- Email: [email protected]
155 Should we be more aggressive in treating patients with small cell lung cancer?
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Poster abstracts of the 14th Annual British Thoracic Oncology Group Conference 2016 / Lung Cancer 91, Suppl. 1 (2016) S1–S71
Small Cell Lung Cancer 153
Small cell lung cancer – an email alert system to reduce time to first treatment
O.J. Nicholas, C.L. Mallett, R.D. Frazer, K. Rowley. Oncology, South West Wales Cancer Centre, Singleton Hospital, Swansea, United Kingdom Introduction: National Institute of Clinical Excellence (NICE) Lung Cancer Quality Standard QS17 (2012) states that patients with small cell lung cancer (SCLC) should be treated within 2 weeks of diagnosis. A departmental audit showed that this target was not being met in 45.4% of patients treated with chemotherapy. We introduced an email alert system for new diagnoses of SCLC to streamline the treatment pathway and minimise delays. Methods: Baseline retrospective audit: January 2014–December 2014. An electronic database search was conducted to identify all SCLC patients. Data were collected on date of histological diagnosis, time to first oncology appointment and date of first treatment (either chemotherapy or radiotherapy). Time from histological diagnosis to first treatment was calculated. Following introduction of a new email alert system, it was prospectively re-audited for the 3 month period from May 2015 to August 2015. Results: 11/34 (32.3%) patients did not receive first treatment within 14 days, 10/22 (45.4%) patients who received chemotherapy as first treatment did not receive first treatment within 14 days. The average time to first treatment was 12.6 days. Action Plan: 1. An analysis of cause of delays was carried out. This showed significant delays from time of histological report to MDT discussion and subsequent clinic. 2. Introduction of a streamlined pathway for patients with new diagnosis of SCLC, including an email alert system from pathology. 3. Disseminate findings to MDT and continuous re-audit. Re-audit results: 8/9 patients (89%) received first treatment within 14 days of diagnosis, a 65.6% reduction from previous audit figures. The average time to first treatment was 10.4 days.
Conclusion: Streamlining the referral, diagnostic and treatment pathway for SCLC can significantly shorten the time from initial diagnosis to first treatment for patients with this malignancy. An email alert system for new diagnosis requiring urgent treatment is a novel method of reducing time to first treatment. Disclosure: All authors have declared no conflicts of interest. 154
Chemotherapy treatment rates and survival in poor performance status small cell lung cancer at a district general hospital
M. Reinius, Y. Rimmer, T. Pulimood, D.M. Patterson. Oncology, West Suffolk Hospital, Bury St Edmunds, United Kingdom Introduction: The management of poor ECOG performance status
(PS) poses a frequent therapeutic dilemma in lung cancer, but small cell lung cancers are inherently more chemo-sensitive. The National Lung Cancer Audit recommends that at least 70% of small cell patients should receive chemotherapy. We present our experience of managing poor PS small cell patients. Methods: Prospective survival data was collected for all patients presenting with poor PS (2–4) SCLC to the West Suffolk NHS Foundation Trust between November 2011 and May 2015. Overall survival rates were estimated using the Kaplan-Meier method, comparing chemotherapy versus best supportive care and also by baseline PS. Results: Of 29 patients presenting with poor PS SCLC (median age 68, range 47–83), 20 (69%) were treated with chemotherapy (55% carboplatin, 30% carboplatin/etoposide and 5% each for CAV, Cisplatin, and gemcitabine/carboplatin). Compared to the largely even spread of baseline ECOG PS (2: 34%, 3: 38%, 4: 28%), the majority of all patients treated were PS2–3 (2: 40%, 3: 50%, 4: 10%) with respective treatment rates of 80%, 91% and 25%. Whilst median survival was 43 days overall, comparison between chemotherapy and best supportive care groups yielded median survival of 123 and 8 days respectively. When categorised by PS, corresponding figures were 126 (PS2), 128 (PS3) and 5 days (PS4). Notably, a 55 year old PS3 patient with rapidly progressing T4N3M1b SCLC with bone marrow infiltration and severe thrombocytopaenia received a regimen of once weekly cisplatin, and survived for 156 days following normalisation of their platelet count and significant initial radiological tumour shrinkage. Conclusion: Our experience has demonstrated encouraging prolongation of survival associated with chemotherapy in this patient group, particularly those presenting with PS 2–3. Single agent platinum is well tolerated and appears to be a useful option. In particular, weekly Cisplatin may warrant further investigation. Disclosure: All authors have declared no conflicts of interest. 155
Should we be more aggressive in treating patients with small cell lung cancer?
