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John Zalcberg



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    FP02 - Health Services Research/Health Economics (ID 120)

    • Event: WCLC 2020
    • Type: Posters (Featured)
    • Track: Health Services Research/Health Economics
    • Presentations: 1
    • Moderators:
    • Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
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      FP02.05 - Value-Based Healthcare Study (VBHC) for Treating Lung Cancer in Victoria, Australia (ID 3782)

      00:00 - 00:00  |  Author(s): John Zalcberg

      • Abstract
      • Slides

      Introduction

      Value in healthcare can be defined as the degree of quality of care received as a function of the cost of delivering care. Value of care has never been formally measured for lung cancer. To our knowledge, there are no publications defining value in lung cancer from either the point of view of consumer, health service, government or funder. Any definition of value must however incorporate quality, service and cost.

      figure 1 vbhc.png

      Lung cancer is the leading cancer burden in Australia, and the leading cause of cancer-related death. Population health efforts target prevention, screening and detection of early, potentially curable lung cancer, delivery of curative and palliative treatments to optimally manage lung cancer. Recently, targeted biologic and immunotherapeutics have demonstrated substantial benefit but also attach substantial economic implications. With each initiative to improve lung cancer outcomes, there is an urgent need to understand the cost, quality and value returned to patients and funding bodies to inform patients, providers and governments. This study was designed to address this universal problem.

      Methods

      A cohort of 200 people diagnosed with non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) over 4 months from 1 November 2020 will be identified at Lung Multidisciplinary meetings (MDMs) at 5 participating Victorian health services and data collected from the Victorian Lung Cancer Registry:

      1.Quality indicators and clinical outcome measures stratified by stage, including proportions i) referred for smoking cessation; ii) receiving MDM discussion prior to definitive treatment; iii) stage I-III receiving treatment with curative intent (surgery/radical radiotherapy, multimodality treatment); iv) NSCLC receiving molecular testing, v) early palliative care referral, vi) emergency admissions, vii) screened for supportive care needs, viii) 1 year overall survival, ix) hospital readmissions for treatment related complications.

      2.Patient Reported Measures collected at multiple timepoints including EORTC QLQ-C30, QLQ-LC29, QLU-C10D, a patient experience survey at diagnosis and at 12 months incorporating value-based priorities.

      3.Consumer Focus Groupscto explore patient perceptions of quality and value with regard to care; utility and acceptability of study methods and consumer value rankings for treatments and outcomes by stage of disease.

      4.Health service costs for diagnostic procedures and treatments to establish cost and cost variation for stage specific treatment, based on optimal treatment guidelines.

      Conclusion

      A Value scorecard will be derived establishing a baseline VBHC model for lung cancer treatment in Victoria, aiming to identify stage-specific interventions to increase relative value for lung cancer care.

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    MA04 - Health Policy and the Real World (ID 217)

    • Event: WCLC 2020
    • Type: Mini Oral
    • Track: Health Services Research/Health Economics
    • Presentations: 1
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      MA04.09 - Impacts of Multidisciplinary Meeting Presentation: Drivers and Outcomes from a Population Registry Retrospective Cohort Study (ID 2037)

      16:45 - 17:45  |  Author(s): John Zalcberg

      • Abstract
      • Presentation
      • Slides

      Introduction

      Evaluation of lung cancer is complex and discussion in a multidisciplinary context is recommended. The benefits of Multidisciplinary Meeting (MDM) presentation have been demonstrated in case series however its population-based impacts demand evaluation. We evaluated the drivers, likelihood of receipt of treatment and survival impacts of MDM presentation in the population-based Victorian Lung Cancer Registry (VLCR).

      Methods

      Patients in the VLCR (Non-Small Cell and Small Cell Lung Cancer), prospectively captured following diagnosis between 2011 to 2020, were categorised as MDM-presented or non-presented based on medical record documentation. The association of patient, disease and hospital characteristics with likelihood of MDM discussion was determined via logistic regression. Median survival was compared using Kaplan-Meier method and mortality risk was assessed using cox-regression modelling. Propensity score matching, landmark analysis (excluding deaths within 6 weeks of diagnosis), and sensitivity analyses with interaction terms were performed to evaluate these results.

