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27th January 2025
Watch all the latest Clinical Excellence event sessions at a time that fits with your busy schedule via Hospital Healthcare Europe (HHE)’s brand new video zone.
Clinical Excellence Catch-up offers a free-to-view selection of on-demand videos bringing you key insights from leading experts in cardiovascular and respiratory care shared at our recent Clinical Excellence events.
The events series focuses on clinical innovation, examples of best practice and the transformation of patient care at Centres of Excellence and other key institutions across the UK.
So, whether you want to revisit some of the fascinating discussions, share the learnings with your team to inspire change at your own hospital, or if you couldn’t make the session and simply want to catch up on everything you missed, visit the Clinical Excellence Catch-up zone now.
Current videos include a panel discussion on managing pulmonary hypertension as a multidisciplinary team (MDT) and an overview of the challenges and management of severe respiratory disease from Ravijyot Saggu, a co-author of the latest European Respiratory Society guideline.
More event session videos will be added to the zone soon, which can be accessed via the dropdown in the Events tab within the main website navigation.
To coincide with events in the Clinical Excellence series, a whole host of additional content and interviews with prominent clinicians from UK Centres of Excellence and other NHS Trusts are being shared on the HHE website – look out for the orange Clinical Excellence tag in the Cardiovascular and Respiratory zones.
This includes a case study from Royal Papworth Hospital on their Enhanced Recovery Unit, which aims to improve the flow and experience of cardiac surgical patients.
And why not read our interview with the Royal Brompton Hospital’s Professor Andy Bush in which he discusses his career highlights, his passion for improving children’s respiratory health and campaigning to ban the promotion of e-cigarettes to young people, as well as his latest research into the early origins of asthma.
Register now for 2025
The agenda for the spring 2025 Clinical Excellence in Cardiovascular Care event is shaping up to be the best one yet, and registration is now open.
Sign up to be among the first to hear the latest innovations in cardiovascular care from some of the UK’s leading experts, with the opportunity to gain CPD hours at this day-long event.
The spring 2025 Clinical Excellence in Respiratory Care event will be announced soon so watch this space.
A perioperative eHealth tool used alongside standard care has been shown to successfully support older patients with abdominal aortic aneurysm throughout their treatment journey.
The app was well used and valued by patients, providing information and positive lifestyle advice before, during and after operations. Patients also appreciated the ability to share the application with relatives, the researchers found.
What’s more, healthcare staff also saw benefits as the app aided the management of a prehabilitation programme and enhanced the digital transformation of healthcare, decreasing their workload.
In the prospective, single-centre cohort study, patients were offered the opportunity to download the app before undergoing abdominal aortic aneurysm surgery. The app provided a range of information for patients, including information about their condition and the surgical techniques involved (endovascular aneurysm repair and open surgical repair), as well as perioperative lifestyle advice, such as exercise programmes, ensuring a healthy diet rich in protein, geriatric care and advice on stopping smoking or drinking alcohol.
The majority of patients reported positive responses using the eHealth app and valued the ability to share relevant information with their relatives.
Over 90% of patients with abdominal aortic aneurysm installed the app (n=59/65), with 10% deactivating it after installation. The mean age of users was 74, and 85% were male. Users were active on the app, opening it a median of 67 times. The interquartile range (IQR) was 33–127, indicating the range of times that patients interacted with the app.
The satisfaction questionnaire was completed by 90% of the participants, rating their experiences with the eHealth tool on a scale from 0 to 10. The median scores were 8 for guidance (IQR 6–8), 8 for information provision (IQR 6–8), 7 for usefulness (IQR 6–8.5) and 8 for recommendation to others (IQR 6–9).
Seven patients provided more in-depth feedback in a semi-structured interview and described positive experiences, particularly related to healthy lifestyle advice and the ability to share information about their abdominal aortic aneurysm care with relatives.
The researchers said the user data and feedback highlighted several areas for improvement, but they emphasised the wide-reaching benefits of using an eHealth tool for supplementary care in older patients with abdominal aortic aneurysm.
Reference
Gjosha, B et al. Positive Experiences with the Use of an eHealth Smartphone Application During the Treatment of an Abdominal Aortic Aneurysm. Annals of Vascular Surgery; Oct 24: DOI: 10.1016/j.avsg.2024.07.112.
A Spanish study aiming to address the environmental impact of inhalers has highlighted the importance of aligning clinical need and sustainability criteria into prescribing practices.