J. Lim 1 , G. Skailes 2 , D. Fyfe 1 . 1 Medical Oncology, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; 2 Clinical Oncology, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom Introduction: Survival in small cell lung cancer (SCLC) remains dismal. In England, median survival for limited stage (LS) and extensive stage (ES) SCLC is estimated at 1 year and 4 months respectively. In 2011, the National Lung Cancer Audit reported that only 69% received systemic treatment. At UHMBT, we have consistently treated >90% of our patients. Whether higher treatment rate results in better survival remains debateable. Methods: A retrospective cohort study of all SCLC patients discussed at the multidisciplinary meeting and treated at UHMBT from 2013 to 2014. Primary outcome was survival. Kaplan-Meier survival analysis was performed (SPSS v.22). Results: A total of 41 patients were included in this study: 56.1% male, mean age 68.7±8.2 years, 90.3% with WHO Performance Status 0 to 2, and 65.9% with ES SCLC. In our cohort, 90.2% received active treatment, with 75.7% receiving 3 to 6 cycles of first line chemotherapy. Additionally, 29.7% received consolidation radiotherapy (36.4% concurrent) and 40.5% had prophylactic cranial irradiation. 62.2% had a good initial response to treatment. 10 patients (27.0%) progressed on treatment. Subsequently, 4 patients went on maintenance STOMP trial. A total of 6 patients later received second line chemotherapy for metastatic relapse. Neutropenia was the most common reason for chemotherapy delay and/or dose reduction, reported in 15 patients (40.5%). Median overall survival in those who received treatment was 9.6 (2.6; 17.8) months. Median survival in those with LS SCLC and ES SCLC were 13.4 (9.6; 13.4) and 8.2 (2.0; 14.5) months respectively (p=0.07). Estimated survival at 1, 3, 6 and 12 months was 91.9%, 73.0%, 64.9% and 45.4% respectively.
Poster abstracts of the 14th Annual British Thoracic Oncology Group Conference 2016 / Lung Cancer 91, Suppl. 1 (2016) S1–S71
157
S57
Comparison of outcomes for early small cell lung cancer (SCLC) treated with surgery versus concurrent chemo radiation (CTRT)
V. Foy 1 , A. Cree 2 , M. Nawaz 3 , C. Faivre-Finn 1 , N. Bayman 2 , H. Sheikh 2 , P. Taylor 4 , F. Blackhall 4 , M.T. Jones 3 , P. Krysiak 3 , R. Shar 3 , Y. Summers 4 . 1 Christie Nhs Foundation Trust, Christie NHS Foundation Trust, Manchester, United Kingdom; 2 Clinical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom; 3 Thoracic Surgery, University Hospital of South Manchester, Manchester, United Kingdom; 4 Medical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom
Figure 1. Kaplan-Meier survival estimates for patients with LS versus ES SCLC who received chemotherapy (n=37).
