Morgan, Helen
(2024)
Factors surrounding treatment decisions in non-small cell lung cancer.
PhD thesis, University of Nottingham.
Abstract
Introduction
Despite good outcomes from both thoracic surgery and radical radiotherapy, more than 1 in 5 people who appear eligible for curative treatment of lung cancer do not receive any treatment at all. Spotlight data from the National Lung Cancer Audit (NLCA) found 15% of people chose not to receive treatment, rather than for medical reasons. The reasons behind this are unclear and are likely influenced by regional differences as well as personal patient beliefs, which are difficult to capture using quantitative data.
In addition, this research took place during the COVID-19 pandemic when social and healthcare restrictions were in place and diagnoses of lung cancer fell. Times of high healthcare demand are likely to exacerbate any pre-existing disparities in care. It is therefore important to identify any people who were disproportionately disadvantaged by the pandemic, to attempt to mitigate for these in the future.
Objectives
This thesis aims to examine some of the factors which contribute to decision-making for people with non-small cell lung cancer. It also aims to identify any groups who were disadvantaged by the COVID-19 pandemic.
Methods
This thesis utilised mixed-methods to investigate several factors surrounding decision making in the treatment of early-stage lung cancer. A narrative review was undertaken to define the meaning of cure in non-small cell lung cancer (NSCLC). Using retrospective Lung Cancer Clinical Outcomes data from 2017-18 collated by the NLCA, 90-day mortality stratified by age and performance status (PS) were calculated and compared to outcomes from the same dataset in 2004-12. Tables were produced with the intention of being used to enhance communication. Medical records were obtained for people with early-stage lung cancer and analysed using multivariable logistic regression to identify independent predictors of treatment with curative intent. Semi-structured interviews of people with lung cancer and healthcare workers were conducted and analysed using the Framework approach to identify perceived barriers to curative intent treatment in the East Midlands.
The Rapid Cancer Registration Dataset (RCRD) collated during 2019 and 2020 was used to examine the impact of the early stages of COVID-19 restrictions on lung cancer treatment and survival. 2020 data were divided according to COVID-19 restrictions at the time of diagnosis and compared with baseline data from 2019. Multivariable logistic regression and testing for interactions were used to examine likelihood of receiving curative intent and systemic anti-cancer treatment (SACT). Survival analyses using Cox regression and Kaplan Meier curves were performed.
Results
Outcomes following thoracic surgery for lung cancer have continued to improve with an overall 90-day mortality of 3.1% compared with 5.9% in 2004-12. The majority of procedures were performed via VATS which conferred a survival advantage in this retrospective study.
12% of people with PS 0-2, stage I-II lung cancer in the East Midlands did not receive active treatment. 17% of these people chose not to receive treatment; two-thirds did not receive treatment due to comorbidities or inadequate lung function. Adjusted odds for receiving surgery were significantly reduced by: age ≥80 (OR=0.31; 95% CI 021-0.44), PS=1 (OR=0.2; 95% CI 0.14-0.29), FEV1 50-79% (OR=0.53; 95% CI 0.38-0.75) and TLCO 50-79% (OR=0.24; 95% CI 0.1-0.56). Diagnosis hospital, sex and deprivation did not significantly alter ORs. Older age and PS=2 decreased the likelihood of receiving radical radiotherapy, but this did not persist with adjustment for lung function (OR 0.88, 95% CI 0.4-193; and OR 0.5, 95% CI 0.16-1.6, respectively). Diagnosing hospital did significantly reduce the likelihood of receiving radical radiotherapy for 2 out of 4 trusts included in analysis.
People with potentially curative NSCLC (n=6) and lung cancer clinicians (n=15) underwent semi-structured interviews. 3 themes were identified: emotional treatment barriers; practical barriers; facilitators. Clinicians focused on practical barriers like hospital location and transport, with facilitators often already established to minimise these. In contrast, patients’ greatest barriers were emotional, particularly fear of an operation and potential side-effects, especially in those with previous cancer experience.
Overall curative intent treatment of NSCLC during the early-stages of the pandemic was well sustained with a fall in line with a drop in diagnoses, however SACT prescriptions fell from 63% in 2019 to 57% during the 1st National Lockdown (p=0.006). The composition of treatment also altered, with comparatively more people receiving radical radiotherapy in place of surgery, and increased use of combined chemo-immunotherapy as use of cytotoxic chemotherapy alone fell. No particular patient groups were especially disadvantaged. Survival fell from the 1st National Lockdown onwards and worsened as 2020 progressed.
Discussion
This work examined some of the factors surrounding decision making in curative intent treatment for NSCLC in the UK. It provided reassuring evidence that real-world short-term post-operative survival continues to improve. These findings however may not always be clearly communicated as fear of surgery and preconceived treatment beliefs are common emotional barriers to treatment. However, fewer people in this research chose not to receive treatment than in previous analyses, which is reassuring. During COVID-19, good efforts at continuing treatment were made however longstanding disparities in treatment continue to exist. Future work to develop a personalised risk communication tool may be useful in shared decision making and dispelling myths around treatment.
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