Focusing on reducing the high carbon footprint of pressurised metered-dose inhalers (pMDIs), the researchers developed a framework promoting the use of eco-friendly alternatives like dry powder inhalers (DPIs) and soft mist inhalers.
pMDIs contribute notably to the carbon footprint of medicines and healthcare, with two puffs of a hydrofluoroalkane (HFA) propelled pMDI being equivalent to driving 2km by car. Therefore, the study’s aim was to create a framework to reduce this environmental burden by implementing greener prescription practices without compromising patients’ health.
The mixed methods research first involved the formation of a multidisciplinary working group, including hospital pharmacists, pulmonologists and academics. A comprehensive database was then developed, incorporating the carbon footprint and other environmental data of inhalers marketed in Spain.
A key element to this was creating a decision-making algorithm integrating both clinical and environmental criteria, allowing healthcare professionals to consider sustainable alternative inhaler types.
The study revealed ‘significant variability in inhaler carbon footprint, with pMDIs showing the highest emissions due to HFA propellants’, the researchers said.
Scenario projections showed that a 10% shift from pMDIs to DPIs could reduce CO2 emissions by up to 40,000 tonnes annually. A 50% shift could save as much as 200,000 tonnes.
The authors concluded that incorporating environmental criteria into inhaler prescribing decisions could substantially reduce the healthcare sector’s carbon footprint and that ‘the decision-making algorithm developed in this study offers a practical tool’ for achieving this.
The study’s findings also highlighted the importance of involving patients in the decision-making process, empowering them to consider the environmental implications of their treatment choices.
Moving forward, the researchers suggested further work was needed to refine the decision-making algorithm and explore its application in other healthcare settings and countries. Additional studies are also required to evaluate the long-term effects of greener inhaler prescribing practices on both patient health and environmental outcomes.
Policymakers should consider incorporating these findings into national healthcare guidelines to promote sustainable prescribing on a broader scale, the researchers added.
Reference
Garin N, Zarate-Tamames B, Lertxundi U, et al. The environmental impact of inhalers: a framework for sustainable prescription practices in Spain. European Journal of Hospital Pharmacy, January 2025. doi: 10.1136/ejhpharm-2024-004402.
Professor Christopher Denton, consultant rheumatologist at the Royal Free Hospital in London, led a recent British Society for Rheumatology guideline working group on managing systemic sclerosis. Here, as lead author of the published recommendations, he explains key aspects of the guideline and highlights new and emerging advances in treatment for this challenging condition.
Systemic sclerosis is a severe and incurable autoimmune rheumatic disease that causes damage and fibrosis in the skin, blood vessels and vital organs. It also impacts hand function, and almost all aspects of everyday living are affected.
It is uncommon, affecting around one in 10,000 of the population. Unfortunately, it has a high mortality and even greater morbidity through its impact on the lungs, heart, kidneys and gastrointestinal tract.1
The first guideline covering the management of systemic sclerosis in all age groups were published in September 2024 by the British Society for Rheumatology following working group discussions among healthcare professionals with expertise in systemic sclerosis, people with lived experience of the condition and patient organisation representatives.2 This is an updated version of an earlier 2015 guideline that only covered adults with this complex disease.3
Systemic sclerosis is a diverse disease, so guidelines need to consider the differences in how people may present with it. Often it takes time to make a firm diagnosis, which can lead to treatment delays.
Early diagnosis using techniques such as capillaroscopy and antinuclear autoantibody testing is important and allows stratification of risk for future complications, including lung fibrosis and severe renal involvement.4
Once diagnosed, there should be a systematic baseline assessment of all the organs that might be affected and regular follow-up testing through the disease course. A particular group highlighted in the new guideline is the subset of cases associated with concurrent malignancy.
This group has certain characteristics that allow for early recognition, including certain antibody associations and clinical features. The approach to these cases is analogous to that taken with adult-onset dermatomyositis.
In line with other recently published recommendations and aligned with the British Society for Rheumatology guideline protocol, young people with systemic sclerosis are included in the recommendations for the first time. This was achieved through strong engagement with the paediatric rheumatology community. For each of the evidence-based recommendations, a statement about relevance to children and adolescent patients is included.
The British Society for Rheumatology guideline includes four key sections:
Each section is framed around key questions that are front and centre of systemic sclerosis management, such as the best approaches to treating heart, lung or gastrointestinal complications. There is also much emphasis on non-lethal manifestations such as digital ulcers as well as non-pharmacological treatments.
