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| Journal of the New Zealand Medical Association,
18-June-2004, Vol 117 No 1196
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Lung cancer treatment in New Zealand: physicians’
attitudes
Tim Christmas, Michael Findlay
Lung cancer remains the leading cause of cancer death in NZ
with over 1500 reported cases presenting each
year.1 The most common type of lung cancer is
non-small cell lung cancer (NSCLC), which represents approximately 75 % of
cases. The 5 year survival is less than 10%.
The investigation and initial management of lung cancer in
New Zealand is mainly undertaken by respiratory physicians, and subsequently
referred on to oncologists or surgeons for treatment (either on an individual
basis or via multidisciplinary meetings or clinics). Although surgery alone is
currently considered the best available treatment (when a primary lung cancer is
localised), there is considerable debate over the optimal treatment of locally
invasive and extensive stage lung cancer.
In spite of several recent clinical trials that appear to
show improved survival rates using newer chemotherapeutic agents and
multi-modality treatments, there is still significant variation in the use of
these therapies internationally. There are, however, several published
international guidelines on the management of lung cancer published by different
organisations, which include: The Scottish Intercollegiate Network (SIGN), the
British Thoracic Society (BTS), the American Society of Clinical Oncology
(ASCO), and (recently) The Australian Cancer Network
(ACN).2–5 Although there are no specific
New Zealand Guidelines, the ACN guidelines have been contributed to and endorsed
by the Thoracic Society of Australia and New Zealand (TSANZ).
The aim of our study was to determine treatment practices by
New Zealand lung cancer specialists, and to determine whether the treatment
decisions are in accordance with the currently available guidelines.
MethodsA questionnaire was developed
and circulated to physicians involved in the non-surgical treatment of lung
cancer. These physicians included all New Zealand adult respiratory physicians
who were active members of the TSANZ, as well as all medical and radiation
oncologists who were active current members of New Zealand Clinical Oncology
Group (NZCOG).
The questionnaire consisted of six case scenarios of
varying stages of NSCLC summarised in Table 1. The information provided in the
case scenarios included a brief clinical summary, which included patient
symptoms, performance status (ECOG), exercise tolerance, existing
co-morbidities. Also, histology, simple spirometry, relevant blood test results,
and results of staging CT and mediastinoscopy where appropriate (ie, enough to
determine performance status and stage of tumour). The surveyed physician was
asked to indicate which treatment they would offer. Results were then forwarded
to the principal investigator (TC).
Table 1. Case summaries
Treatment options for each scenario included surgery
alone, surgery plus adjuvant treatment (chemo or radiotherapy) radical
radiotherapy (RT), combined chemo/radiotherapy (chemo/RT), chemotherapy alone,
best supportive care (BSC; defined as palliative treatment which could include
analgesics, steroids and palliative radiotherapy but not including the other
treatment options), and other.
A follow-up email of the questionnaire was sent to
individuals who did not respond, and subsequent attempts to contact them were
made by phone.
ResultsCompleted questionnaires were
received from 31 (81%) respiratory physicians, 15 (71%) medical oncologists, and
8 (30%) radiation oncologists. Forty-four (77%) of those respondents reported
having immediate access to thoracic surgery in their town/city, 51 (89%) have
radiotherapy, and 100% have access to chemotherapy
Survey results are summarised in Table 2.
Table 2. Favoured treatment options by specialist for
each case scenario (expressed as percentage)
*Radical radiotherapy.
†Resection plus adjuvant chemotherapy or radiotherapy. ‡Chemotherapy alone. §Combined chemotherapy and radiotherapy. IIBest supportive care. DiscussionThis study examines what treatment
is likely to be offered to patients (with different stages of NSCLC) by New
Zealand lung cancer specialists. It demonstrates there is considerable
heterogeneity in treatment preferences between different specialties, and
suggests that treatment for lung cancer may depend significantly on the type of
specialist the patient is referred to. It also suggests that respiratory
physicians tend to be the most conservative in their treatment preferences.
Although the actual treatment given to patients with lung
cancer can only be determined by reviewing case notes of treated cases of NSCLC,
this data is consistent with other studies.6
Access to treatment, particularly chemotherapy, does not appear to be a barrier
to delivery of treatment.
There is consistent agreement among practitioners (and
current guidelines) that surgery is the most appropriate treatment for early
stage disease. However, treatment of locally advanced and extensive disease with
good performance status appears to be more controversial. The preferred
treatment for locally advanced disease (Case 3 and Case 4) by respiratory
physicians was BSC, and only a small percentage considered active therapy for
these cases compared with medical oncologists. Medical oncologists were much
more likely to offer radical RT or combined/RT than respiratory physicians. In
advanced disease, only 8% of respiratory physicians would consider the use of
chemotherapy compared with 67% medical oncologists.
