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Elizabeth Belcher

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    PL02 - Presidential Symposium including Top 7 Rated Abstracts (ID 89)

    • Event: WCLC 2019
    • Type: Plenary Session
    • Track:
    • Presentations: 1
    • Now Available
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      PL02.06 - In Hospital Clinical Efficacy, Safety and Oncologic Outcomes from VIOLET: A UK Multi-Centre RCT of VATS Versus Open Lobectomy for Lung Cancer (Now Available) (ID 1257)

      08:00 - 10:15  |  Author(s): Elizabeth Belcher

      • Abstract
      • Presentation
      • Slides


      VATS is currently the most popular form of access for lung cancer resection in the UK. However, there is limited comparative information from high quality randomised controlled trials and no information on early oncologic outcomes for quality assurance for a minimal access approach. VIOLET is the largest randomised trial conducted to date to compare clinical efficacy, safety and oncologic outcomes of VATS versus open surgery for lung cancer.


      VIOLET is a parallel group randomised trial conducted across 9 UK thoracic surgery centres. Participants with known or suspected primary lung cancer were randomised in a 1:1 ratio to VATS (one to four ports) or open lobectomy. Randomisation was stratified by surgeon. Patients within clinical stage cT1-3, N0-1 and M0 using TNM 8 with disease suitable for VATS or open surgery were eligible to join the trial. We report on early outcomes in the period from randomisation to hospital discharge after surgery.


      From Jul 2015 to Feb 2019, 2,109 patients were screened to randomise 503 participants to VATS (n=247) or open (n=256) lobectomy. The mean age (SD) was 69 (8.8) years and 249 (49.5%) were male. Baseline clinical T category was cT1 333 (67.3%), cT2 125 (25.2%), cT3 37 (7.5%) with cN0 466 (94%) and cN1 30 (6%). Lobectomy was undertaken in 221 (89.5%) patients randomised to VATS and 232 (90.6%) patients randomised to open surgery. The in-hospital mortality rate was 1.4% (7/502) and the conversion rate from VATS to open was 5.7% (14/246) with the main reasons listed as pleural adhesions (n=4) and bleeding (n=4).

      There were no differences in R0 resection; which was 98.8% (218/223) in the VATS group and 97.4% (228/234) in the open group; P=0.839 or in nodal upstaging from cN0/1 to pN2 disease which was observed in 6.2% (15/244) of the VATS group and 4.8% (12/252) of the open group; P=0.503.

      The median (visual analogue) pain score was 4 (interquartile range, IQR 2 to 5) in both groups on day one with 3 (1 to 5) in the VATS group and 4 (2 to 5) in the open group on day two.

      A significant reduction of overall in-hospital complications was observed in patients receiving VATS at 32.8% (81/247) compared to open 44.3% (113/255) surgery; P=0.008 without any difference in serious adverse events between the two groups, which was 8.1% (20/247) for VATS and 7.8% (20/255) for open surgery; P=0.897.

      Patients randomised to VATS had a shorter median (IQR) length of stay of 4 (3 to 7) versus 5 (3 to 8) days compared to patients randomised to open surgery, P=0.008.


      In early stage lung cancer, VATS lobectomy is associated with significantly lower in-hospital complications and shorter length of stay compared to open lobectomy. This was achieved without any compromise to early oncologic outcomes (pathologic complete resection and upstaging of mediastinal lymph nodes) nor any difference in serious adverse events in the early post-operative period.

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    PL03 - Relevant Aspects of Lung Cancer Management (ID 90)

    • Event: WCLC 2019
    • Type: Plenary Session
    • Track: Advanced NSCLC
    • Presentations: 1
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      PL03.01 - Establishing a Nurse Led Follow-Up Service for Patients With Resected Early Stage Lung Cancer (ID 3591)

      09:15 - 10:45  |  Author(s): Elizabeth Belcher

      • Abstract
      • Slides


      Specialist nursing roles within thoracic surgical centres in the UK are unique to each centre and develop to meet the needs of the local service. In Oxford we identified that the follow-up of patients after resection of early stage lung cancer could be improved and would be suitable for management by a specialist nurse.

      Prior to the introduction of the specialist nursing role patients were reviewed by the junior doctors working in the clinic, offering limited continuity of care and often presenting challenges in following-up abnormal results.