The fourth section of the guideline covers specific aspects of service delivery within the NHS. It will help to plan the recommended practice and provide templates and standards for service and patient-specific future audit.
There has been nearly a decade of progress in managing systemic sclerosis, which is captured in the updated guideline.
There are now evidence-based treatments, approved drugs for interstitial lung disease in systemic sclerosis, and more robust support for approaches such as autologous haematopoietic stem cell transplantation. The latter has been shown in robust trials to have a profound benefit for appropriate cases, and the guideline includes specific expert direction on the assessment and evaluation of cases for this procedure.
There is growing support for the treatment of vascular disease, including pulmonary arterial hypertension, and the updated guideline complements guidance from other relevant bodies such as the World Symposium for Pulmonary Hypertension.5
The first major area of progress has been advances in cellular therapy. Large, robust clinical trials and registry studies have confirmed the long-term benefit of autologous haematopoietic stem cell transplantation in poor prognosis systemic sclerosis.6 The new guideline covers this for adults and highlights that it is also a treatment option for juvenile-onset systemic sclerosis.
Critical guidance to help select and evaluate patients so that maximum benefit and minimal harm are achieved is included with simple summaries for case selection. This treatment shows what can be accomplished and provides a pivotal demonstration of disease modification.
Progress has also been made in managing vasculopathy in systemic sclerosis and therefore scleroderma renal crisis, digital ulcer disease, Raynaud’s phenomenon and pulmonary hypertension are all covered clearly in the guideline. These sections summarise evidence-based practice and highlight that systemic sclerosis is as much a cardiovascular disease as a fibrotic condition.7
However, fibrosis of the lung is now the most frequent cause of systemic sclerosis-associated death, and there have been studies providing evidence for treatment.
The guideline includes expert direction on the evaluation and treatment of interstitial lung disease, including a combination of immunosuppression with antifibrotic treatment (nintedanib) in cases of progressive disease.8
Other approaches have been approved based on clinical trial results, including biological therapy with tocilizumab and rituximab.9 These may be especially effective in certain stages and subsets of systemic sclerosis, as indicated in the guideline.
While not yet routinely available in the NHS, it is hoped that the growing evidence base for these biological agents and general utilisation in other global healthcare settings will facilitate access to these treatments in the future. It is likely that, at present, the use will generally be restricted to cases of sclerosis fulfilling the requirements to access rituximab or tocilizumab for other manifestations of overlap syndrome such as arthritis, myositis or vasculitis.
Despite progress in treatment for some of the most serious aspects of systemic sclerosis, including interstitial lung disease, pulmonary hypertension and scleroderma renal crisis, there is still much more to address.
As survival overall has improved, the importance of non-lethal burden is pivotal for people living with systemic sclerosis. Inclusion of people with lived experience in the guideline working group highlighted this challenge, as did the strong involvement and endorsement of the guideline by the charity Scleroderma and Raynaud’s UK.
The British Society for Rheumatology guideline protocol includes an expectation that the guideline will be revised and updated. There is unprecedented interest in systemic sclerosis and its complications from the pharmaceutical industry and many clinical trials are ongoing.
The results of such trials, generally adding new potential treatments to background standard of care immunosuppression, will provide the evidence base for future guidelines. Still, it is likely that as one therapeutic mountain is scaled, another challenging peak will emerge. The updated guideline for systemic sclerosis represents an important milestone in the journey but the final destination is still some way off.
Christopher Denton PhD FRCP FMedSci
Consultant rheumatologist, Royal Free London NHS Foundation Trust, UK
24th January 2025
Good physical fitness combined with muscular strength could reduce cancer patient deaths, a recent study suggests.
Researchers found that tailored exercise plans may prolong life for people living with cancer and boost their chances of survival. The study, published in the British Journal of Sports Medicine, could have implications for clinical practice, with muscle strength exercises employed to increase life expectancy.
The international researchers, led by Edith Cowan University in Australia, pooled data from 42 studies published in English in five databases up to August 2023 to examine whether physical fitness could extend survival rates in cancer patients. The 47,694 patients in the studies had an average age of 64 and had been diagnosed with various types and stages of cancer.
Muscle strength was determined by handgrip strength measurements. Depending on age, a handgrip strength of below 13 kg to below 25 kg was classified as low strength for women. Low strength was classified as below 20 kg to below 40 kg for men. Cardiorespiratory fitness was assessed using either cardiopulmonary exercise testing (CPET) or a six-minute walk test (MWT).
