How can we improve five-year lung cancer survival?

For the last ten years, lung cancer has consistently been the UK’s biggest cancer killer.^1,2In 2014 alone, it was the cause of almost 35,900 deaths,³ which is more than breast⁴ and bowel cancers combined.⁵

Over recent years, in response to the growing need to address cancer outcomes as a whole, the four UK nations have undertaken significant efforts to help support improvements in long-term survival. According to the latest data, five-year lung cancer survival has now effectively been doubled over the last decade in England,⁶ with improvements also seen in Scotland,⁷ Wales⁸ and Northern Ireland.⁹

However, whilst in-roads have been made, there is still a great deal more to be done. Due to a wide variety of factors, not least growing financial pressures within the NHS and resource strain, lung cancer is not prioritised as it should be compared with other common cancer types and the quality of patient outcomes can vary considerably across the UK.¹⁰ In addition, while long-term survival has improved, rates still fall significantly behind other comparable developed countries.¹¹

Survival ambition

Recently a new series of recommendations on how to tackle poor long-term survival rates were published by the UK Lung Cancer Coalition (UKLCC). The group has called for a re-doubling of effort by both governments and the lung cancer community – and has set a survival target of raising five-year lung cancer survival to 25% by 2025 across the UK.¹²

To achieve this ambition and put together a cohesive ten-year strategy for improvement, the UKLCC sought to explore the current perceived barriers to long-term lung cancer survival, not only by reviewing the most recent clinical evidence, but also by gauging the opinions of both the lung cancer community and patients. This involved undertaking a survey of 148 UK healthcare professionals from across the multi-disciplinary team (MDT) and a poll of over 1,000 UK GPs. Alongside this, the UKLCC also surveyed 102 patients and carers on their experiences of care and attitudes towards survival. Respondents were asked for their specific views on a range of topics which included prevention, screening, awareness, referral and diagnosis, and treatment and variation.

Prevention

Without doubt, tobacco use is the most important preventable cause of lung cancer in the UK. While there are a proportion of patients who have never smoked who have developed lung cancer, the majority of cases are preventable, with 86% of cases caused by smoking alone.¹³ However, whilst also reducing the number of cases, the risk of total mortality and rate of recurrence of lung cancer is also substantially lower in smokers who manage to quit smoking following diagnosis of early stage lung cancer or small cell lung cancer.¹⁴ Whilst rates of smoking-related lung cancers reflect historical smoking trends, more needs to be done to support local services, such as those for smoking cessation, to reduce future incidence and to improve the survival of patients who are newly diagnosed.¹³

The UKLCC research demonstrated that health care professionals believe that a reduction in smoking rates is the second most important factor, after early diagnosis, for improving five-year survival rates in lung cancer.

Screening

We know from international examples that screening is also an effective way to increase early identification. For example, a study in the United States showed a 20% reduction in lung cancer specific mortality using low spiral CT screening tools.¹⁵ Positive steps are also being taken in the UK, with local initiatives such as UKLS¹⁶ and ECLS¹⁷ which assess screening techniques and the benefits of introducing screening across the country.

According to the UKLCC’s research, 52% of health professionals believe that a national screening programme for lung cancer should be introduced. It is therefore encouraging that these findings show that clinicians agree with the growing evidence base that screening is an effective way to enable early diagnosis and have the desire for such an initiative implemented as a means of improving survival. However, a decision is unlikely to be made regarding the introduction of screening until the UK national screening committee makes a recommendation based on the results of the NELSON trial.

Awareness

Lack of awareness among patients of the signs and symptoms of lung cancer, and when to see their doctor, continues to be a core issue for lung cancer survival. The UKLCC research reveals that 40% of patients surveyed did not know that chest pain, weight loss and tiredness are possible symptoms of lung cancer – and only 27% of patients saw their doctor because they recognised that they were experiencing signs and symptoms of the disease. Approximately, one third of GPs (32%) and health care professionals (35%) identified public awareness campaigns as the most important factor for improving early-stage diagnosis. Evidently, we need to invest more in these campaigns to ensure that they reach more patients, at the right time.

