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Take a look at a selection of our recent media coverage:
11th February 2025
Speaking at Hospital Healthcare Europe’s recent Clinical Excellence in Respiratory Care event, Dr Zaheer Mangera shared insights into the evolution of the neoadjuvant lung cancer pathway, its benefits and challenges, and notable changes to the TNM standards used to classify malignant tumours.
Click here to read part one of Dr Mangera’s overview of lung cancer management and diagnosis, including insights into the latest guidance, diagnostic and treatment targets and a deep dive into lung cancer screening and incidental findings.
The neoadjuvant lung cancer pathway has triggered a paradigm shift in how we’re treating our patients. About 20-25% of patients with non-small cell lung cancer have resectable disease at the time of presentation, yet 30-55% of patients undergoing curative surgery have recurrence.
What can we do to try to improve the cure rates in these groups? Historically, there’s always been some modest success with both adjuvant and neoadjuvant approaches.
A big study, CheckMate 816, looked at patients with Stage 1B lung cancer, with a tumour size of over four centimetres without any nodal metastases, to anything up to Stage 3A.
The researchers looked at patients deemed to have resectable disease at the time of multidisciplinary team (MDT) input, with a very good performance status of zero or one. This would be the first instance of having cancer treated, and they shouldn’t have an anaplastic lymphoma kinase/epidermal growth factor receptor (EGFR) mutation.
They were offered nivolumab immunotherapy, regardless of their programmed death-ligand 1. Alongside, they had a platinum-based chemotherapy versus just chemotherapy alone. They then restaged patients then proceeded to surgery.
The primary endpoint was looking at event-free survival and pathological response to treatment. It found clear difference in the event-free survival curve between those who had nivolumab with chemotherapy versus those who had chemotherapy alone. A statistically meaningful difference was sustained well beyond the three-to-four-year period.
It’s now part of NICE guidance, albeit not part of the lung cancer guidance specifically, as it’s a separate NICE technological appraisal (TA876). It’s really made us think about how we can get these patients through a pathway and the challenges involved.
The first patient on this pathway at my hospital had excellent response to the neoadjuvant treatment, then went on to have an uncomplicated surgery and now is just on standard follow-up.
Trying to give chemotherapy before surgery makes an already complex pathway even more complex. It lengthens the pathway considerably, because those three cycles can take over two months to get through, plus the required follow-up scans.
So, although the first treatment would have been given, the time it takes for you to then close the loop at your MDT and say the whole treatment has been finished is definitely elongated.
For most patients, if you offer them surgery, they want a tumour out. Of course, there are lots of other tumour groups where you give neoadjuvant treatment and so having discussions about the process is not new to the oncologist, but it’s new to our surgeons.
There are risks of toxicities, although the trial data reports that the risk is not excessive, and patient tolerance is usually very high. It does mean we need to get an EGFR status as rapidly as possible. If you’re waiting a full four weeks for the EGFR status, before you can start treatment, it can mean considerable wait time to treatment in patients who have high-risk disease – those who are on the cusp of cure and not being cured.
We’re developing rapid EGFR pathways through our pathology labs where you can get the EGFR done more rapidly or even sometimes using the CtDNA blood tests.
And how do you standardise all these care plans and pathways across all cancer alliances and Trusts to ensure everyone is on board, everyone eligible for this treatment is getting it and to ensure we really accurately record it? It’s a real cornerstone of the National Lung Cancer Audit in how we collect our data now.
NICE guidance tells us that anyone with a PET-added lymph node, or a lymph node greater than 10 millimetres, should have an endobronchial ultrasound (EBUS). This sounds reasonable, but we know from different trials that there can be a discrepancy between PET and actual lymph node sampling itself, with false negatives and false positives.
This isn’t ideal if somebody is on the cusp between having radical surgery or needing combination therapy, for example, with neoadjuvant treatment. We know that even with PET/CT and EBUS, you can still miss some patients with nodal disease, and it only becomes evident at time of surgery when you’re removing the entire node.
Accurate staging is important. There are different ways of deciding which lymph nodes are higher risk. Sometimes it’s at ultrasonography when you recognise the risk. At the time of EBUS, you can accurately measure the size, which can be more accurate than CT, PET and PET/CT. And you may well see that the nodes are actually a conglomerate of nodes, for example.