The analysis suggested that both muscular strength and good physical fitness are associated with a significantly lower risk of death from any cause in cancer patients. Patients who maintained strong muscles and good overall fitness had a 31-46% lower risk of dying from any cause compared to those with poor muscle strength and low cardiorespiratory fitness. This risk continued to fall by 11% for each unit increase in muscular strength and 18% for each unit increment in cardiorespiratory fitness.
In patients with advanced-stage cancer (stages 3 and 4), muscle strength and cardiorespiratory fitness were associated with an 8-46% reduced risk of all-cause mortality and a 19-41% lower risk of death from any cause among those with lung or digestive cancers.
‘Our findings highlight that muscle strength could potentially be used in clinical practice to determine mortality risk in cancer patients in advanced stages and, therefore, muscle strengthening activities could be employed to increase life expectancy,’ the researchers concluded.
A previous study published in the same journal suggested that young men with a higher level of cardiorespiratory fitness had a significantly lower risk of developing several cancers in later life.
A version of this article was originally published by our sister publication Nursing in Practice.
Speaking at Hospital Healthcare Europe’s Clinical Excellence in Respiratory Care event, Ravijyot Saggu discussed the challenges and management of severe respiratory disease in the context of the 2024 European Respiratory Society guideline on managing severe respiratory disease in adults.
In 2024, the European Respiratory Society (ERS) convened a multiprofessional respiratory task force group to undertake a review of the symptomatic treatment of advanced respiratory disease, noting that there is often a lack of large randomised controlled trials in this area, resulting in evidence for interventions being conflicting and of varying quality.
The result was the creation of a clinical practice guideline and recommendations to support clinicians and the wider multidisciplinary team in delivering optimum patient care in this area.
At the Clinical Excellence event, chair Dr Zaheer Mangera, respiratory consultant and lung cancer lead at North Middlesex University Hospital NHS Trust in London, introduced respiratory and medicines optimisation pharmacist Ravijyot Saggu, one of the guideline co-authors, to share her views.
Ms Saggu, who is also chair of the UKCPA Respiratory Committee and clinical member of the NHS England Respiratory Clinical Reference Group, discussed the challenges of respiratory care and severe lung disease, as well as the ERS advanced symptom management guideline 2024 and its implications for practice. Scroll down and click play to watch now.
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23rd January 2025
Women are waiting longer for lung transplantation than men, a French retrospective study finds, showing changes to clinical guidelines and policies are needed to address gender inequalities.
Lung transplantation is a highly dynamic segment of solid organ transplant, where gender is known to play a central role, the study authors wrote in ERJ Open Research.
Previous research using US lung transplantation data had found women had a lower chance of receiving a transplant than men and waited longer before transplant.
For this study the authors evaluated the differences between men and women before transplantation, during and immediately after surgery and in the months and years following transplantation using data from the French Cohort in lung transplantation (COLT) database – the first to analyse all three periods of the transplantation pathway.
Overall, 1,710 participants (802 women and 908 men) were included in the study, with analysis showing women waited an average of six weeks longer for transplantation, spending 115 days on the transplant list compared with 73 days for men.
Women were less likely than men to undergo transplantation (91.6% vs 95.6%), the data showed.
At the time of registration on the lung transplant list, women were younger than men (47 years vs 54 years) and they displayed fewer comorbidities, including ischemic heart disease and cardiovascular risk factors.
In both genders, the main underlying disease was COPD/emphysema, followed by cystic fibrosis and interstitial lung disease.
In other differences, pre-transplant anti-human leukocyte antigen (HLA) antibodies were more prevalent in women than in men (46% vs 26%) for both class I and class II, with the number of pre-transplant class I anti-HLA antibodies associated with an increased waiting time.
It was also more common for women to receive lungs from height- and sex-matched donors, despite higher female-waiting list mortality and a higher proportion of male donors, the authors wrote.
They stressed that women with oversized lung transplantation, defined by predicted total lung capacity ratio and weight, did not have worse survival, therefore suggesting that size matching criteria could be less stringent.
Post-transplantation, women had a significantly higher survival rate than men, with 34.4% of female recipients dying compared with 42.7% of male recipients.
Survival rates were also higher among women than men at five years post-transplantation (70% vs 61%).
