15% of all lung cancer (a combination of three drugs —
as a standard therapy in those cases. At least two-thirds of cyclophosphamide, Adriamycin
who can tolerate cisplatin. Even patients present with widespread and vincristine) alternating with
though vinorelbine-carboplatin disease with metastases to organs etoposide-cisplatin is superior to
may have less side effects than outside of the chest. This is using CAV alone. Some clinicians
the standard vinorelbine-cisplatin, referred to as extensive disease. still use this alternating regimen,
it is not considered an acceptable Limited disease refers to disease which yields similar results to
regimen because of the lack of confined to the thorax. In the etoposide-cisplatin alone and
data on its efficacy relative to latter situation, patients are is consistent with provincial
other regimens that have been treated with a combination of practice guidelines. The data
carefully tested in clinical trials. chemotherapy and radiotherapy. from the regional cancer centres
Figure 9b shows that 72% of The Lung DSG’s practice guideline indicate that virtually all cases
the regimens being administered for limited stage small cell lung are treated with regimens that
are acceptable according to cancer recommends etoposide- are consistent with the practice
provincial guidelines. Vinorelbine cisplatin (CISPETOP/CISPET-RT) guideline recommendations
(VINOREL) alone is included as as the standard chemotherapy made by the Lung DSG.
Figure 9b Percentage of Stage IV NSCLC Patients Treated with Chemotherapy Consistent with
Provincial Guidelines, Jan – Dec 2002
100%
80%
VINOREL
Number of Treated Cases
VINO/CARBO
60%
OTHER
CONSISTENT
40% WITH
GUIDELINES
20%
Consistent with
Guidelines:
- VINOCISP
- CISPVINB
0% - VINOREL
HAM KNG LND NEO NWO OTT TSB WND ALL RCC - GEMCIT
- CISPETOP/CISPET-
# of Cases: 25 11 39 24 22 65 8 11 205 RT/ETOPCARBO
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
10
CLINICAL FOCUS ON LUNG CANCER
Figure 10 Percentage of Small Cell Lung Cancer Cases Treated with Chemotherapy Regimen —
Not TMN Staged, Jan – Dec 2002
100%
80%
Number of Treated Cases
OTHER
60%
CISPETOP
CISPET-RT
ETOPCARBO
40% CAV/CAV-
CISPETOP
20%
0%
HAM KNG LND NEO NWO OTT TSB WND ALL RCC
# of Cases: 28 36 49 44 17 74 10 29 287
Regional Cancer Centre
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
Role of Palliative Care care clinics have been Access to Cancer
established to support Treatment — Wait Times
Palliative care plays a very the needs of cancer patients
important role in the management generally, and particularly It is not known at what point
of lung cancer patients because, those with symptoms that waiting for cancer treatment can
as noted in the section on lung are proving difficult to manage lead to physical harm. Intuitively,
cancer mortality, the five-year with conventional medical it makes sense to begin treatment
survival of lung cancer patients interventions. as promptly as possible after the
is less than 15%. Most patients diagnosis of cancer. On the other
would benefit from a palliative Future initiatives should hand, cancer takes many years
care team to assist in symptom optimize the integration of to reach a size that is clinically
management, psychosocial supportive care and palliative detectable, so several weeks or
support, and attention to spiritual care services into the manage- months of waiting, depending
needs. Unfortunately, there is ment of the lung cancer patient. on the tumour site may actually
little information about the pro- And there is a need for more have little or no impact on
portion of patients who actually data on the proportion of the ultimate disease outcome,
have access to such important patients who are provided such although waiting does affect the
supportive care and palliative care and the degree to which patient’s quality of life. There
care assistance. In some cancer their symptoms are palliated. are data to show that anxiety
treatment facilities, palliative
11
Figure 11 Lung Cancer Radiation Therapy Wait Times, 2000 Q1 to 2003 Q1
20 Referral to Treatment
15
10.0 10.1 9.7 10.1 9.7 10.0 9.7
10 8.3 9.0 8.7 8.9 8.9
8.1
5 3.4 3.9 3.4 3.3 3.4 3.4 3.4
3.1 3.0 3.1 3.1 3.0 3.0
0
2000 2000 2000 2000 2001 2001 2001 2001 2002 2002 2002 2002 2003
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
Valid No.
of Cases 449 434 418 445 427 419 394 400 460 423 462 476 434
50th Percentile 90th Percentile
Note: Excludes all time intervals greater than 20 weeks per period.