The shape can be helpful: is it oval versus round? Are the margins clear? This is a really good one because very often when you can’t find the lymph node or you can’t really see the margins, it can sometimes be reassuring compared to where you see distinct margins.
Is it homogenous, does it echo-signal consistently throughout or have subtle changes between one area and the next? Is the central hilum structure present or is it absent? Is there any evidence of necrosis?
In future, we’re largely trying to transition to any lymph node over 10 millimetres on CT being biopsied, as well as any lymph node with fluorodeoxyglucose avidity and any lymph node with high-risk features. The only way you can do that is by doing an EBUS.
The TNM 8th edition is what we’re using at the moment and the TNM 9th edition, which is due to go live imminently. The changes are reasonably subtle and there’s no significant ground shift in how we stage lung cancers.
First of all, N2 lymph nodes are going to be split into N2a and N2b. Currently it’s just N1, N2, N3 and we’re now going to have a sub-category for lymph node station N2, with N2a being single station involvement and N2b being multiple station involvement.
It doesn’t really comment too much on size here, so it still does need a little bit of working out in MDT with what you’re going to do with different lymph node groups and how it may or may not change your management and approach to the patient.
Then you’ve got your M stages. M1a and M1b are largely unchanged but M1c is split into M1c1 and M1c2.
M1c1 is multiple extrathoracic metastases in a single organ system, so multiple liver or brain metastases, rather than single metastases, and M1c2 is extrathoracic metastases in multiple organ systems.
This will subtly change the staging and may make a difference to what your approach might be. Having metastases doesn’t mean you don’t have radically treatable disease, and our oncology teams have specific MDTs for patients with metastatic disease and stereotactic ablative radiotherapy MDTs.
More and more of these metastatic diseases can be treated and that’s why it’s important to differentiate between M1b, M1c1 and M1c2 because some of these patients, particularly with M1b may well still have radically treatable disease if it’s just a single metastasis in a single organ.
Dr Zaheer Mangera is a respiratory consultant and the lung cancer lead at North Middlesex University Hospital, now part of the Royal Free London NHS Foundation Trust in London, UK.
View the agenda and register for our next Clinical Excellence in Respiratory Care event now.
31st January 2025
Speaking at Hospital Healthcare Europe’s Clinical Excellence in Cardiovascular Care event, Dr Rebecca Dobson discussed the acute need to assess cardiovascular risk in cancer care, understanding cardiotoxicity and the importance of multidisciplinary team coordination in cardio-oncology.
Following on from her previous Clinical Excellence session in which she discussed the need and demand for cardio-oncology services, Dr Rebecca Dobson, consultant cardiologist specialising in imaging and cardio-oncology at Liverpool Heart and Chest Hospital, turned her attention to considerations such as baseline assessment, cardiovascular risk factors and the impact of systemic anti-cancer therapy on the cardiovascular system – even years down the line.
Dr Dobson also championed collaborative care between cardiology, oncology, radiology and other fields to ensure patients can continue their cancer therapy alongside cardio-protective therapies to optimise their short- and long-term outcomes.
Trends change, and cancer is becoming more common, but happily cancer survival has also doubled in the UK in the last 40-50 years. It’s really important that we, as cardiologists and cardiology teams, don’t shy away from this group of patients, because there’s a lot we can do from a cardiovascular perspective to help them live long, healthy lives after they’ve had cancer.
The authors of a recent paper in the European Heart Journal looked at all patients with cancer and stratified them according to cancer mortality rate and cardiovascular disease mortality rate.
In one group, the patients sadly have very high cancer mortality rates (70-90%) and, as a cardiologist, there’s very little I can do with that cohort of patients to change the natural trajectory of that disease. The impact from a cardio-oncologist perspective is relatively low.
The second group of patients have a slightly lower cancer mortality rate (40-60%) and an increasing cardiovascular disease mortality rate (10-20%), and there’s more we can do in terms of trying to reduce long-term effects of systemic anti-cancer therapies and reducing the risk of cardiotoxicity to avoid cardiovascular complications.
In the third group, these patients are as likely to die from cardiovascular disease as they are from their cancer – both at 20-30%. It’s really important that we don’t cure these patients’ cancer and then leave them alone. We really need to optimise the cardiac care of these patients to consider them as a whole, not just as a cancer patient.