      Results

      Of 9,628 patients, 5,900 (61.3%) were discussed at MDM, 3,728 (38.7%) were not. Patients in the non-MDM group were more likely to be ≥80 years old (p<0.001), with poorer performance status (p<0.001) and advanced stage at diagnosis (43.4% vs. 34.0% clinical stage IV, p<0.001). Non-MDM patients were less likely to undergo surgery (22.1 vs 31.2%, p<0.001), chemotherapy (44.7 vs 49.0%, p<0.001) or radiotherapy (34.2 vs 44.4%, p<0.001). They were less likely to be referred from a sub-acute vs acute facility (p<0.001), private vs public hospital (p<0.001) or inner regional vs major city hospital (p<0.001).

      Patients were less likely to be presented at MDM if clinical stage IV (OR 0.34, p<0.001), referred from an inner regional (OR 0.52, p<0.001), subacute facility (OR 0.57, p<0.001) or private hospital (OR 0.18, p<0.001)

      MDM-presented patients overall had better median survival (1.70 vs 0.75 years, p<0.001) and a 25% reduced overall mortality risk (HR 0.75 (0.71 to 0.80), p<0.001), MDM presentation was strongly associated with receipt of treatment (surgery 0.30 (0.27-0.33), p<0.001; chemotherapy 0.55 (0.52-0.59) p<0.001; radiotherapy 0.88 (0.83-0.93) <0.001). This protective effect was confirmed on propensity score analyses and consistent across hospital types and locations. Factors associated with a higher mortality were age >80 years (HR 1.63, p>0.001), male gender (HR 1.17, p<0.001), ECOG 4 (HR 6.04, p<0.001), clinical stage IV (HR 6.55, p<0.001) and referral from subacute hospital (HR 1.60, p<0.001).

      Non-documentation of ECOG status, tumour histopathology and clinical stage were associated with significantly lower likelihoods of MDM discussion (OR 0.34, 0.35, 0.29 respectively, p<0.001) and higher mortality (HR 1.51, 1.34 and 2.90 respectively, p<0.001).

      Conclusion

      In this population-based lung cancer registry, being male, ≥80 years of age, of high ECOG, advanced clinical stage and poor documentation of clinical characteristics were associated with lower likelihood of MDM discussion, lower likelihood of treatment and a higher mortality risk. MDM presentation conferred survival benefit in lung cancer across all hospital types and locations. This study supports the use of MDM presentation as a crucial component of lung cancer management and identifies patient subgroups where discrepancies in care exist and urgent action is needed.

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    OA05 - Value and Quality in Lung Cancer (ID 216)

    • Event: WCLC 2020
    • Type: Oral
    • Track: Health Services Research/Health Economics
    • Presentations: 1
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      OA05.06 - Lessons Learned from the Victorian Lung Cancer Registry: Opportunities for Quality Improvement in Lung Cancer Management and Outcomes (ID 1455)

      15:30 - 16:30  |  Author(s): John Zalcberg

      • Abstract
      • Presentation
      • Slides

      Introduction

      The development of clinical quality registries (CQR) is a strategy promoted by the Australian Commission on Safety and Quality in Health Care to systematically monitor the quality of health care within specific clinical domains by routinely collecting, analysing and reporting health-related information. Strategic objectives include confirmation of safety, improvement in quality and value of patient-centred health care, improving compliance with evidence-based guidelines and to provide evidence-based support for the development of future guidelines and standards.

      Lung cancer is a disease that meets key criteria for registry development in that evidence based, well executed sequences of care improve patient outcomes, the consequences of poor quality care provide serious risk to patients and the condition is associated with a high cost to the health system.