Conclusion: The survival for this centre which treats a high proportion of SCLC patients appears to be higher than pooled national data estimated median survival of 7.6 months. This would support national endeavour to increase the proportion of patients treated with chemotherapy. Disclosure: All authors have declared no conflicts of interest. 156
Outcomes after surgery for small cell lung cancer in the West of Scotland
C. Hanna, V. Maclaren, C. Featherstone. Clinical Oncology, West of Scotland Cancer Centre, Glasgow, United Kingdom Introduction: There is increasing interest in the role of surgery for resection of early stage small cell lung cancer (SCLC) tumours but there is lack of consensus on the treatments that should be offered post-operatively. This audit will increase understanding about the treatment of and outcomes for patients with SCLC who have undergone surgery in the West of Scotland recently. Methods: A retrospective search for patients who had surgical specimens revealing small cell lung cancer between 1/1/2009 and 1/3/2015 was carried out. Electronic records including radiology, chemotherapy prescriptions, clinical letters and pathology reports were analysed. Results: Thirty patients underwent surgery and had a diagnosis of SCLC. Further assessment was carried out for the 23 patients who underwent lobectomy or wedge resection and nodal sampling. These included 10 males and 13 females with a median age of 71. 15 of these patients did not have a histological diagnosis prior to surgery, 7 were known to have SCLC and 1 had a diagnosis of large cell neuroendocrine lung cancer. Surgical staging revealed that the majority of patients had T1 (11/23) and N0 disease (13/23) and 19/23 pathology specimens showed clear margins. Most patients (15/23) had adjuvant chemotherapy and most often with carboplatin and etoposide (10/15). Surprisingly only one patient was treated with consolidation thoracic radiotherapy and three had prophylactic cranial irradiation. Disease relapse occurred in 9/23 patients. Two of these patients went on to have radiotherapy, three had both chemotherapy and radiotherapy and four had best supportive care only. Follow up ranged from 8 months to 5.8 years. Median overall survival was 23.3 months and median progression free survival was 20.8 months. Conclusion: We report on our experience of treating small cell lung cancer with surgery. This was mostly because pathology was unknown prior to surgery. Adjuvant radiotherapy and chemotherapy were used less frequently than expected. Disclosure: All authors have declared no conflicts of interest.
Introduction: SCLC accounts for 15% of lung cancers and is characterised by rapid growth and development of metastasis. The role of surgery in early stage SCLC is controversial and there is paucity of outcome data with modern CTRT combinations in this group of patients. In this study we compare outcomes for early stage SCLC treated with surgery versus concurrent CTRT. Methods: Patients who underwent surgery for early stage (T1–2 N0– 1, T3 N0) SCLC during 2005–2015, at University Hospital of South Manchester, were identified from pathology reports. Data was collected from patient notes regarding demographics, toxicities and outcomes. Patients receiving concurrent CTRT for early SCLC, over the same time period, were identified from the electronic records at The Christie. Results: At present 56% (10/18) of the surgical cohort are alive compared with 73% (11/15) of the concurrent chemoradiation group. Of the 8/18 that died in the surgical cohort, 3 relapsed with brain metastasis, 4 with extra cranial systemic disease and 1 of cardiac failure. There were no cases of local recurrence. Of this group 7/8 patients had completed planned chemotherapy, 7/8 had R0 resections and 1/8 had R1 resection, subsequently completing thoracic radiotherapy. 4/8 received PCI. In the concurrent CTRT group, 4/15 died, 1 relapsed with brain metastasis, 2 with extra cranial systemic disease and 1 died of non-small cell lung cancer; 2/4 completed planned chemotherapy, all completed planned thoracic radiotherapy and 1/4 received PCI.
Demographics Number Average age (range) Male/female Average number of co-morbidities Performance status (PS) 0 PS 1 PS 2 PS not recorded Staging T1 N0 T2 N0 T1 N1 T2 N1 T3 N0 Not recorded Treatment summary Number who completed planned 4 cycles of chemotherapy (includes dose reductions and change in chemotherapy regimen) Percentage that received thoracic radiotherapy after R1 resection (n=4) Number that received PCI Survival Median follow up (years) 1 Year survival 2 year Survival
Surgery
Concurrent CTRT
18 68 (47–77) 7/11 (39%/61%) 2 2 (11%) 5 (28%) 1 (6%) 10 (55%)
15 61 (48–75) 9/6 (60%/40%) 0.66 6 (40%) 8 (53%) 0 1 (7%)
8 (44%) 5 (28%) 2 (11%) 1 (6%) 1 (6%) 1 (6%)
3 (20%) 5 (33%) 2 (13%) 5 (33%) 0 0
16/18 (89%)
13/15 (87%)
3/4 (75%) 12/18 (67%)
N/A 12/15 (80%)
4.8 94% 77%
3.4 85% 70%