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
Figure 12 Lung Cancer Systemic Therapy Wait Times, 2000 Q1 to 2003 Q1
20 Referral to Treatment
15
10 8.8 9.1 8.7
7.6 8.1 8.0 7.7 8.1 7.4
7.1 7.3 7.0 7.3
5 3.4 3.1 3.6 3.3 3.9 3.3 3.3 3.1 3.2 3.7
2.9 3.0 3.0
0
2000 2000 2000 2000 2001 2001 2001 2001 2002 2002 2002 2002 2003
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
Valid No.
of Cases 140 151 149 154 153 160 161 151 117 130 140 116 123
50th Percentile 90th Percentile
Note: Excludes all time intervals greater than 20 weeks per period.
Source: Cancer Care Ontario (Oncology Patient Information System, 2003)
12
CLINICAL FOCUS ON LUNG CANCER
levels are high for people awaiting the average wait times (50th The benchmark time interval
a diagnosis, and again from percentile and 90th percentile) from referral to treatment
diagnosis to the actual start for radiation and systemic therapy for lung cancer is four weeks
of treatment. In this context, from referral to treatment. and, as can be seen, almost
the Canadian Association of all radiotherapy treatment
Radiation Oncologists recom- Cancer Care Ontario now centres achieve this standard.
mends that the time interval posts wait time information However, it should be noted
from referral to the start of on its Web site, which displays that the wait times apply to
treatment should be no longer the median (average) wait both radical and palliative
than four weeks. There are, times from referral to treatment cases. Palliative cases may
however, no standards for for the preceding three months be seen in rapid access
wait times for surgery or the www.cancercare.on.ca/ palliative clinics where the
administration of chemotherapy. access_waitTimes.htm. consultation, planning and
There is not much data available These wait times are updated treatment are all given on
concerning wait times for lung monthly based on data from the same day. This practice
cancer surgery. From a study of the regional cancer centres and will tend to average down
surgical wait times at hospitals Princess Margaret Hospital. The the wait times and patients
associated with cancer centres table below shows the median requiring radical therapy
in Ontario and published in the wait time from referral to start may be expected to have
Canadian Medical Association of treatment for lung cancer, wait times that are longer
Journal in August of 2001, the by centre, for the three-month than those posted.
average wait time from referral period of May to July 2003.
to surgery was 36 days. Recent
wait time data from the Princess Centre Weeks
Margaret Hospital, University
Health Network, suggests an Hamilton Regional Cancer Centre 3.9
even more serious waiting time Kingston Regional Cancer Centre 2.7
problem. Time from referral
to operation had grown from London Regional Cancer Centre 1.9
36 days for lung cancer patients
in January of 2001 to 70 days in Northeastern Ontario Regional Cancer Centre 3.9
March of 2003. The rate limiting Northwestern Ontario Regional Cancer Centre 2.9
steps appear to be access to
operating rooms and the avail- Ottawa Regional Cancer Centre 3.0
ability of specialized personnel,
Princess Margaret Hospital 1.0
including anaesthetists.
Chemotherapy treatment does Toronto Sunnybrook Regional Cancer Centre 2.0
not have the same resource
constraints as radiation therapy Windsor Regional Cancer Centre 4.7
or surgery. Therefore, waiting
times for chemotherapy are gen-
erally shorter. Where wait times
exceed four weeks from referral
to treatment, the underlying
cause is usually either a shortage
of medical oncology consultants
or poor access to imaging studies
(CT or MRI scan), which are
necessary to assess the disease
extent prior to the start of treat-
ment. Figures 11 and 12 show
13
Conclusions Lung cancer commonly presents For small-cell lung cancer,
in an advanced stage of disease, chemotherapy is the backbone
Lung cancer is one of the most which precludes surgical of treatment, and most
common malignancies in Ontario resection for cure. For locally patients receive the two-drug
and the leading cause of cancer advanced disease, a combination chemotherapy regimen etoposide-
deaths. of chemotherapy and radio- cisplatin. Practice within regional
therapy is recommended for cancer centres is uniformly
Waiting times to access a
patients who are well enough consistent with evidence-based
consultation with a medical or
to receive this combination recommendations.