      Objectives: This report describes the development, preliminary results and lessons learned from the development of the VLCR.

      cqr.png

      Methods

      Design: This is an observational, narrative description of a CQR for monitoring, describing and driving quality improvement in the management of lung cancer in Victoria, Australia. Setting: The VLCR recruits from 19 Victorian health services, 44 hospitals, including metropolitan, regional, public and private hospitals. A Danish surgical resection registry cohort was evaluated to provide international survival benchmarking. Participants: All patients with newly diagnosed primary lung cancer (NSCLC and SCLC) at institutions participating in the VLCR. This report describes 8,180 registrations between 2011-2018. Intervention: Implementation of a CQR for population-based capture and reporting of risk adjusted, bench-marked quality indicators in lung cancer management.

      Results

      Between 2011-2018 a total of 8,180 patients (NSCLC 6,548, SCLC 891) with newly diagnosed lung cancer were registered, mean age 70 years, 57% male. Supportive care screening (28%), palliative care referral (stage IV) within 8 weeks of diagnosis (38%), provision of adjuvant chemotherapy following stage II resection (39%), proportion of lung cancer resections with ³5 lymph nodes resected (59%) and Multi-Disciplinary Meeting presentation (69%) provide opportunities for quality improvement. Reassurance is provided by high levels of pathological diagnostic confirmation (91%), low levels of aggressive end of life chemotherapy (5%) and 90 mortality following resection (3%).

      Conclusion

      The implementation of a population-based registry with >80% population coverage is feasible. Reporting demonstrates significant variation from clinical practice guidelines, variation in practice between metropolitan and regional as well as public and private hospitals and identifies clear actionable targets for quality improvement. The VLCR identifies important quality improvement opportunities and provides a model for a national lung cancer CQR.

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    P09 - Health Services Research/Health Economics - Real World Outcomes (ID 121)

    • Event: WCLC 2020
    • Type: Posters
    • Track: Health Services Research/Health Economics
    • Presentations: 1
    • Moderators:
    • Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
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      P09.05 - Surveillance, Patterns of Recurrence and Survivorship in Early Stage Lung Cancer Patients Following Curative Intent Treatment (ID 3771)

      00:00 - 00:00  |  Author(s): John Zalcberg

      • Abstract
      • Slides

      Introduction

      Background: Early stage Non-Small Cell Lung Cancer (NSCLC) may be treated with surgery and or radiotherapy with curative intent and expectation of prolonged survival. This population however remains at high risk of both disease recurrence and the development of new primary lung cancers. Follow up of such patients for the purpose of detection of recurrence or new cancer may enable further (re)treatment and benefit survival. Despite recommendation for follow up there is little evidence or consensus regarding follow up modality, interval or duration. This study was conducted to observe patterns of surveillance of early stage NSCLC patients and impacts of detection of recurrence/new disease, retreatment and survival.

      Methods

      We retrospectively analysed surveillance undertaken in Stage I-IIIA NSCLC patients treated with curative intent surgery and or radiotherapy between 2011-2017 at a university hospital in Melbourne, Australia. Patient demographics, tumour characteristics, stage and treatment factors were accessed from the Victorian Lung Cancer Registry. Documented follow up was recorded when documentary evidence detailed a systematic follow up for > 6 months. Follow up protocols were categorised according to imaging modality, interval, guideline concordance and were followed until new primary, disease recurrence or death. Statistical analyses included descriptive statistics, chi2, multivariate linear and logistic regression analysis and Kaplan Meier survival analysis (Stata).

      Results

      Two hundred consecutive patients were included female (44.5%), 60-79 years of age (70.5%), adenocarcinoma (65.5%), treated by surgery only (57.5%), radiotherapy only (25%) or combination treatments (17.5%) and documentary record of follow up beyond 6 months was evident for just 27.5%. Recurrence was detected in 68 (34%), new primary disease in 10 (5%) with median follow up 22.5 months. Recurrence risk was increased for patients >80 years (p=0.03), higher stage IIIA (p<0.001), radiotherapy only (p<0.001), combined therapy (p<0.001), and reduced for those with documented follow up protocol (p<0.01) see Table. Documentation of follow up beyond 6 months was associated with reduced risk of mortality HR 0.3 (95% CI 0.16-0.53) p<0.001. Survival was increased in those with documented follow up (p=0.005), new primary disease (p=0.001), asymptomatic recurrence (p=0.003), and radical retreatment of recurrent/new disease (p<0.001).