Conclusion: The numbers of patients presenting with early stage SCLC are small and the role of surgery remains a subject of debate, as there is no randomised clinical trial evidence to guide treatment decisions. Our data demonstrates similar outcomes for patients treated
Poster abstracts of the 14th Annual British Thoracic Oncology Group Conference 2016 / Lung Cancer 91, Suppl. 1 (2016) S1–S71
Small Cell Lung Cancer 153
Small cell lung cancer – an email alert system to reduce time to first treatment
O.J. Nicholas, C.L. Mallett, R.D. Frazer, K. Rowley. Oncology, South West Wales Cancer Centre, Singleton Hospital, Swansea, United Kingdom Introduction: National Institute of Clinical Excellence (NICE) Lung Cancer Quality Standard QS17 (2012) states that patients with small cell lung cancer (SCLC) should be treated within 2 weeks of diagnosis. A departmental audit showed that this target was not being met in 45.4% of patients treated with chemotherapy. We introduced an email alert system for new diagnoses of SCLC to streamline the treatment pathway and minimise delays. Methods: Baseline retrospective audit: January 2014–December 2014. An electronic database search was conducted to identify all SCLC patients. Data were collected on date of histological diagnosis, time to first oncology appointment and date of first treatment (either chemotherapy or radiotherapy). Time from histological diagnosis to first treatment was calculated. Following introduction of a new email alert system, it was prospectively re-audited for the 3 month period from May 2015 to August 2015. Results: 11/34 (32.3%) patients did not receive first treatment within 14 days, 10/22 (45.4%) patients who received chemotherapy as first treatment did not receive first treatment within 14 days. The average time to first treatment was 12.6 days. Action Plan: 1. An analysis of cause of delays was carried out. This showed significant delays from time of histological report to MDT discussion and subsequent clinic. 2. Introduction of a streamlined pathway for patients with new diagnosis of SCLC, including an email alert system from pathology. 3. Disseminate findings to MDT and continuous re-audit. Re-audit results: 8/9 patients (89%) received first treatment within 14 days of diagnosis, a 65.6% reduction from previous audit figures. The average time to first treatment was 10.4 days.
Conclusion: Streamlining the referral, diagnostic and treatment pathway for SCLC can significantly shorten the time from initial diagnosis to first treatment for patients with this malignancy. An email alert system for new diagnosis requiring urgent treatment is a novel method of reducing time to first treatment. Disclosure: All authors have declared no conflicts of interest. 154
Chemotherapy treatment rates and survival in poor performance status small cell lung cancer at a district general hospital
M. Reinius, Y. Rimmer, T. Pulimood, D.M. Patterson. Oncology, West Suffolk Hospital, Bury St Edmunds, United Kingdom Introduction: The management of poor ECOG performance status
(PS) poses a frequent therapeutic dilemma in lung cancer, but small cell lung cancers are inherently more chemo-sensitive. The National Lung Cancer Audit recommends that at least 70% of small cell patients should receive chemotherapy. We present our experience of managing poor PS small cell patients. Methods: Prospective survival data was collected for all patients presenting with poor PS (2–4) SCLC to the West Suffolk NHS Foundation Trust between November 2011 and May 2015. Overall survival rates were estimated using the Kaplan-Meier method, comparing chemotherapy versus best supportive care and also by baseline PS. Results: Of 29 patients presenting with poor PS SCLC (median age 68, range 47–83), 20 (69%) were treated with chemotherapy (55% carboplatin, 30% carboplatin/etoposide and 5% each for CAV, Cisplatin, and gemcitabine/carboplatin). Compared to the largely even spread of baseline ECOG PS (2: 34%, 3: 38%, 4: 28%), the majority of all patients treated were PS2–3 (2: 40%, 3: 50%, 4: 10%) with respective treatment rates of 80%, 91% and 25%. Whilst median survival was 43 days overall, comparison between chemotherapy and best supportive care groups yielded median survival of 123 and 8 days respectively. When categorised by PS, corresponding figures were 126 (PS2), 128 (PS3) and 5 days (PS4). Notably, a 55 year old PS3 patient with rapidly progressing T4N3M1b SCLC with bone marrow infiltration and severe thrombocytopaenia received a regimen of once weekly cisplatin, and survived for 156 days following normalisation of their platelet count and significant initial radiological tumour shrinkage. Conclusion: Our experience has demonstrated encouraging prolongation of survival associated with chemotherapy in this patient group, particularly those presenting with PS 2–3. Single agent platinum is well tolerated and appears to be a useful option. In particular, weekly Cisplatin may warrant further investigation. Disclosure: All authors have declared no conflicts of interest. 155
Should we be more aggressive in treating patients with small cell lung cancer?
