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Measuring the outcomes of lung cancer treatment.

Why should we be interested in the treatment and outcome of patients with lung cancer in South East Scotland, as described by Erridge and colleagues on page 491–4981? I believe that this is an important study for two main reasons. First it is an exemplary study of two time(1995 and 2002) and geography-defined cohorts of patients. They attempted to identify all the patients diagnosed with lung cancer within their carefully defined boundaries in the two time periods, described their management and summarized the outcomes. They did this by marrying up the information from their own prospectively collected dataset with that from the cancer registry. All too often reports of this kind are institution-based and not population-based and, even worse, the institution may be a tertiary referral center accepting patients from and undefined or unknowable geographical area. It is therefore impossible to know what the “true” denominator population is for any process or outcome measure that is reported. Equally misleading may be the reports issued solely by cancer registries, whose figures are so dependent on the quality of the registration, coding, and follow-up processes, which is very variable. All registries are area-based (country, region, or city), but there may be no or inadequate linkage between registries even within the same country and certainly across national borders. The most reliable and honest data has to come, as this study does, from prospectively collected and recorded cases in a specific disease database, checked against other institutional databases (such as the oncology center records) as well as the regional cancer registry. By doing this for the 2002 cohort, they identified a further 106 “registry” cases (11% of the total) with significantly worse outcomes, which might otherwise have been missed. Second, they have shown a significant survival difference between the two cohorts with better survival in the latter cohort, even allowing for an overall increase in life expectancy in Scotland. They identified a number of organizational changes that had occurred between the 1995 and 2001 and reported a significant increase in the proportion of patients with non-small cell lung cancer (NSCLC) having radical radiotherapy and receiving chemotherapy. Although it is difficult to attribute the improved outcomes to any particular change in organization or treatment, it is reassuring to see that a deliberate and focused effort at improvement has had a measurable effect. One important missing factor in this study is any information on comorbidity. They hint that the significant poorer outcomes in one of the localities (Fife) in their region might be attributable to this but have no data to support this. A very similar study from another UK region2 published last year (which incidentally showed similar survival outcomes with much lower rates of radical radiotherapy and chemotherapy) did report comorbidity. Of 204 patients with Stage I–IIIA NSCLC, 92 (46%) were not treated with curative intent, 32% of these because of poor lung function, 17% because of other comorbidities, and 5% because of advanced age. Comorbidities, especially lung and heart disease, are clearly important in the determining whether curative treatment is possible for patients with lung cancer. Variations in these, as well as the age profiles, may account for some of the regional and