The Cancer Committee chose for their in-depth site to do a review of lung cancer. The years 1994 to 1998 were compared with 1999 to 2003. Small cell lung cancer for this time period was reviewed as well as non-small cell lung cancer.
From 1994 to 1998, 172 cases of non-small cell lung cancer were diagnosed and or received part or their entire first course of treatment at Lawrence General Hospital. Of these cases, 98 were males and 74 were female. For this same time period, 31 cases of small cell lung cancer were diagnosed and or received part or their entire first course of treatment at Lawrence General Hospital, with 17 males and 14 females comprising the 31 cases. Thus, the incidence of lung cancer for Lawrence General Hospital was a total of 203 cases for 1994 to 1998, 115 males (57%) and 88 females (43%).
There were 149 cases of non-small cell lung cancer that were diagnosed and or received part or their entire first course of treatment at Lawrence General Hospital from 1999 to 2003. The 149 cases included 81 males and 68 females. The incidence of small cell lung cancer for 1999 to 2003 was 30 cases; 14 males and 16 females. The total incidence of lung cancer for Lawrence General Hospital for the years 1999 to 2003 was 179. Ninety-five (53%) of these were male patients and 84 (47%) were female patients.
The age breakdown for these cases is detailed in the table below.
| 30-39 | 40-49 | 50-59 | 60-69 | 70-79 | 80-89 | 90+ | |
| 1994-1998 NSC Lung Ca | 3 | 14 | 28 | 47 | 55 | 24 | 1 |
| 1994-1998 Small Cell Lung Ca | 1 | 4 | 7 | 7 | 10 | 2 | 0 |
| 1999-2003 NSC Lung Ca | 1 | 9 | 16 | 43 | 55 | 23 | 2 |
| 1999-2003 Small Cell Lung Ca | 0 | 3 | 2 | 6 | 14 | 5 | 0 |
| Totals | 5 | 30 | 53 | 103 | 134 | 54 | 3 |
The majority of the patients (35%) were diagnosed between the ages of 70-79. This is similar to the age at diagnosis reported by the National Cancer Data Base (NCDB) for 2001 cases, with the majority of their non-small cell lung cancer cases (35%) and small cell lung cancer cases (34%) being diagnosed in patients between the ages of 70 and 79.
The population of Lawrence, Massachusetts is diverse but this diversity is not demonstrated in the lung cancer patients in this study. For cases of non-small cell lung cancer for 1994 to 1998, 3 of 172 (2%) were black and 16 of 172 (9%) were of Hispanic origin. Patients with small cell lung cancer for this same time period were 97% Caucasian and 1 or 31 cases (3%) were American Indian. The ethnicity of this group was 26 (84%) non-Hispanic and 5 Hispanic (16%). For the time period 1999 to 2003, for non-small cell lung cancer patients, the breakdown was 139 (93%) whites, 4 (3%) blacks, 3 (2%) Asians and 3 (2%) ³Others². Ethnicity statistics were 131 (88%) non Hispanic and 18 (12%) Hispanic. The breakdown for the small cell lung cancer patients was 28 non Hispanic (94%) and 2 (6) Hispanic patients and 29 (97%) white patients and 1 (3%) black patient of small cell lung cancer. The difficulty of coding race and ethnicity is well known and these statistics corroborate this assumption since the population of Lawrence, MA according to the MCDC Demographic Profile from the 2000 census for Lawrence, Massachusetts was 40% white, 6% black, 76% Hispanic and 46% ³other² race. However, the increased emphasis on accuracy of reporting race and ethnicity from the Massachusetts State Cancer Registry has provided better data for the later years with the increase in the reporting of Hispanics in the ethnicity breakdown.