J. Lim 1 , G. Skailes 2 , D. Fyfe 1 . 1 Medical Oncology, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom; 2 Clinical Oncology, University Hospitals of Morecambe Bay NHS Foundation Trust, Lancaster, United Kingdom Introduction: Survival in small cell lung cancer (SCLC) remains dismal. In England, median survival for limited stage (LS) and extensive stage (ES) SCLC is estimated at 1 year and 4 months respectively. In 2011, the National Lung Cancer Audit reported that only 69% received systemic treatment. At UHMBT, we have consistently treated >90% of our patients. Whether higher treatment rate results in better survival remains debateable. Methods: A retrospective cohort study of all SCLC patients discussed at the multidisciplinary meeting and treated at UHMBT from 2013 to 2014. Primary outcome was survival. Kaplan-Meier survival analysis was performed (SPSS v.22). Results: A total of 41 patients were included in this study: 56.1% male, mean age 68.7±8.2 years, 90.3% with WHO Performance Status 0 to 2, and 65.9% with ES SCLC. In our cohort, 90.2% received active treatment, with 75.7% receiving 3 to 6 cycles of first line chemotherapy. Additionally, 29.7% received consolidation radiotherapy (36.4% concurrent) and 40.5% had prophylactic cranial irradiation. 62.2% had a good initial response to treatment. 10 patients (27.0%) progressed on treatment. Subsequently, 4 patients went on maintenance STOMP trial. A total of 6 patients later received second line chemotherapy for metastatic relapse. Neutropenia was the most common reason for chemotherapy delay and/or dose reduction, reported in 15 patients (40.5%). Median overall survival in those who received treatment was 9.6 (2.6; 17.8) months. Median survival in those with LS SCLC and ES SCLC were 13.4 (9.6; 13.4) and 8.2 (2.0; 14.5) months respectively (p=0.07). Estimated survival at 1, 3, 6 and 12 months was 91.9%, 73.0%, 64.9% and 45.4% respectively.
Poster abstracts of the 14th Annual British Thoracic Oncology Group Conference 2016 / Lung Cancer 91, Suppl. 1 (2016) S1–S71
157
S57
Comparison of outcomes for early small cell lung cancer (SCLC) treated with surgery versus concurrent chemo radiation (CTRT)
V. Foy 1 , A. Cree 2 , M. Nawaz 3 , C. Faivre-Finn 1 , N. Bayman 2 , H. Sheikh 2 , P. Taylor 4 , F. Blackhall 4 , M.T. Jones 3 , P. Krysiak 3 , R. Shar 3 , Y. Summers 4 . 1 Christie Nhs Foundation Trust, Christie NHS Foundation Trust, Manchester, United Kingdom; 2 Clinical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom; 3 Thoracic Surgery, University Hospital of South Manchester, Manchester, United Kingdom; 4 Medical Oncology, Christie NHS Foundation Trust, Manchester, United Kingdom
Figure 1. Kaplan-Meier survival estimates for patients with LS versus ES SCLC who received chemotherapy (n=37).