      FactorLevelRecurrenceNew primary diseaseNo recurrence or new diseaseRecurrenceNew Primary
      N6810122Chi2 pSHR (95% CI)p-valueSHR (95% CI)
      Age at diagnosis (years)<6012 (17.6%)1 (10.0%)9 (7.4%)0.1211
      60-6920 (29.4%)6 (60.0%)44 (36.1%)0.53 (0.27-1.03)0.061.88 (0.21-16.54)
      70-7927 (39.7%)2 (20.0%)42 (34.4%)0.66 (0.35-1.24)0.190.58 (0.05-6.45)
      ≥809 (13.2%)1 (10.0%)27 (22.1%)0.41 (0.18-0.92)0.030.58 (0.04-9.62)
      SexFemale28 (41.2%)6 (60.0%)55 (45.1%)0.5211
      Male40 (58.8%)4 (40.0%)67 (54.9%)1.12 (0.69-1.82)0.650.53 (0.15-1.87)
      Smoking statusNever smoked7 (10.4%)0 (0.0%)21 (18.4%)11
      Ex-smoker41 (61.2%)3 (30.0%)71 (62.3%)1.77 (0.80-3.91)0.163.8e+06 ( 1.2e+06- 1.3e+07)
      Current smoker19 (28.4%)7 (70.0%)22 (19.3%)1.92 (0.82-4.49)0.132.0e+07 ( 8.4e+06- 4.7e+07)
      Pack Years median (IQR)45.0 (35.0, 60.0)48.5 (37.5, 65.0)42.5 (30.0, 50.0)
      ECOG0-157 (95%)6 (86%)80 (88%)0.3111
      2+3 (5%)1 (14%)11 (12%)0.62 (0.18-2.08)0.441.80 (0.21-15.37)
      Stage of NSCLCI25 (36.8%)5 (50.0%)86 (70.5%)<0.00111
      II18 (26.5%)3 (30.0%)20 (16.4%)2.23 (1.21-4.11)0.011.92 (0.46-8.09)
      IIIA25 (36.8%)2 (20.0%)16 (13.1%)3.43 (1.98-5.94)<0.0011.43 (0.29-7.09)
      Histology of tumourAdenocarcinoma41 (66.1%)5 (55.6%)85 (73.9%)11
      Squamous cell carcinoma20 (32.3%)4 (44.4%)28 (24.3%)1.25 (0.73-2.12)0.411.96 (0.54-7.13)
      Large cell carcinoma1 (1.6%)0 (0.0%)2 (1.7%)1.12 (0.18-6.85)0.90.00 (0.00-0.00)
      Primary treatmentRadiotherapy28 (41.2%)4 (40.0%)20 (16.4%)<0.00111
      Surgery40 (58.8%)6 (60.0%)102 (83.6%)0.42 (0.26-0.68)<0.0010.40 (0.12-1.37)
      Surgical procedureLobectomy29 (43.9%)5 (50.0%)73 (68.9%)11
      Pnemonectomy5 (7.6%)0 (0.0%)5 (4.7%)1.87 (0.80-4.39)0.150.00 (0.00-0.00)
      Segmenectomy or wedge resection4 (6.1%)1 (10.0%)8 (7.5%)1.53 (0.58-4.02)0.392.83 (0.33-24.01)
      Primary treatmentSurgery Only22 (32.4%)5 (50.0%)88 (72.1%)11
      Monoradiotherapy26 (38.2%)4 (40.0%)20 (16.4%)3.45 (1.95-6.09)<0.0012.55 (0.68-9.53)
      Adjuvant therapies20 (29.4%)1 (10.0%)14 (11.5%)4.31 (2.35-7.90)<0.0011.05 (0.12-9.03)
      Protocol strictNo protocol beyond 6 months specified53 (77.9%)7 (70.0%)83 (68.0%)11
      Protocol beyond 6 months specified15 (22.1%)3 (30.0%)39 (32.0%)0.49 (0.28-0.85)0.010.67 (0.19-2.36)
      Any prior MDMNo prior MDM22 (35.5%)3 (42.9%)54 (46.6%)0.36
      Any prior MDM40 (64.5%)4 (57.1%)62 (53.4%)
      Type of eventRecurrence Loco26 (38%)0 (0%)
      Regional metastatic42 (62%)0 (0%)
      Metachronous disease0 (0%)10 (100%)
      Recurrence detectionSymptom presentation32 (%)2 (%)0 (%)
      Surveillance imaging (routine)34 (%)8 (%)0 (%)
      Incidental finding (trauma scan or neurosurgery scan)2 (%)0 (%)0 (%)
      Re treatment typeSABR/SBRT27 (49%)7 (78%)
      Surgical resection6 (11%)1 (11%)
      Chemoradiotherapy4 (7%)0 (0%)
      Chemotherapy4 (7%)0 (0%)
      Immunotherapy5 (9%)0 (0%)
      Immunotherapy + Radiotherapy1 (2%)0 (0%)
      Radiosurgery7 (13%)1 (11%)
      Radiofrequency ablation1 (2%)0 (0%)
      Treatment intentRadical intent12 (18%)6 (60%)
      Palliative intent43 (65%)3 (30%)
      Palliative care referral7 (11%)1 (10%)
      Best supportive care4 (6%)0 (0%)