Study lead author Dr Adrien Tissot of from the Pulmonology Department at Nantes University Hospital, France, said people on the lung transplant waiting list had a poor quality of life and high mortality risk.
‘For these patients, waiting is suffering, and the longer the wait the worse these women are suffering,’ he said.
‘Clinicians, patients and policy makers must acknowledge this gender difference as it’s essential for appropriate action to be taken.’
Dr Tissot suggested early listing for women or revising the allocation policy of donor lung to recipient could be considered.
‘We believe our findings, such as the potential role of size matching and its consequence on access to lung transplantation, and length of time on the waiting list, may also apply in other countries where lung transplantation is performed,’ he said.
Also commenting on the findings, Dr Michael Perch, chair of the European Respiratory Society’s Group on Lung Transplantation and a senior consultant at Rigshospitalet in Copenhagen, Denmark, said there could be several reasons why women waited longer for transplantation, including differences in education and health literacy, socioeconomic differences, immunological factors and donor-recipient size matching.
‘Clinicians and policymakers alike must question why there is a focus on gender and size matching in transplantation when evidence shows that, in lungs, these factors do not determine a woman’s chance of survival, and it ultimately risks an increase of women dying while waiting for a transplant,’ he said.
‘It is unacceptable for women to be waiting longer than men for these lifesaving donations, so effective corrective measures must be introduced.’
Our aim at Hospital Healthcare Europe, is to support patient care and improve outcomes by sharing inspirational examples of best practice in secondary care from across the UK and Europe – and that’s where you come in.
If you’re working on a new and exciting way to transform clinical practice and would like to share it with colleagues, we want to hear from you.
We’re interested in pilot projects, applied research and case studies covering all areas of clinical and professional expertise including:
No project is too large or too small and it can be an individual passion project, a whole multidisciplinary team effort or something in between.
All you need to do to be considered for publication is submit an an abstract of up to 100 words, sending it via email to Hospital Healthcare Europe’s secondar care content director Andrea Porter with the subject line: HHE article submission.
This should briefly outline what your project set out to achieve, who and what was involved, as well as the top-line findings and/or impact on best practice and patient care. And if you’re just starting out on the project and would like to document the process with us, let us know!
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The Government has pledged to develop a digital platform to share up-to-date medical information between NHS and care staff to speed up and improve care in both hospital and the home.
The reforms have promised to fully digitise all care providers by the end of the Parliament and to join up systems so NHS and care staff have access to real-time social care, GP and hospital data.
This instant access to the latest information, including when someone last took their medication, means individuals will not need to repeat information about their care needs multiple times and care staff will avoid wasting time trying to find information about the people they care for.
It also means clinicians will have access to information about someone’s recent care history to help them determine the best treatment for their needs.
Commenting on the announcement, NHS Chief Executive, Amanda Pritchard, said: ‘Social care has a huge impact on the NHS, with thousands of people in hospitals who are medically fit for discharge the current strain the sector is under has significant consequences for both NHS productivity and performance, so we hope this vital action plan and commitment to create a national care service will both help better support people and ease pressure on hospital wards.‘
The Government also announced an independent commission into adult social care, chaired by Baroness Louise Casey of Blackstock. This will set out recommendations for ‘how to rebuild’ the adult social care system to meet current and future needs of the population.
The first phase of the commission will identify the critical issues and set out recommendations for improvement in the medium term. It will report in 2026. The second phase will look at longer-term reform and will report in 2028.
Health secretary, Wes Streeting, said the investment and reforms ‘will help to modernise social care, get it working more closely with the NHS, and help deliver our Plan for Change.’
He added however that longer term action was needed to meet the demands of care in the future.
He said: ‘The independent commission will work to build a national consensus around a new national care service able to meet the needs of older and disabled people into the 21st century.
‘I have written to opposition parties to invite them to take part in the commission’s work, and asked Baroness Louise Casey to build a cross-party consensus, to ensure the national care service survives governments of different shades, just as our NHS has for the past 76 years.’
In response to the announcement, the chair of the Health and Social Care Committee, Layla Moran MP, said: ‘This announcement from the Government on a commission to look at social care is welcome, however this cannot be an exercise in kicking the can down the road. We urge bravery and courage from the Government and all political parties to work together to act boldly and urgently.
‘We are concerned that any further delay perpetuates the hardship for individuals and their families, as well as the cost to the NHS and local authorities.’