One cannot study lung cancer without reviewing the influence of tobacco on the patient population. Small Cell Lung cancer is considered a direct result of tobacco use and the registry data supports this information. For all the years in this study, there were a total of 61 patients, only one of which never used tobacco products. Unfortunately, for the years 1994 to 1998 there were 17/31 (55%) cases of unknown tobacco use versus the years 1999 to 2003 when this number is 2/30 (7%). Again, this reflects the increased accuracy of the reporting of this data item partly based on the emphasis of the importance of this information taught to registrars from the staff at the Massachusetts Cancer Registry. From 1999 to 2003, 16 (53%) patients currently smoked cigarettes at the time of their diagnosis and 11 (37%) patients had used tobacco products in the past.
For those patients diagnosed during 1999-2003 with non-small cell lung cancer, the data shows 60/149 (40%) patients smoked at the time of their diagnosis, 73 (49%) previously used tobacco products, 9 (6%) never smoked and 7 (5%) were coded as smoking history unknown. For similar patients during the years 1994-1998 6/172 (3%)patients were coded as having never smoked, 59 (34%) patients currently smoked at the time of their diagnosis, 32 (19%) were coded as having used tobacco products previous to their diagnosis and 75 (44%) were coded as smoking status unknown. The improvement in data collection for smoking history is also evident in the non-small cell lung cancer patients for the years 1999-2003 as was seen above in the small cell lung cancer patients, with 5% smoking history unknown as compared to 44% smoking status unknown for the years 1994-1998.
Stage at diagnosis is often used to determine the efficacy of screening efforts in a community and the availability of health care for the residents. Although, screening programs for lung cancer has not proven efficacious, it is still important to review the stage at presentation of these patients. The table below details the staging information.
| AJCC 0 | AJCC 1 | AJCC 2 | AJCC 3 | AJCC 4 | UNKNOWN | TOTAL | |
| 1994-1998 NSC Lung Ca | 0 | 38(22%) | 6(3%) | 64(37%) | 51(30%) | 13(8%) | 172 |
| 1994-1998 Small Cell Lung Ca | 0 | 0 | 0 | 11(35%) | 16(52%) | 4(13%) | 31 |
| 1999-2003 NSC Lung Ca | 0 | 24(16%) | 7(5%) | 42(28%) | 53(36%) | 23(15%) | 149 |
| 1999-2003 Small Cell Lung Ca | 0 | 1(3%) | 1(3%) | 10(34%) | 14(47%) | 4(13%) | 30 |
| Totals | 0 | 63(16%) | 14(4%) | 127(33%) | 134(35%) | 44(12%) | 382 |
From a data quality standpoint, the disturbing trend is the increase in the unstaged cases. The American College of Surgeonsı Commission on Cancer does not want any site to have over 10% of cases unstaged per year. The information by year is not broken down but for the combined years 1994-1998 there were only 8% of the cases of non-small cell lung cancer unstaged but that percentage increases to 13% for the data from the years 1999-2003. This is an area where our quality control efforts will need to be targeted for the future.
As is often the case, lung cancer patients do not present to their physicians very often in early curable stages. For the total population of this study, only 20% presented in early stages, while 68% presented in stages 3 and 4. This is more a reflection of the insidious nature of the disease rather than a commentary on the state of health care in Lawrence. It would be interesting to break down the stage 3 cases to stage 3A and Stage 3B, consideration can be given to examining that information at a future date.
The NCDB data for 2001 lung cancers shows similar staging breakdowns with non-small cell lung cancers presenting in late stages (62% stage 3 and 4 combined) and small cell lung cancer with a similar staging presentation as well (81% stage 3 and 4 combined).