Conclusion: The survival for this centre which treats a high proportion of SCLC patients appears to be higher than pooled national data estimated median survival of 7.6 months. This would support national endeavour to increase the proportion of patients treated with chemotherapy. Disclosure: All authors have declared no conflicts of interest. 156
Outcomes after surgery for small cell lung cancer in the West of Scotland
C. Hanna, V. Maclaren, C. Featherstone. Clinical Oncology, West of Scotland Cancer Centre, Glasgow, United Kingdom Introduction: There is increasing interest in the role of surgery for resection of early stage small cell lung cancer (SCLC) tumours but there is lack of consensus on the treatments that should be offered post-operatively. This audit will increase understanding about the treatment of and outcomes for patients with SCLC who have undergone surgery in the West of Scotland recently. Methods: A retrospective search for patients who had surgical specimens revealing small cell lung cancer between 1/1/2009 and 1/3/2015 was carried out. Electronic records including radiology, chemotherapy prescriptions, clinical letters and pathology reports were analysed. Results: Thirty patients underwent surgery and had a diagnosis of SCLC. Further assessment was carried out for the 23 patients who underwent lobectomy or wedge resection and nodal sampling. These included 10 males and 13 females with a median age of 71. 15 of these patients did not have a histological diagnosis prior to surgery, 7 were known to have SCLC and 1 had a diagnosis of large cell neuroendocrine lung cancer. Surgical staging revealed that the majority of patients had T1 (11/23) and N0 disease (13/23) and 19/23 pathology specimens showed clear margins. Most patients (15/23) had adjuvant chemotherapy and most often with carboplatin and etoposide (10/15). Surprisingly only one patient was treated with consolidation thoracic radiotherapy and three had prophylactic cranial irradiation. Disease relapse occurred in 9/23 patients. Two of these patients went on to have radiotherapy, three had both chemotherapy and radiotherapy and four had best supportive care only. Follow up ranged from 8 months to 5.8 years. Median overall survival was 23.3 months and median progression free survival was 20.8 months. Conclusion: We report on our experience of treating small cell lung cancer with surgery. This was mostly because pathology was unknown prior to surgery. Adjuvant radiotherapy and chemotherapy were used less frequently than expected. Disclosure: All authors have declared no conflicts of interest.
Introduction: SCLC accounts for 15% of lung cancers and is characterised by rapid growth and development of metastasis. The role of surgery in early stage SCLC is controversial and there is paucity of outcome data with modern CTRT combinations in this group of patients. In this study we compare outcomes for early stage SCLC treated with surgery versus concurrent CTRT. Methods: Patients who underwent surgery for early stage (T1–2 N0– 1, T3 N0) SCLC during 2005–2015, at University Hospital of South Manchester, were identified from pathology reports. Data was collected from patient notes regarding demographics, toxicities and outcomes. Patients receiving concurrent CTRT for early SCLC, over the same time period, were identified from the electronic records at The Christie. Results: At present 56% (10/18) of the surgical cohort are alive compared with 73% (11/15) of the concurrent chemoradiation group. Of the 8/18 that died in the surgical cohort, 3 relapsed with brain metastasis, 4 with extra cranial systemic disease and 1 of cardiac failure. There were no cases of local recurrence. Of this group 7/8 patients had completed planned chemotherapy, 7/8 had R0 resections and 1/8 had R1 resection, subsequently completing thoracic radiotherapy. 4/8 received PCI. In the concurrent CTRT group, 4/15 died, 1 relapsed with brain metastasis, 2 with extra cranial systemic disease and 1 died of non-small cell lung cancer; 2/4 completed planned chemotherapy, all completed planned thoracic radiotherapy and 1/4 received PCI.
Demographics Number Average age (range) Male/female Average number of co-morbidities Performance status (PS) 0 PS 1 PS 2 PS not recorded Staging T1 N0 T2 N0 T1 N1 T2 N1 T3 N0 Not recorded Treatment summary Number who completed planned 4 cycles of chemotherapy (includes dose reductions and change in chemotherapy regimen) Percentage that received thoracic radiotherapy after R1 resection (n=4) Number that received PCI Survival Median follow up (years) 1 Year survival 2 year Survival
Surgery
Concurrent CTRT
18 68 (47–77) 7/11 (39%/61%) 2 2 (11%) 5 (28%) 1 (6%) 10 (55%)
15 61 (48–75) 9/6 (60%/40%) 0.66 6 (40%) 8 (53%) 0 1 (7%)
8 (44%) 5 (28%) 2 (11%) 1 (6%) 1 (6%) 1 (6%)
3 (20%) 5 (33%) 2 (13%) 5 (33%) 0 0
16/18 (89%)
13/15 (87%)
3/4 (75%) 12/18 (67%)
N/A 12/15 (80%)
4.8 94% 77%
3.4 85% 70%
Conclusion: The numbers of patients presenting with early stage SCLC are small and the role of surgery remains a subject of debate, as there is no randomised clinical trial evidence to guide treatment decisions. Our data demonstrates similar outcomes for patients treated