Matthew Taylor, chief executive of the NHS Confederation, said the announcement set out some ‘welcome commitments’.
‘The Government’s ambition to find a long-term solution for social care is commendable and we urge all parties to work together to create a consensus for action,’ he said. ‘We know that significant change will require difficult choices, but the pressure on social care and impact on the NHS means that governments can no longer kick the can further down the road.
‘But while we wait for the commission to report back it seems likely that the Government may need to provide further short-term support for the social care sector – particularly to break the continued cycle of difficult winters the health and care sectors have experienced.’
Nuffield Trust deputy director of policy, Natasha Curry, added: ‘We welcome the additional funding and the measures designed to support the sector in the shorter term. But we remain concerned that this is still insufficient given the immense financial pressure that the sector is under.‘
A version of this article was originally published by our sister publication Healthcare Leader.
17th January 2025
Speaking at Hospital Healthcare Europe’s recent Clinical Excellence in Respiratory Care event, Dr Zaheer Mangera shared insights into the lung cancer pathway and its management and diagnosis in accordance with NICE and other guidance, paying particular attention to the benefits and challenges of early diagnosis and lung cancer screening.
Cancer waiting times are never far from the headlines, and recent figures on these targets for all cancers show mixed success, with the target for the faster diagnosis standard being met (77.4% vs 75%) but the 31-day decision to treat and 62-day referral to treat standards falling short of their respective targets (91.0% vs 96% and 69.4% vs 85%).
When it comes to lung cancer, more than 5,000 cases have been identified through the NHS Targeted Lung Health Check Programme since its launch in 2019. Some 76% of these were found at the earliest stages of one and two, offering those patients the best chance of survival.
In fact, NHS data shows a 7.4% improvement in lung cancer early diagnosis rates from April 2023 to March 2024 compared to March 2019 to February 2020. However, the overall picture is varied and there’s still work to be done to ensure targets are met, screening successes continue and patients receive the best treatment as early as possible.
Respiratory consultant Dr ZaheerMangera is the lung cancer lead at North Middlesex University Hospital – now part of the Royal Free London NHS Foundation Trust – in London, UK. Optimising and delivering a successful lung cancer pathway is one of his main focuses, and this requires a careful balance of speed, accuracy and resource.
There hasn’t been much dramatic change to NICE guidance – since 2019, it’s been more subtle. Some of the big changes have been around early diagnosis, specifically lung cancer screening, which I’ll come onto shortly.
The way I look at NG122 is that it provides a basic framework, setting down the minimum criteria for delivering a lung cancer pathway. Lots of the guidance relates to order, process and speed. It doesn’t really provide a manual of how you should treat lung cancer, but it does touch on some important aspects.
Faster diagnosis consumes us as lung cancer physicians – everything is about speed, getting patients discharged off the pathway as quickly as possible, and trying to get those who do have lung cancer through it so they can get treatment at lightning speed.
The document Millimetres Matter, published by the United Kingdom Lung Cancer Coalition in 2018, is an important first stepping stone in terms of speeding up the lung cancer pathway. It recognises that when looking at the T-stage of a tumour, the stage of a patient can change just by a millimetre. And those changes can happen within the course of a 62-day lung cancer pathway.
We want everyone to be sprinting towards that finish line, whether it’s discharging from the pathway or making a lung cancer diagnosis. But we know from numerous lung cancer audits year-on-year that there’s huge variety of performance. Some Trusts are doing an excellent job getting patients through the pathway rapidly, others not so good.
But this speed is important as this report highlights a 16% mortality increase if the time from diagnosis to surgery goes beyond 40 days. So, it’s important we challenge ourselves to 62 days, knowing significant numbers of patients’ cancers will progress within the lifetime of that pathway.
Patient experience is really important. Sometimes my patients say everything’s going too quickly for them, but most want to get their diagnosis the day before yesterday.
Many would have been to their GP or emergency department several times before even arriving on the pathway. It’s all about trying to consistently drive standards up and recognise what specific standards we should be focusing on to even out performance across the different Trusts.
With the lung cancer pathway, Trusts aren’t actually competing with each other, but we want them to be within a hair’s breadth of each-other – like in the Paris Olympics 100m final – because we don’t want to see an ongoing postcode lottery as to whether patients survive the pathway and get access to the best treatments within a rapid timeframe. This all coincides with the faster diagnosis standard.