These results are similar to those found in a survey of UK
lung cancer specialists (predominantly respiratory physicians) where only 9%
would offer combined chemo/RT for locally advanced disease, and only 11% would
consider chemotherapy for advanced metastatic
disease.7
Gregor et al showed that diagnosis of lung cancer in
Scotland was made by respiratory physicians 66% of the time, and 75% of those
patients were usually managed or reviewed by respiratory physicians during the
first 6 months after diagnosis. However, only 8.2% of these patients received
chemotherapy, and 10.4% radical RT for localised
disease.8
In contrast, Muers et al reported that respiratory
physicians were more likely to refer for RT and chemotherapy than general
physicians who often look after non-small cell cancer patients in UK District
General Hospitals.9
If this situation is similar to New Zealand, then lung
cancer patients in smaller New Zealand provincial centres may be less likely to
receive active treatment than patients in larger centres where there is easier
access to thoracic surgery or oncology services.
Why is there so little agreement between these groups over
the role of non-surgical treatments of lung cancer? In particular, what is the
role of chemotherapy alone or in combination with RT? Are respiratory physicians
too nihilistic, or is this a reflection of medical oncologists over enthusiasm
with chemotherapy?
Firstly, the reluctance to offer chemotherapy to lung cancer
patients may be due to the commonly held belief that lung cancer is a (self
inflicted) disease of the elderly, which precludes them from chemotherapy. This
is supported by Brown et al who found that chemotherapy was utilised in 21% of
patients with NSCLC (aged under 65 years) compared with 0% in those over 65
years—thus suggesting age is an important factor in determining whether
chemotherapy is adopted.10 However, performance
status rather than age has been shown to be the major factor in determining
benefit from chemotherapy.11
Secondly, the failure by respiratory physicians to offer
chemotherapy may reflect scepticism about the benefits of chemotherapy among
physicians. In a UK survey, 60% of cancer specialists reported that they would
seek an overall improvement in survival of greater than 10% before considering
chemotherapy. This is an unrealistic expectation in view of published
data.8
The recently written ACN Guidelines recommend chemotherapy
as an appropriate treatment option for good performance (ECOG <2) lung cancer
patients with advanced disease. Radical radiotherapy is also recommended for
good performance status patients with inoperable locally advanced disease as is
combined chemo/radiotherapy.5 The low numbers
of respiratory physicians prepared to offer chemotherapy in New Zealand does not
appear to reflect inability to access chemotherapy.
The use of chemotherapy alone or in combination with
radiotherapy in NSCLC is supported by a large meta-analysis of 52 published
randomised controlled trials (RCTs) published in
1995.12 This analysis showed that the addition
of modern chemotherapy (defined as platinum based chemotherapy) significantly
improved survival for NSCLC, particularly the advanced-disease group where
chemotherapy treatment resulted in a modest but highly statistically significant
improvement in survival when compared with BSC alone. This has been confirmed in
recent randomised trials.12,13
Mean survival was however only increased by 6–8 weeks.
Chemotherapy has also been shown to be cost-effective in palliation of symptoms
and improving quality of life.14 The addition
of chemotherapy to radical radiotherapy also showed a modest but significant
improvement in survival in patients with locally advanced NSCLC. This has been
confirmed in RCTs although improvement is traded off against increased
toxicity.12,15
Although it is difficult to show major improvements in
5-year survival in these studies, countries that have adopted more aggressive
treatment policies seem to have greater overall survival rates. Based on the
best currently available figures, New Zealand has a dismal survival
rate—5%. This is comparable to Scotland, a country with similar clinical
practice to New Zealand, but contrasts with Australia's 11% and 14% in some
European countries.6,8,16,17
The study design can be criticised on the basis that cases
are hypothetical rather than actual cases (and there are obviously many factors
other than stage of tumour and clinical fitness which determine treatment). This
does not, however, detract from the finding that there appear to be significant
differences in treatment preferences between lung cancer specialist groups, and
(at worst) demonstrates concerning nihilism—particularly among respiratory
physicians.
A possible bias in this study is that it is more likely to
over-estimate the aggressiveness of treatment by physicians—as it does not
take any account other factors such as patient
preferences.18
Major variation shown in the attitudes to treatment of lung
cancer between specialty groups is likely to be multifactorial; however, it
highlights a need for standardisation of treatment—this is best achieved
through multidisciplinary clinics and implementation of guidelines.
There are many guidelines currently available; however, the
most appropriate for New Zealand are the Australian Cancer Network guidelines,
endorsed by the TSANZ and available in the
Internet.5 These guidelines provide summaries
of relevant RCTs and meta-analyses, as well as treatment statements that can be
used to guide treatment decisions. However, it is likely that adherence to these
guidelines will have implications in terms of increasing oncology services
costs. These economic implications will have to be weighed up against the
public’s expectations if we wish to improve outcomes for patients with
lung cancer.
Author information:
Tim Christmas, Respiratory Physician, Green Lane Hospital, Auckland; Michael
Findlay, Professor of Oncology, University of Auckland, Auckland.
Acknowledgements: We
thank Colin Wong (for formatting the questionnaire and emailing it to TSANZ
members) as well as Associate Professor John Kolbe and Dr Tanya McWilliams for
their helpful advice in manuscript preparation.
Correspondence: Dr
Tim Christmas, Green Lane Hospital, Green Lane West, Auckland. Fax: (09) 631
0712; email: TimC@adhb.govt.nz
References:
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