As a consequence of increasing cancer rates and survival, more patients are being exposed to potentially cardiotoxic therapies, and more people with pre-existing cardiovascular disease – who 30 years ago would have died of their cancer – are now surviving. That’s where the subspecialty of cardio-oncology has come from.
We specifically see three different groups of patients. Firstly, we see patients at the beginning of their cancer journey to risk-stratify them. That could be a patient with any cardiovascular disease who then receives a cancer diagnosis and needs to be risk-stratified and optimised from a cardiovascular perspective. Importantly, there needs to be a discussion with the oncology team about that patient’s cancer therapy to ensure it won’t destabilise their existing cardiovascular disease.
As patients go through their cancer journey, we screen and monitor them to detect cardiovascular injury at earliest possible stage so we can get them on appropriate cardio-protective therapies and reduce the interruptions to systemic anti-cancer therapy.
This has been a big change over the last 10 or 20 years. Historically, if you had cancer and then you developed potential cardiotoxicity, it was a binary decision. Sadly, for these patients, cancer therapies were generally discontinued, whereas now we try to continue cancer therapy wherever possible.
The last group of patients we see within the cardio-oncology service is screening and monitoring patients who are cured of their cancer but are at risk of significant long-term cardiovascular late effects.
Classically, this would be patients who had a haematological malignancy or a bone cancer as children or young adults and received significant amounts of anthracycline chemotherapy. We know that puts them at risk of late-effects even 30 years later.
We don’t want these patients to be discharged and forgotten about but then present in adulthood in heart failure. So, we’ve set up a service, certainly in Liverpool, whereby every patient who has had a significant dose of anthracyclines gets put into a late effects clinic. We see them every three to five years, so they don’t fall off that cliff.
Baseline assessment is a little bit contentious from an oncology point of view, and oncology teams have a lot to do with their patients when they first get their cancer diagnosis. To then ask them to also risk-stratify patients from cardiovascular perspective is challenging.
As a cardio-oncologist, I see my role as facilitating this baseline assessment and I work with the region’s oncology teams to do this.
It helps us consider what changes may be required to systemic anti-cancer therapy and enables us to potentially detect undiagnosed cardiovascular problems at baseline.
We are performing increasingly more investigations on patients receiving chemotherapy and radiotherapy. It can be difficult to interpret these investigations without a baseline for comparison otherwise we won’t know if cancer therapy has caused an issue or whether there was pre-existing disease. It also enables us to reduce the risk of cardiotoxicity as patients move through treatment.
I recommend that you download the European Society of Cardiology’s guidelines on cardio-oncology because it gives a helpful overview. It’s a large document but there’s lots of useful information in there.
When I talk to oncologists, they’ll often ask, ‘how do we assess cardiovascular risk, what is it we need to do?’ The first thing to say is that not every patient needs every test. I’m a real believer in that there’s no point doing a test unless you know what you’ll do with an abnormal result. That’s particularly challenging for oncology teams who aren’t used to dealing with echoes, troponins, NT-proBNPs, cardiac MRI scans or sometimes even ECGs.
It’s really important to tailor the approach to the patient depending on their comorbidities and what systemic anti-cancer therapy is proposed. Things like age, sex, demographics, past medical history, lifestyle factors like smoking or being overweight, a family history – if alarm bells are ringing as the history is being taken and the examination is happening, then you might think that the patient needs to go on to have further complementary tests.
It’s really important when we’re setting up these services that cardiology teams work collaboratively with oncology teams to make sure pathways are in place to help us work out what we’re going to do with the abnormalities.
There’s an easy way of quantifying risk now. If you download the free ESC app, you can access risk calculators. It’s easy to fill out the yes or no questions and it gives you a risk at the end: low, medium, high and very high.
The four outcomes are very arbitrary, but the ESC cardio-oncology guidelines stipulate that this is the approximate risk we should be discussing with patients – high-risk conversations will be very different to low-risk ones.
If you’re low risk, you’ve got a less than 2% chance of developing cardiotoxicity, although note that it’s not zero – I always tell patients we can never say they won’t develop a cardiovascular problem. Low-risk patients should have standard monitoring, and, hopefully, as cardiologists or cardio-oncologists, we don’t need to get involved with them.