A lot of my time is spent looking at how many patients are breaching the 62-day pathway and how many are inside it, but the faster diagnosis standard is important. It’s quite a simple principle: within 28 days of the referral being sent by primary care, the patient needs to know whether they have a cancer or not. They don’t necessarily need to know the treatment plan or next steps, but they need to be told that much.
At my Trust – a medium-sized district general hospital in London – the last audit showed that for every 100 GP referrals, there were three cancers found, meaning there are 97 patients sitting there worrying they may have lung cancer. So, the benefits are huge if we can achieve this 28-day target of telling patients.
If we look at the National Optimal Lung Cancer Pathway (NOLCP), we’re expecting Trusts to ensure that the patient has had an X-ray, ideally, before they’ve even seen us. We’re also looking at the CT being done within 72 hours of that referral.
We’re failing at this in my Trust quite abysmally at the moment, which is really disappointing. It’s even more disappointing that we were achieving this pre-Covid and so post-Covid there has clearly been a catastrophic collapse in how we arrange and deliver our radiology. There are lots of different factors behind that, but we certainly haven’t been able to achieve this CT target for quite some time.
But the way we mitigate that is by trying to fast-track high-risk patients, particularly those with an X-ray abnormal for lung cancer specifically. Something being developed in a number of Trusts, which I think is live in Manchester, is artificial intelligence (AI) reporting of X-rays. If there is an abnormality, it can get flagged for reporting by a radiographer or radiologist earlier on. This is one area where we may be able to pick up these high-risk cancers much more quickly.
Ideally, we want patients to meet a lung cancer specialist – or a clinical nurse specialist in Trusts that have them – within the first six days. By day 14, we want the whole panel of tests done: PET/CT, if relevant, spirometry and more advanced lung function tests like gas transfer.
Then by day 21, we want that full multidisciplinary team (MDT) discussion where we make a treatment plan, so by day 28 we’re giving the patient the all-clear or telling them the diagnosis. That gives plenty of time to get treatment started by day 49 – the maximum length of the NOLCP.
The paradigm shift is that rather than giving ourselves 62 days, we’re trying to get that treatment within 49 days, which is what we’re increasingly being audited against. Although the National Lung Cancer Audit is still publishing the 62-day results, but it’s the 49 days that’s quite important now.
More hospitals have endobronchial ultrasound (EBUS) as part of their suite of investigations compared to a decade ago, so there’s less referral into other centres. But time to EBUS can still be problematic and patients in some areas, particularly for general anaesthetic EBUS procedures.
We’ve also seen a whole range of barriers in my own Trust around PET/CT scans. We’ve been waiting three to four weeks for a PET/CT and more recently have got them done within three to four days as more scanners come online. The issues are the physical infrastructure required to get a PET/CT scanner in, radiology reporting limitations and the fact that there won’t be this scanner in every hospital – there is going to be a hub and spoke model.
Perhaps most pertinent barrier is getting access to molecular markers for treatment plans, epidermal growth factor receptor (EGFR) status and immunohistochemistry. In my practice, it can be a full four weeks from the day I take the biopsy before we’ve got access to the full molecular markers.
Another innovation is access to circulating tumour DNA (ctDNA) blood tests. It’s been online for over a year, and my Trust has been part of a pilot for the last six months. A simple blood test is sent to a specialist lab and you get a very detailed report within two weeks. It’s particularly good if you’ve got somebody with stage three cancers or above where there’s metastases and some tumour DNA has spilt into the blood. We’re getting quite a few false negatives where the patient may well have cancer, but there’s just not enough tumour DNA present for any meaningful results to be gained from the blood test. But this can speed things up, and you can use it alongside your biopsy results to determine appropriate treatments.
The first thing to say about early diagnosis is that within the NHS, there is almost a pseudo screening programme, given how many patients are receiving all kinds of CT scans that incidentally pick up early lung cancers.
These are all very fruitful pathways for us lung cancer physicians because we tend to pick up asymptomatic lung cancer from, say, the chance CT colonogram that may have included a CT chest as part of its protocol. There are hundreds of CT coronary angiograms being done every month at our local tertiary cardiology centre and we’ll see a small percentage of them, but it actually ends up being quite a large number with reported nodules.
For those of you working alongside rapid diagnostic centres where, typically, patients will present with symptoms of weight loss, but no clear pathway for them to be referred to, they’ll be churning out quite a lot of CT chest-abdomen-pelvis. There’s direct access to CT pancreas in many areas for GPs, which can sometimes include a CT chest – the list goes on. We’re seeing lots of imaging, and we’re finding lots of incidental findings, and it’s quite a rich resource.