Referral and diagnosis

Detecting cancer early and initiating treatment as quickly as possible following a diagnosis of lung cancer are imperative for improving survival rates. The NHS in England has set a waiting time standard of two weeks between urgent referral and hospital appointment to test for lung cancer and has also committed to the standard that treatment starts no more than 31 days after a treatment plan is agreed¹⁸ €” with similar standards set across the UK. We also know from the latest statistics that across the UK, cancer waiting times vary and the targets which are set by nations are often missed.^19,20,21 The UKLCC survey showed 36% of patients surveyed waited over one month for a definitive diagnosis after an initial suspicion of lung cancer was made by their doctor – and 17% waited over two months.

Treatment and variation

More needs to be done to ensure that there is quick and equitable access to diagnosis and treatment across the UK and to ensure that MDTs, which are a crucial part of delivering this, have sufficient capacity and resource to do so. A standardised lung cancer pathway within each UK nation was identified by healthcare professionals as a way of improving survival rates and this may further assist in combatting local variation rates. If health professionals believe they can do better for all patients by implementing new standards of care such as these, the benefits of doing so must be assessed and implemented by policymakers and health service leaders. The UKLCC research revealed that 61% of healthcare professionals believe a standardised lung cancer pathway would improve lung cancer survival rates and 52% believe that a lack of capacity and resource presents one of the greatest challenges to their MDT for improving lung cancer survival rates.

Together with this, tackling variation was identified as one of the key priorities within the report by the Independent Cancer Taskforce. Given the importance of timely, appropriate, treatment as early as possible in the lung cancer pathway, it is essential that efforts are taken to tackle this barrier. The UKLCC research shows that 84% of secondary/tertiary health professionals believe regional inequalities in health and care have an impact on lung cancer survival rates. For example, in England the percentage of lung cancer patients receiving anticancer treatment varied by hospital trust from 31.6% to 83.2% in 2014.¹⁰

Key recommendations

Following the insights from these surveys, the UKLCC developed a comprehensive set of 20 UK-wide principles which are phased for immediate, medium, and long term delivery by 2025. These include:-

The prioritisation by UK governments of the improvement of lung cancer survival in any future plans or strategies relevant to the delivery of broader health, respiratory and/or cancer services.
The establishment of a UK-wide taskforce to achieve ‘25 by 25′ in line with European best practice.
Public health bodies across the UK commiting to the adoption of annual public awareness campaigns, funded nationally, which are focused on raising awareness of the signs and symptoms of lung cancer.
Ring-fencing budgets for smoking cessation services and improve public health initiatives/ programmes and prevention services, which focus on reduction in smoking rates, aligning with current national guidance and initiatives
The launch of pilot data programmes to assess and address the significant variation in five-year lung cancer survival across the UK
The introduction of UK-wide screening for all at-risk groups, informed by the results of the NELSON lung cancer screening study, which are due in 2017
The 62-day waiting time target to start cancer treatment has been breached consistently for the past two years: The UKLCC is calling for a comprehensive audit to improve cancer waiting times.

It is imperative that such actions are taken to maintain this positive momentum in lung cancer. While we are all too aware of the competing pressures currently facing health organisations across the UK, it would be wrong to respond to these pressures simply by curtailing the ambition of improving five-year lung cancer survival by 25% by 2025. By setting a ten-year vision for lung cancer survival, underpinned by tailored initiatives for each UK nation, we believe that these recommendations provide a transformative and attainable plan for lung cancer outcomes so that, year on year, patients diagnosed with lung cancer are living longer.

Acknowledgements: The UKLCC is the UK’s largest multi-interest group in lung cancer and was established in 2005 to help bring lung cancer out of the political, clinical and media shadow and improve one-year and five-year survival rates – which has been achieved. Its membership includes leading lung cancer experts, senior NHS professionals, charities and healthcare companies and is the largest multi-interest group in lung cancer of its kind.

The UKLCC is keen to work with all interested organisations and bodies to improve the quality and outcomes of lung cancer treatment and care. For a copy of our latest report, and more information about our work and our partners, please visit our website or contact our secretariat. www.uklcc.org.uk

Mr Richard Steyn, Chair of the UKLCC, and Consultant Thoracic Surgeon and Associate Medical Director, Surgery, Heart of England NHS Foundation Trust.

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