Medium-risk patients should have closer monitoring, which will differ depending on your region’s resources. We don’t see medium-risk patients here, but we often speak with oncology teams and suggest closer echo or blood pressure monitoring, whatever the issue might be.
High-risk and very high-risk patients have a substantially increased risk of cardiotoxicity. A cardio-oncologist or a cardiologist with an interest in oncology should be involved to optimise them from a cardiovascular perspective. It’s about having an open discussion with the oncologist about their proposal and the additional risk and then feeding that back to the patient.
I tell patients this is a balancing act and we’re trying to ensure the benefit of cancer treatment outweighs cardiovascular risk. There are only few circumstances where it doesn’t and the risk of killing them with chemotherapy is higher than the risk of curing them.
People have different levels of acceptable risk and different priorities, so involving them in decisions is really important. My role is to facilitate safe cancer therapy.
Whenever we thought about cancer and the heart, we used to think about Herceptin and heart failure. Certainly, we do see left ventricular systolic dysfunction associated with Herceptin, but nowhere near as frequently as we used to because of all the cardio-oncology measures that are in place.
Occasionally we see patients with dramatic cardiotoxicity that develops as they’re receiving their cancer therapy. Classically, for example, someone who is receiving paclitaxel and acutely decompensates. They might get chest pain or go into heart failure, but, actually, these patients tend to do well and it’s reversible so they recover as quickly as they deteriorated.
We see patients who have early cardiotoxicity in the days and weeks following systemic anti-cancer therapy, or we can see it months or years later. There’s a challenge there to unpick the timeline and work out what’s causing what. Certain drugs are good at causing late effects and other drugs cause acute cardiotoxicity.
I learn all the time, as cancer therapies develop, about new cardiovascular toxicities or new presentations of cardiotoxicity. It’s really important to keep an open mind when looking after patients who have cardiac issues and have received, or are receiving, systemic anti-cancer therapies and think could these two things be related.
Not only do we see a spectrum in terms of the timeline, we see a spectrum with the cardiotoxicity and the clinical presentation.
Hypertension is hugely under-recognised and under-treated in cancer patients. We know there’s a lot of overlap between risk factors for cancer and for cardiovascular disease, so it’s not surprising that many cancer patients have hypertension. If you add in that they’ve been diagnosed with cancer; they’re likely to be undergoing challenging, difficult-to-tolerate treatments; and they’re anxious, frightened, in pain, anaemic and tired – all these will raise their blood pressure.
Then you’re giving them cancer drugs, many of which can cause hypertension. We can see why 40% of patients with cancer have hypertension. But we undertreat it and we excuse it, but we should be managing it like we would with any other patient with hypertension. We should be monitoring them appropriately and getting them on antihypertensive medications.
Vascular toxicity tends to be more of an issue with the treatments we use for gastrointestinal cancers. We see destabilisation of coronary artery plaques, patients presenting with myocardial infarction, patients with coronary artery spasm. This may just be a bit of indigestion-type chest pain, and the patient may not even present to a healthcare professional but, at the other end of that spectrum, we’ve seen patients with coronary artery spasm who’ve presented with a cardiac arrest. It’s really important that these patients are taken seriously when they say they’ve got chest pain and that everyone is aware that it is a recognised vascular toxicity of the these chemotherapeutic agents.
Myocarditis is an increasing worry with patients who receive checkpoint inhibitors or immunotherapy. When I started in cardio-oncology, we only used immunotherapy for patients with melanoma or renal cell carcinoma. Now, around 75% of cancer patients are eligible for treatment with immunotherapy and that’s not just in a palliative setting, but in a neoadjuvant and adjuvant setting.
Checkpoint inhibitors have a 2% risk of causing myocarditis, and if we miss this and don’t treat it, the patient will die from the myocarditis. So, it’s really important that we consider this in patients who have received immunotherapy because they may present innocuously with fatigue, ankle swelling, breathlessness. You can see there’s a challenge there because what cancer patient doesn’t have those symptoms? But keep it in mind for these patients because the sooner you recognise it, the better the outcome for the patient.
But it’s not all about cardiac function. We need to consider blood pressure, QT interval, myocarditis and, thinking about later effects, things like ischemic heart disease.