The message is that all lung MDTs – whether diagnostic or treatment – are absolutely being flooded with incidental findings but as some of these are picking up early lung cancers, it’s very difficult for us to say we want that Pandora’s box to be closed and we want this imaging to be a bit more thoughtful and a bit more targeted. This is going to be an area that becomes increasingly important for us to navigate.
Lung cancer screening has captured the imagination of the UK, particularly of England, and we’re seeing more lung cancer pathways. Some are hospital-based, some are in community hospitals, and some are roaming around with patients sometimes being invited to screening on lorries in supermarket car parks.
The lung cancer screening story started back in the 1970s, but real major changes to practice were first initiated by a study initiated in the 2000s and reported on around 2010/11. Here, America’s National Lung Screening Trial found you could secure a 20% reduction in lung cancer mortality if you started screening high-risk patients, typically smokers between age 50 and 70. Subsequent studies, like the European Nelson Study, found a mortality reduction of up to 26%.
It answered the question, beyond any reasonable doubt, that if you want to try to improve cancer mortality, earlier diagnosis is the strategy, and you need an appropriate tool to do that. A non-contrast, low-dose CT is a very effective way of ruling in or ruling out lung cancers.
One interesting outcome is a differential in the mortality gain between men and women. In the Nelson Study, for example, you can get up to 33% improvement in mortality in females compared to males where it’s around 25%, and it’s listed as a risk reduction.
This doesn’t necessarily change our approach, but it tells us a bit about the biology of cancer in women, and how they may well have more treatment options and better response to treatments. But remember, this population are smokers or ex-smokers, so it doesn’t answer the whole question about the difference between men and women but it’s an interesting observation.
In the UK, you have to be between the age of 55 and 75, you need to be registered with a GP, and you need to have a smoking history. Different risk assessment tools or prediction models are used – whether it’s LLPv2 or a PLCO – and, depending on the risk score, you can be invited for a CT scan screening.
There are lots of challenges around targeted lung health checks and the first is how many patients are agreeing to have a scan. CT scans aren’t usually as problematic as other types of screening – such as bowel screening – and may feel less invasive for some patients, but they still require the patient to engage, taking time off work or travelling quite some distance in some cases.
Nationally, the most recent update reveals around 42% of patients have a CT scan when invited. Some areas, like North East London, for example, have an uptick of around 80%.
It all depends what strategies are in place to try to improve uptake and how you can engage with your community and engage with people who may be at risk, including people without English as their first language and other groups that are more difficult to reach.
The number of nodules that our colleagues are finding in these targeted health checks is monumental. AI reporting and having a clear protocol for these does help, and a lot of these incidental findings can be dismissed without ever coming directly into an NHS lung cancer pathway.
In my experience, we’re only seeing those who are genuinely higher risk or are borderline. We’re not seeing too many patients who just need a standard lung nodule follow-up.
It’s a challenge in terms of aligning clinical systems and ensuring everything works, given most hospitals don’t have integrated systems. You’ll have a targeted lung health check serving a number of different hospitals that all have different systems that don’t talk to each other.
Where I work, we’re still receiving referrals by email, which of course is problematic if an email isn’t read or actioned in the usual way.
There are questions over whether we should be scanning younger or older patients and that will always be a big debate – have we got the age groups correct?
And this is all being done in the context of an under-resourced lung cancer service. Looking at the national picture, our mortality rates are still well behind most of Europe. A lot of this is to do with the actual resources and numbers of PET/CT scanners, chest physicians and oncologists.
We can identify other life-threatening findings, like an aortic aneurysm that’s about to rupture, for example. Patients will get spirometry during the testing phases as well, so you can diagnose COPD. The CT findings themselves can offer important lung findings, such as undiagnosed pulmonary fibrosis or other interstitial lung diseases – bronchiectasis, for example – and cardiac conditions such as the degree of calcification of the coronary arteries.
It’s also an opportunity to offer a tobacco dependency service, because many of these patients will be current smokers, and so it’s a good way of offering a treatment for their tobacco dependency.
Click here to read part two of Dr Mangera’s overview of lung cancer management and diagnosis, which focuses on the evolution of the neoadjuvant lung cancer pathway and notable changes to the TNM standards used to classify malignant tumours.
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