radiation oncologist for lung
of therapies and Cancer Care
cancer are not excessive and Overall, the data from the
Ontario’s guideline recommen-
times from consult to treatment Decision Support Unit using
dation appears to have been
are generally modest. The average DS-Web show a high degree
adopted in regional cancer
(median) wait time from referral of consistency of practice with
centres. The available data
to treatment in most regional guideline recommendations
does not allow us to determine
cancer centres and the Princess generated by the Lung DSG of
if all patients who could
Margaret Hospital is less than Cancer Care Ontario’s Practice
potentially benefit from this
the four week target set by Guidelines Initiative.
therapy actually receive it.
Cancer Care Ontario.
For metastatic non-small cell
Unfortunately, there is less data
lung cancer, a variety of
available on waiting times for
cisplatin-based chemotherapy
surgery or on other important
regimens can be used to palliate
quality issues such as surgical
symptoms and prolong survival
resection rates and peri-operative
for those patients who are of
mortality. The Surgical Oncology
good performance status and
Program is currently addressing
who have not lost significant
these data deficiencies and
amounts of weight. Practices in
developing quality indicators.
regional cancer centres appear
However, Ontario has a long
to be consistent with evidence-
history of excellence in thoracic
based practice guidelines.
surgery and it is highly probable
However, there is no data to
that measures of quality will
inform us as to whether all
rate highly in thoracic surgical
candidates who could benefit
oncology, with the exception of
from this therapy receive it.
timeliness of access.
14
CLINICAL FOCUS ON LUNG CANCER
Glossary of Terms as number of new cases per unit Regimen
time per fixed number of people; The plan that outlines the
Adjuvant chemotherapy e.g., number of new cases of dosage, schedule and duration
The use of anti-cancer drugs after cancer per 100,000 persons in of treatment.
surgery to decrease the chance one year). Regional involvement
of the cancer coming back. Locally advanced cancer The spread of cancer from
Adjuvant therapy Cancer that has spread only to its original site to nearby
A treatment method used in nearby tissues or lymph nodes. surrounding areas.
addition to the primary therapy; Lymph nodes Risk factors
used to increase the effectiveness Small bean-shaped organ that Anything that may increase a
of treatment. acts as a filter to collect bacteria person’s chance of developing
Age-standardized rate and other foreign substances cancer. It may be an activity,
The number of new cases of from the lymphatic system to be such as smoking, diet, family
cancer or cancer deaths per processed by the immune system. history, environmental agents
100,000 that a population would Metastasis or many other things.
have if it had a standard age The spread of cancer cells from Side effect
structure. Standardization is the original site to other parts of An effect on the body caused
necessary when comparing several the body. by cancer treatment other than
populations that differ with Modality the effect on the cancer; also
respect to age because age has A type or kind of treatment (sur- called adverse reaction.
such a powerful influence on gery, chemotherapy, radiotherapy). Small cell lung cancer
Multimodality therapy A histological type of lung cancer
mortality and morbidity indicators.
Age-specific rate Therapy that combines more than characterized by rapid growth
The number of new cases of one method of treatment such as clinically and characteristic
cancer or cancer deaths during chemotherapy and radiation. small cells as seen under the
Neoadjuvant therapy microscope.
the year, expressed as a rate
Therapy given before the primary Staging
per 100,000 persons in a given
treatment to treat a cancer to A method to describe the size
age group.
Chemotherapy improve the effectiveness of the of a tumour and the extent of
A drug or combination of drugs primary treatment; neoadjuvant its spread.
used to kill cancer cells and fight therapy can be chemotherapy or Standard treatment
cancer. radiation therapy. Treatment that has been proven
Combination chemotherapy Non-small cell lung cancer effective and is commonly used.
Treatment using two or more The most common histological Surgical resection
anti-cancer medications. type of lung cancer; includes Removing tissue from the body
Combined modality therapy adenocarcinoma, squamous cell through a surgical procedure.
Two or more types of treatment carcinomas, large cell anaplastic Systemic disease
are given either at the same time and bronchial alveolar carcinomas. Disease that affects the whole
or in sequence; may include Ontario Cancer Registry body rather than only an organ.
The population-based database Systemic treatment
combinations of radiation,
that includes information on all Treatment that reaches cells
chemotherapy, surgery, or others.