Patients who had radiotherapy, particularly mediastinal or left-sided radiotherapy, many years ago can present years down the line with quite significant proximal coronary artery stenoses. And it never fails to amaze me how many patients forget to tell you they’ve had cancer when you’re taking their history. I think a lot of patients block it from their memory. So, particularly if a younger patient is presenting with angina-type symptoms and you think it’s a bit unusual, always ask about their cancer history specifically.
I always say to the oncology teams regionally that cardiotoxicity is a bit of a jigsaw. Certainly, understanding the patient’s clinical presentation is key, and then using that with complementary biochemical and other cardiac investigations to fit everything together.
Within cardiology teams, we’re all familiar with troponin and NTproBNP, but remember, the oncology teams are not. It’s important we help them interpret these and have pathways in place so they know what to do with abnormalities.
Imaging, obviously, is our backbone of decision making within cardio-oncology. It’s really a complimentary modality to help us put into context the clinical signs and symptoms and the biochemistry. Where possible, we should be measuring global longitudinal strain (GLS) and ejection fraction using 3D volumes in all our oncology patients.
We know 3D volumes are more reproducible and have less temporal variability. We don’t want to stop someone’s chemotherapy because we think they’ve dropped the ejection fraction when, actually, it’s just because the pictures were a bit rubbish and the 2D ejection fraction was way off. We need to make sure we’ve got accurate, reproducible echo data to help guide our decision-making.
There’s been a real shift over the last decade in trying to continue chemotherapies and radiotherapies and permitting a certain degree of cardiotoxicity. It comes back to the question of at what point does the risk outweigh the benefit?
It’s about changing your mindset from ‘should this therapy be discontinued’ to ‘how can this therapy be continued’. Because we know that if we interrupt anti-cancer therapy, it’s an independent prognostic marker for worse disease-free survival and overall survival.
For the patients with asymptomatic cardiotoxicity or mild-to-moderate cardiotoxicity, the challenge is trying to work out what to do to safely continue their cancer therapies. And that’s where the cardio-oncology service comes in with increased screening, monitoring, optimising of cardio-protective therapies.
It’s important that if we stop therapies, we consider rechallenging them. In the past, nobody would be rechallenged, but many patients will have a successful rechallenge once they’ve been optimised from a cardiovascular perspective.
That brings us back to the multidisciplinary team (MDT) and the importance of that two-way discussion with cardiology and oncology in terms of making sure that we’ve thought about everything to enable treatment to continue or be restarted.
When you’ve got a cardiologist making unilateral decisions, you’re going to run into difficulties. A pivotal part of our service is that we see patients quickly. There’s no point a patient being referred with their chemotherapy discontinued and me saying I’ll see them in six months, which is probably what a lot of cardiology outpatient waiting times are. We’ve set our service up to see patients within two weeks. If we can’t see them within that timeframe then we offer advice on cardiovascular risk to ensure treatment interruptions are minimised.
Efficient communication throughout is important. I work at Liverpool Heart and Chest Hospital, four miles from Clatterbridge Cancer Centre. That’s a different Trust with a different electronic patient record. We can’t see each other’s echocardiograms, so it’s challenging, but we’ve worked hard to improve communications between the teams.
We’re becoming more aware that it’s not just thinking about a patient’s heart or cancer but thinking holistically because these patients are complex and we want to get the decisions right.
In terms of the MDT, people dip in and out, depending on the patient and the clinical need. We have cardiologists, a cardio-oncology specialist nurse, specialised cardiac physiologists, medical and clinical oncologists, palliative care specialist nurses, pharmacists, radiologists, surgeons, anaesthetists, a dietitian.
When I started the cardio-oncology service in 2019, we ran a fortnightly clinic, but now we run three per week. We have a weekly ward round at Clatterbridge Hospital, four weekly oncology echo lists and a weekly virtual MDT where we ensure we have oncology, cardiology and radiology representation as a minimum.
Everyone’s perspective is different, and it’s really important that we all understand these to ensure that patients have the right decisions made.
Momentum is increasing, and certainly people are more aware of it now than they were 10 years ago. There are not many fully fledged cardio-oncology services, but I think more and more cardiologists and oncologists are aware of cardiotoxicity and are seeing patients within their clinics and realising they need to funnel them in a slightly different way.