      Following the successful development of a nurse led early follow-up clinic1 we instituted a nurse led CT follow-up program for patients on long term surgical follow-up after resection of lung cancer.

      Guidelines recommend that patients are followed up after lung cancer resection2, how this is provided is at the discretion of each individual service and varies in the imaging modality and frequency of interventions3.

      Following review of international guidelines3 and in conjunction with the lung cancer multidisciplinary team we devised a CT follow-up program:

      • CT chest, abdomen and pelvis every 6 months for 2 years after surgery followed by an appointment to be given the results.

      • CT chest, abdomen and pelvis at 3, 4 and 5 years after surgery followed by an appointment to be given the results.

      All patients undergoing lung cancer resection, where adjuvant treatment is either not indicated or declined, are entered into the follow-up program (see diagram). The programme is co-ordinated and CT results triaged by the specialist nurse.

      Following successful introduction of nurse led follow-up in the face to face clinics we found that feedback from patients on our CT follow-up programme indicated they find two trips to the hospital burdensome and they frequently requested results of surveillance imaging over the telephone. In addition, limited capacity in the thoracic surgery clinics led to patients waiting a long time for a face to face appointment to be informed of their imaging results. To address these issues, we developed a model of nurse led telephone follow-up after surveillance imaging. The criteria for telephone appointments are:

      • CT results show no abnormality or minor changes requiring a repeat CT chest in 3 months

      • Patients can communicate adequately over the telephone:

      – Reasonable command of English

      – Able to hear telephone conversations

      – No cognitive impairment

      Patients who do not fit these criteria are given an appointment in a face to face clinic.

      The specialist nurse reviews all the CT follow-up results and allocates patients to the most appropriate clinic, ensuring patients are reviewed in the appropriate setting for their needs and those who need to be see urgently are prioritised. Abnormalities and concerns detected during the follow-up programme are presented at the multidisciplinary meetings by the specialist nurse, who takes responsibility for the actions requested by the team.

      In the period January 2013 to December 2017 there were 546 specialist nurse face to face clinic appointments in 189 clinics for 285 patients with primary lung cancer. The telephone clinic commenced in April 2017 and in the first twelve months there were 254 patient appointments in 51 telephone clinics

      The presence of the specialist nurse within the follow-up clinics has increased clinic capacity and efficiency, reduced waiting time for appointments, promotes junior medical training and ensures continuity of care for the patients. The patients appreciate the continuity of care and improved access to specialist nursing support. The role is appreciated and respected by the multidisciplinary team.

      The telephone clinic has been very well received by patients. They appreciate the opportunity to receive their results without having to make a second journey to the hospital (traffic and parking in Oxford is notoriously bad). They continue to receive continuity of care as the nurse who calls them is the same nurse who they saw at their first follow-up appointment in the face to face clinic. The introduction of the telephone clinic has increased overall clinic capacity and reduced the waiting time for appointments within the face to face clinics.

      In order to effectively carry out this role the specialist nurse requires advanced practice skills1. Qualifications in history taking and clinical examination, advanced communication skills and non-medical prescribing are all held by the specialist nurse carrying out this role. In order to request CT imaging IRMER training was undertaken and an appropriate requesting protocol approved by the hospital clinical governance committee.

      In conclusion we have demonstrated that nurse-led follow-up after lung cancer resection is an effective way of ensuring high quality care for this group of patients. The specialist nurse is able to provide continuity of care and ensure that all imaging results are followed up appropriately. The role requires the support of the multidisciplinary lung cancer team to work effectively across all elements of the patient pathway.

      1. Mitchell J. Relevance of a specialised nurse in thoracic surgery. J Thorac Dis 2018:S2583-S2587.

      2. National Institute for Health and Clinical Excellence (NICE). CG121 - Lung cancer. London: NICE; 2011 Available at Accessed 2.3.12.

      3. Belcher E, Mitchell J, Benamore R, et al. Does the manner of follow-up after lung cancer surgery improve survival? In: Modi P, ed. Perspectives in Cardiothoracic Surgery. London: Society for Cardiothoracic Surgery in Great Britian and Ireland; 2018;3:247-258.

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