Five-year relative survival diagnoses of cancer reported in all over the body by travelling
A measure of the reduction in Ontario since 1964. It includes through the bloodstream.
limited data about diagnosis Three-year moving average
life expectancy due to a diagnosis
(date, type of cancer), death Rate calculated using the sum of
of cancer. Relative survival is
(date, cause), treatment, and the new cases of cancer or cancer
estimated from life tables as the
the individual (date of birth, sex, deaths for a three-year period
ratio of the observed survival
census division of residence at and the population estimates for
of cancer cases five years after
diagnosis/death) for all cancer those same years. Three-year
diagnosis to the expected survival
patients. It does not include data moving average rates are shown
of individuals of the same age
on risk factors, stage, grade, or on all graphs describing trends
in the general population.
Fraction non-melanoma skin cancers. in order to smooth out annual
Dose of radiation for a single Prevalence fluctuation.
The total number of active cancer Tumour histology
treatment.
Incidence cases in the population at the The type of cancer as classified
A rate showing how many new current moment in time. by its appearance under the
cases of a disease occurred in a Radiation treatment microscope.
X-ray treatment that damages or Unresectable
population during a specified
kills cancer cells. Cannot be surgically removed.
interval of time (usually expressed
15
Practice Guideline Publications of the Lung Disease Site Group
1. Logan DM, Lochrin CA, Darling G, Eady A, Newman TE, Evans WK and the Lung Cancer Disease
Site Group. Adjuvant radiotherapy and chemotherapy for stage II or IIIA non-small cell lung cancer
after complete resection. Cancer Prevention & Control 1997;1(5):366-78.
2. Okawara G, Rusthoven J, Newman T, Findlay B, Evans WK and the Lung Cancer Disease Site Group.
Unresected stage III non-small cell lung cancer. Cancer Prevention & Control 1997;1(3):249-59.
3. Lopez PG, Stewart DJ, Newman TE, Evans WK and the Lung Cancer Disease Site Group.
Chemotherapy in stage IV (metastatic) non-small cell lung cancer. Cancer Prevention & Control
1997;1(1):18-27.
4. Goss GD, Logan DM, Newman TE, Evans WK and the Lung Cancer Disease Site Group. Use of
vinorelbine in non-small cell lung cancer. Cancer Prevention & Control 1997;1(1):28-38.
5. Goss G, Paszat L, Newman T, Evans WK and the Lung Cancer Disease Site Group. Use of
preoperative chemotherapy with or without postoperative radiotherapy in technically resectable
stage IIIA non-small cell lung cancer. Cancer Prevention & Control 1998; (1):32-9.
6. Okawara G, Gagliardi A, Evans WK, and the Cancer Care Ontario Practice Guidelines Initiative
Lung Cancer Disease Site Group. The role of thoracic radiotherapy as an adjunct to standard
chemotherapy in limited-stage small-cell lung cancer. Current Oncology 2000;7(3):162-72.
7. Kotalik J, Yu E, Markman BR, Evans WK, and the Cancer Care Ontario Practice Guidelines Initiative
Lung Cancer Disease Site Group. Practice guideline on prophylactic cranial irradiation in small-cell
lung cancer. International Journal of Radiation Oncology • Biology • Physics 2001;50(2):309-316.
8. Ellis P, Mackay JA, Evans WK, and the Lung Cancer Disease Site Group. Use of gemcitabine in
non-small-cell lung cancer. Current Oncology 2003;10(1):3-26.
Practice guidelines are published on Cancer Care Ontario’s Web site:
www.cancercare.on.ca/access_PEBC.htm.
16
Cancer Care Ontario is the government’s principal adviser on cancer issues, with a mission
to improve the performance of the cancer system by driving quality, accountability and
innovation in all cancer-related services. In addition to working in partnership with hospitals
providing cancer care across the province, Cancer Care Ontario directly manages the
Ontario Breast Screening Program, the Ontario Cervical Screening Program, the Ontario
Cancer Registry and the New Drug Funding Program, and runs a multifaceted program
in cancer research.
Cancer Care Ontario
620 University Avenue
Toronto, ON M5G 2L7
www.cancercare.on.ca
Phone: 416-971-9800
E-mail: Publicaffairs@cancercare.on.ca
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