We’re all aware that the NHS has no money, so trying to develop business cases and set up new services is incredibly challenging, but one of the things that I feel really strongly about is if we set up those services and risk stratify patients to optimise them at baseline, we’re hugely reducing the risk of cardiotoxicity and saving money. The drugs that we use to treat cardiotoxicity cost tens of thousands of pounds per patient, and if we can reduce the risk of that happening in the first place, prevention is definitely better than cure. I think the service will pay for itself over time, but that is very challenging.
The challenge is getting enough people interested. Everyone is busy and when you go along to a TAVI operator or a cardiothoracic surgeon and say, ‘I want to get you interested in cardio-oncology’, people run the other way. But the service does speak for itself: the more patients we see, the more we assess cardiovascular risk, the less interruptions to systemic anti-cancer therapy are happening. The oncology team certainly values the service, and they are desperate for help with this group of patients.
So, in terms of tips for setting it up, get an interested oncologist on board and start your discussions there to build a joint business case.
In terms of funding, it took me four years to get funding for a cardio-oncology specialist nurse. The only way I managed in the end was getting our local Cancer Alliance to fund a year’s salary and a private donor contributing as well. We’re all facing challenges in the current climate and it’s about looking at alternative funding sources. So, could your local hospital charity do a funding campaign for you to help with these services?
With capacity, the way we’ve set the service up means these patients are all going through dedicated cardio-oncology clinics. We make sure we save urgent slots every week, but we drowned in patients after a couple of years and I suspect that as demand goes up again, we’ll struggle. But for now, we’ve just doubled the number of clinics that we offer, and having a cardio-oncology nurse specialist has further allowed us to increase our capacity.
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.
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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.
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.
View the agenda and register for our next Clinical Excellence in Respiratory Care event now.
4th December 2024
Our latest Clinical Excellence in Respiratory Care event included a fascinating panel discussion on managing pulmonary hypertension as a multidisciplinary team (MDT). Here, you have exclusive access to the session recording.
Hospital Healthcare Europe and Hospital Pharmacy Europe editor Helena Beer was delighted to be joined by three specialist clinicians for this panel discussion: David Kiely, consultant respiratory physician and professor of pulmonary vascular medicine at Sheffield Teaching Hospitals NHS Foundation Trust, alongside Colm McCabe, respiratory consultant in pulmonary hypertension, and Heba Nashat, consultant cardiologist in pulmonary hypertension – both at the Royal Brompton Hospital in London.
Recorded on 21 November 2024 and shared at the Clinical Excellence event the following week, the panellists discussed diagnostic challenges and the role of imaging technology in pulmonary hypertension, integrating cardiology and pulmonology treatment plans and how to best work together as an MDT for the benefit of the patient. Scroll down to watch now.
Watch more Clinical Excellence event sessions via our new Clinical Excellence Catch-up zone.
You can find brand new interviews and case studies, plus round ups of previous Clinical Excellence event sessions and much more in our Respiratory zone – just look out for the orange Clinical Excellence tag to read a whole host of content that can help to inspire your practice.
We’ve recently started work on 2025 content and there are some brilliant pieces coming through the pipeline so remember to check back regularly so you don’t miss out.
If you haven’t already, you can also sign up to our newsletters, which will bring all our latest content, including Clinical Excellence straight to your inbox each week.
View the agendas and register for our next Clinical Excellence in Respiratory Care and Clinical Excellence in Cardiovascular Care events now.
17th October 2024
Hospital Healthcare Europe (HHE) is delighted to welcome respiratory consultant Dr Zaheer Mangera as a speaker on the diagnosis and management of lung cancer at the upcoming Clinical Excellence in Respiratory Care event on 25 November 2024.
Dr Mangera, who is the lung cancer lead at North Middlesex University Hospital NHS Trust, will touch on guidelines from the National Institute for Health and Care Excellence as he considers the importance of early diagnosis and indications for chest radiotherapy, helping patients to understand what their risk factors are and what interventions are available to them, plus the effectiveness of diagnostic and staging investigations.
This session complements his contribution to the previous Clinical Excellence in Respiratory Care event in May 2024 in which he joined a panel discussion on the use of diagnostic imaging for respiratory conditions, with a particular focus on lung cancer.