      Conclusion

      In this cohort there was poor documentation and implementation of systematic follow up surveillance strategies following curative intent treatment. A systematic follow up strategy following curative intent treatment of early stage disease may increase asymptomatic detection, increase retreatment and prolong survival. There is an important need to further confirm utilisation of follow up and consequent benefits.

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    P11 - Health Services Research/Health Economics - Quality of Life (ID 123)

    • Event: WCLC 2020
    • Type: Posters
    • Track: Health Services Research/Health Economics
    • Presentations: 1
    • Moderators:
    • Coordinates: 1/28/2021, 00:00 - 00:00, ePoster Hall
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      P11.01 - Exploring Patient Reported Quality of Life in Lung Cancer Patients: A Qualitative Study (ID 3780)

      00:00 - 00:00  |  Author(s): John Zalcberg

      • Abstract
      • Slides

      Introduction

      In Australia lung cancer is the leading cause of cancer-related death, and represents a major disease burden substantially impacting on quality of life (QoL). Patient-reported outcome measures (PROMs) have been identified as effective methods of evaluating patient QoL. Existing lung cancer specific PROMs however, have uncertain utility and minimal patient involvement in their design and development. This qualitative study aimed to evaluate the patient perspective of existing PROMs and to explore their appropriateness for population-based descriptions of lung cancer-related QoL.

      Prior presentations: Australian Lung Cancer Conference 2020

      Methods

      A descriptive qualitative study was conducted consisting of semi-structured interviews with 14 patients recruited from the Victorian Lung Cancer Registry (VLCR) and Alfred Hospital via purposive sampling. Interviews first explored the factors most important to lung cancer patients QoL and secondly, patient’s perspectives on the appropriateness of existing PROMs. Thematic analysis was used to develop themes and content analysis was conducted to determine PROM acceptability.

      Results

      Five novel themes were identified by patients as having important impacts on QoL:

      1. Personal attitude towards the disease is important for coping

      2. Independence is valued

      3. Relationships with family and friends are important

      4. Relationships with treating team are meaningful

      5. Limited personal and public awareness of lung cancer

      These patient-identified impacts are poorly covered in existing lung cancer-specific PROMs. Patients welcomed and appreciated the opportunity to complete PROMs. However, they identified problems with existing PROMs relevance, tone and formatting.

      Conclusion

      Existing lung cancer PROMs poorly reflect the five themes identified in this study as most important to lung cancer patients QoL. This study reaffirms the need to review existing PROMs to ensure currency and construct validity. Future PROM development must engage patient generated themes and evolve to reflect the changing management and therapeutic landscape.

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