Treatment analysis is a key component of any study done on registry data. The following tables provide treatment information by stage for the small cell lung cancer cases and then the non-small cell lung cancer cases. These two different histologies of lung cancer are treated very differently. Small cell lung cancer tends to be treated as a systemic disease regardless of the stage at presentation and surgery is hardly ever indicated. However, the treatment options are more complex for the treatment of non-small cell lung caner patients and this is demonstrated in the treatment information in the tables below.
| AJCC 1 | AJCC 2 | AJCC 3 | AJCC 4 | UNKNOWN | |
| 1994-1998 NSC Lung Ca | 0 pts | 0 pts |
4 no Rx
3 chemo 1 rad 3 rad/chemo |
2 no Rx
8 chemo 2 rad 4 rad/chemo |
3 chemo
1 rad chemo |
| 1999-2003 NSC Lung Ca | 1 rad/chemo | 1 chemo |
1 no Rx
4 chemo 1 rad 4 rad/chemo |
5 no Rx
2 chemo 6 rad/chemo 1 imm/chemo |
2 no Rx
1 chemo 1 rad/chemo |
As would be expected for this disease, the majority of patients diagnosed and treated in 1994-1998 received chemotherapy (42% for 1994-1998 & 27% for 1999-2003) but for the time period 1999-2003 the majority of patients received combined chemotherapy and radiation therapy (33% for 1999-2003 & 23% for 1994-1998). Interesting to note is the increase in those patients receiving no treatment; 16% were not treated in 1994-1998 but 27% were not treated in 1999-2003. Many of these patients suffer from other co morbid diseases due to their smoking history and are not candidates for any treatment.
The NCDB data for small cell lung cancer corroborates the treatment patterns for Lawrence General Hospital. In 2001, NCDB hospitals reported 39% of patients received combined radiation and chemotherapy and 31% received chemotherapy alone.
| AJCC 1 | AJCC 2 | AJCC 3 | AJCC 4 | UNKNOWN | |
| 1994-1998 NSC Lung Ca |
4 no Rx
0 chemo 4 rad 0 rad/chemo 29 surgery 1 surg/rad |
0 no Rx
0 chemo 0 rad 0 rad/chemo 4 surgery 1 surg/rad 1 surg & rad/chemo |
19 no Rx
6 chemo 16 rad 10 rad/chemo 3 surgery 2 surg/chemo 4 surg/rad 3 surg & rad/chemo 1 rad/immuno |
24 no Rx
5 chemo 17 rad 3 rad/chemo 0 surgery 1 surg & chemo 1 surg/rad |
8 no Rx
1 chemo 1 rad 1 rad/chemo 2 surg |
| 1999-2003 NSC Lung Ca |
3 no Rx
0 chemo 4 rad 2 rad/chemo 14 surgery 1 surg & rad/chemo |
1 no Rx
0 chemo 1 rad 1 rad/chemo 2 surgery 1 surg/chemo 1 surg & rad/chemo |
9 no Rx
6 chemo 7 rad 16 rad/chemo 1 surgery 1 surg/chemo 2 surg & rad/chemo |
23 no Rx
11 chemo 10 rad 8 rad chemo 1 surgery |
15 no Rx
2 chemo 0 rad 2 rad/chemo 2 surgery 2 surg & chemo/rad |
For Stage 1 cases, the most common type of treatment was surgery alone for the Lawrence General Hospital data. The 2001 data from NCDB indicates the majority of patients with stage 1 non-small cell lung cancer also receiving surgery alone (67%). This benchmark NCDB data demonstrates treatment for stage 1 non-small cell lung cancer is the same as national standards.
With only 13 Stage 2 cases for all years, it is not possible to make a valid comparison with national standards. The majority of Lawrence General cases received surgery with or without adjuvant treatment. This is the same for the 2001 NCDB data with 38% received surgery alone and 25% received surgery and adjuvant treatment.
For Stage 3 Lawrence General cases, an increase in patients treated with combination chemotherapy and radiation therapy is noted in the 1999-2003 cases over the 1994-1998 cases, which were predominantly treated with radiation alone. The NCDB 2001 data demonstrates this same treatment practice with 34% receiving combined radiation and chemotherapy, 16% receiving radiation therapy alone and 6% receiving surgery, radiation therapy and chemotherapy. Again, patients treated at Lawrence General Hospital can be assured they will receive the standard of care for their cancer.