Dr Mangera will also join colleagues from Sheffield Teaching Hospitals NHS Foundation Trust and Royal Brompton Hospital for a panel discussion on the management of pulmonary hypertension as a multidisciplinary team.
Find out more about the upcoming Clinical Excellence in Respiratory Care event and register for free to hear the latest from Dr Mangera on lung cancer and more.
This latest event in HHE’s Clinical Excellence series brings together renowned experts from recognised Centres of Excellence and other key institutions to share best practice and explore the latest advances in respiratory care including diagnosing lung cancer, personalised approaches to asthma and COPD treatment and managing pulmonary hypertension and sleep disordered breathing.
Providing the opportunity to gain CPD hours, the day-long event will also focus on how to best use multidisciplinary teams (MDT) and improve patient care in this area. The agenda has been created by HHE with guidance from industry experts to offer respiratory physicians and members of the wider MDT a comprehensive overview of this broad clinical area.
To coincide with this event and others in the Clinical Excellence series, a whole host of additional content and interviews with prominent clinicians from Centres of Excellence and beyond have been published on the HHE website – look out for the orange Clinical Excellence tag in the Cardiovascular and Respiratory zones.
This includes a summary of a fascinating session from cardio-oncologist Dr Rebecca Dobson on the need and demand for cardio-oncology services, how they’ve developed over time and the current state of play in this evolving field.
The Clinical Excellence schedule for 2025 will be announced soon, including new clinical areas, so watch this space.
15th October 2024
Hospital Healthcare Europe’s Clinical Excellence in Respiratory Care event is back this November with a jam-packed agenda looking at the latest advances in clinical care – and registration is now open.
Taking place on 25 November, this one-day respiratory event for the multidisciplinary team brings together renowned experts from recognised Centres of Excellence and other UK and EU hospitals to share their experiences of clinical innovations, examples of best practice and how they are improving patient care.
This time, topics include the NICE guidance on the management and diagnosis of lung cancer with insights from Dr Zaheer Mangera, respiratory consultant and lung cancer lead at North Middlesex University Hospital NHS Trust, and an overview of sleep disordered breathing from Dr Alanna Hare, consultant physician, Department of Sleep and Ventilation, Royal Brompton and Harefield Hospitals.
Florence Schleich, respiratory physician, Department of Pneumology, University of Liege, Belgium, will share her take on personalised medicine approaches in managing respiratory conditions including asthma and chronic obstructive pulmonary disease (COPD).
Dr Mangera will also be involved in a panel discussion on the management of pulmonary hypertension as a multidisciplinary team with David Kiely, consultant respiratory physician at Sheffield Teaching Hospitals NHS Foundation Trust, Colm McCabe, respiratory consultant in pulmonary hypertension, and Heba Nashat, consultant cardiologist in pulmonary hypertension – both at Royal Brompton Hospital.
This year’s autumn respiratory care offering has been developed by the team at Hospital Healthcare Europe and Hospital Pharmacy Europe with guidance from industry experts.
The event is free to attend and comprises individual presentations, panel discussions and sponsored sessions delivered virtually live and on-demand, all tailored to provide maximum convenience and work around your busy schedule.
Select sessions most relevant to your clinical practice, specifically tailoring the day to your needs, and gain CPD hours from the comfort of your computer.
With a whole host of fascinating insights and inspiration for improving patient care, it’s not to be missed. Register now to join us for Clinical Excellence in Respiratory Care on 25 November and on demand.
To coincide with this event, a whole host of additional content and interviews with prominent clinicians from Centres of Excellence and beyond has been published on the HHE website – look out for the orange Clinical Excellence tag in the Respiratory zone.
This content includes an inspirational conversation with Professor Andy Bush, consultant paediatric chest physician at London’s Royal Brompton Hospital, about his career highlights, his passion for improving children’s respiratory health and campaigning to ban the promotion of e-cigarettes to young people, and his research into the early origins of asthma.
And Professor Mona Bafadhel discusses a new tool that has identified COPD as a crucial cardiovascular disease risk indicator. She explains how she hopes it will impact health inequalities and ensure better access to preventative therapies.
The Clinical Excellence schedule for 2025 will be announced soon, including new clinical areas, so watch this space.
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