The majority of the Stage 4 cases for Lawrence General Hospital for 1999-2003 did not receive treatment (43%) but 19% received radiation therapy, 21% received chemotherapy alone and 15% receiving radiation therapy combined with chemotherapy. The NCDB data noted 24% receiving no treatment, 25% receiving radiation therapy alone, 25% receiving radiation therapy combined with chemotherapy and 18% receiving chemotherapy alone. Again, treatment practices for this stage of disease at Lawrence General Hospital are comparable to the national treatment statistics.
Since surgery is not indicated for Stage 4 cases and surgery is usually only indicated for Stage 3A surgeries, an in depth analysis was done on the specific surgical procedures performed on these late stage cases. Also, the unknown stage cases were also reviewed, since staging is usually available in those cases undergoing surgery.
The specific surgery breakdown for the Stage 3, 4 and unknown stage cases is detailed below:
| Stage 3 | Stage 4 | Stage UNKNOWN | |
| 1994-1998 |
3 Lobectomies or bilobectomies
1 lobectomy or bilobectomy & chemo 1 pneumonectomy and chemo 2 lobectomy or bilobectomy & rad 2 pneumonectomies & rad 3 lobectomies or bilobectomies & rad/chemo |
l lobectomy or bilobectomy & chemo
1 lobectomy or bilobectomy & rad 1 lobectomy or bilobectomy & rad |
2 lobectomy or bilobectomy |
| 1999-2003 |
1 lobectomy or bilobectomy
1 surgery nos & chemo 2 lobectomy or bilobectomy & chemo/rads |
1 wedge resection |
1 pneumonectomy & 1 wedge resection
1 lobectomy or bilobectomy & rad chemo 1 pneumonectomy and rad/chemo |
After reviewing the unknown stage cases, all of these cases underwent surgical procedures that should have allowed staging to be done on them. These cases will need to be reviewed further and a stage determined and assigned. All of the Stage 4 cases from 1994-1998 should be reviewed to determine if the staging is accurate, and if so, why was surgery done on these cases with distant disease. The Stage 3 cases cannot be analyzed until they are broken down into Stage 3A and Stage 3B. This further analysis will be done and reported to the Cancer Committee.
And finally, one must review the survival statistics for these patients to complete the study. The table below provides the Lawrence General Hospitalıs 5 year relative survival statistics for both time periods and both small cell lung cancer and non-small cell lung cancer patients.
| AJCC 1 | AJCC 2 | AJCC 3 | AJCC 4 | UNKNOWN | |
| 1994-1998 NSC Lung Ca | 83% (38 pts) | 82% (7 pts) | 80% (64 pts) | 82% (51 pts) | 78% (12 pts) |
| 1994-1998 Small Cell Lung Ca | No pts | No pts | 86% (11 pts) | 87% (16 pts) | 93% (4 pts) |
| 1999-2003 NSC Lung Ca | 79% (23 pts) | 81% (7 pts) | 77% (43 pts) | 82% (53 pts) | 67% (23 pts) |
| 1999-2003 Small Cell Lung Ca | 92% (1 pt) | 79% (1 pt) | 75% (10 pts) | 81% (14 pts) | 80% (4 pts) |
| 1995-1996 NCDB NSC Lung Ca | 39% (43388 pts) | 23% (11808 pts) | 8% (53343 pts) | 1% (55057 pts) | |
| 1995-1996 NCDB small cell Lung Ca | 17% (3036 pts) | 11% (1368 pts) | 8% (11873 pts) | 1% (20497 pts) |
The survival results for the Lawrence General Hospital patients seem significantly better than those reported by the NCDB for the years 1995 to 1996. However one must use caution when examining these results, as the small number of patients in each stage grouping for Lawrence General Hospital makes it highly likely that these results are not statistically significant.
In conclusion, comparison of data from Lawrence General Hospital lung cancer patients with NCDB lung cancer patientsı data demonstrates the national standard of care is available at Lawrence General Hospital.