|Lung cancer single map||Consumer summary document|
The lung cancer domain of the Atlas of Healthcare Variation gives clinicians, patients and providers an overview of the diagnosis and treatment of lung cancer in New Zealand, by district health board (DHB) and regional cancer network (RCN).
Lung cancer, as a high volume cancer with large inequities and a relatively poor survival rate, continues to have the greatest impact on overall cancer morbidity and mortality in New Zealand. Two reports recently published by the Ministry of Health show[1, 2]:
- lung cancer accounted for the most cancer-related deaths
- lung cancer accounts for nearly a third of all Māori cancer deaths
- one- and five-year survival rates remain poorer for Māori than non-Māori
- people who live in areas of high deprivation are also disproportionately affected by lung cancer, with men 3.2 times more likely to be diagnosed with lung cancer than men living in the least deprived areas.
International cancer data from GLOBOCAN shows New Zealand male age-standardised rates (ASRs) were lower than both the United Kingdom and Australia. In contrast, female ASRs were higher than Australia but lower than the United Kingdom.
The cancer pathway, from presentation of the patient at a health care service to diagnosis, treatment (surgery, chemotherapy, radiotherapy or palliative care) and end-of-life care, was used as a framework for considering potential lung cancer indicators.
Data sources and method
Data for this domain was drawn from a number of sources. The primary source used to identify patients was the New Zealand Cancer Registry (NZCR). The NZCR collects detailed pathological information about each tumour, as well as key demographic information. The major sources of information for the NZCR are laboratory reports, post-discharge reports from publicly funded hospitals, death certificates, autopsy reports and discharge reports from private hospitals. The NZCR holds mainly pathological staging data as there is no current process for obtaining clinical staging data from DHBs.
Other data sources that were linked to NZCR data included the National Minimum Dataset, the National Non-Admitted Patients Collection (NNPAC) and the mortality collection. The Pharmaceutical Collection which includes hospital and community chemotherapy drug dispensing for cancer patients, was used to identify chemotherapy drugs dispensed to lung cancer patients. Primary health organisation (PHO) enrolment data was used to estimate general practice consultation rates.
Lung cancer patients were defined as those patients aged 15 or older with cancers of the lung, trachea or bronchus registered for the first time between January 2008 and December 2012. Figure 1 shows the number of lung cancer patients included in the analyses by cancer types.
Figure 1. Number of lung cancer patients by cancer type
The domain includes indicators for lung cancer incidence and cancer treatment. Further analysis of lung cancer diagnosis and survival at the New Zealand population level can be found in the appendices to the lung cancer Atlas methodology.
Lung cancer incidence and five lung cancer treatment indicators are shown on the map. Lung cancer treatment options are determined by a number of factors. These include the type of lung cancer, where the cancer is located, the patient’s general health (performance status), whether the cancer has spread (extent of disease), results of blood tests and scans, and patient choice.
Early stage diagnosis of lung cancer offers the best opportunity for treatment to potentially cure the disease.
- Stage (extent) of disease at diagnosis was available for 63.5 percent of lung cancer patients (2008–12) on the NZCR.
- Of those with documented extent, 74.6 percent of patients had advanced stage (distant extent) disease at diagnosis.
- New Zealand has a high percentage of patients diagnosed with distant extent disease compared with other countries where the same staging system is used eg, Australia (New South Wales, 49.1 percent) and United Kingdom (Northern Ireland, 56.8 percent).
Key trends across treatment indicators:
- Older people had lower treatment rates for surgery, radiotherapy and chemotherapy.
- Māori had lower rates of surgery but higher chemotherapy and radiotherapy treatment rates.
- Males had lower chemotherapy and surgery rates than females.
- Lung cancer incidence
- In total, 9916 people were first diagnosed with lung cancer in New Zealand between 2008 and 2012.
- The age-specific rate of lung cancer increased with age; 0.9/100,000 people aged 15–39 years were diagnosed with lung cancer, while for people over 70 years of age the rate was in excess of 280/100,000 people.
- Māori had higher rates of lung cancer at an earlier age than non-Māori.
- The overall crude incidence of lung cancer varied two-fold between DHBs (33.1/100,000–74.3/100,000) and 1.3 fold between RCNs (40.2/100,000–54.5/100,000).
- Anti-cancer treatment following diagnosis (2012 only)
Anti-cancer treatments have an effect on the tumour itself, not just on symptoms. For lung cancer patients, the most common anti-cancer treatments are surgery, chemotherapy, radiotherapy or a combination of the three.
- Overall, 60.1 percent of patients received anti-cancer treatment.
- Anti-cancer treatment rates decreased with age from 79.4 percent of 40–59-year-olds to 29.8 percent of over-80-year-olds.
- The Māori treatment rate (66 percent) was higher than non-Māori (58.5 percent) reflecting the lower age at which Māori are diagnosed.
- Male patients had a lower treatment rate than female patients (58.2 percent vs 62.1 percent).
- The anti-cancer treatment rate varied between DHBs (53.2–68.6 percent) but there was little variation between RCNs (57.6–62.2 percent).
- The anti-cancer treatment rate in New Zealand is similar to that of England and Wales (61 percent) in 2012.
- Lung cancer surgery following diagnosis
Surgery, with the aim of curing disease, is the treatment of choice for patients diagnosed with early stage non-small cell lung cancer (NSCLC). Surgery is rarely used as a treatment in small cell lung cancer (SCLC).
- Overall, 14.7 percent of NSCLC patients with a pathological diagnosis had lung cancer surgery (2008–12). The percentage of patients receiving surgery increased from 13.8 (2008–10) to 14.8 (2010–12)
- Surgical resection rates were lower for Māori (13.3 percent) than non-Māori (15 percent).
- Rates decreased with age from 31.0 percent for people aged 15-39 years to 6.1 percent for people aged 80 years and older.
- Male resection rates were slightly lower than female rates (13.7 percent vs 15.8 percent).
- The surgical rate showed significant variation between DHBs (6.7–19.6 percent) and RCNs (9.9–17.3 percent).
- The surgical resection rate for New Zealand NSCLC patients with a pathological diagnosis is lower than in Australia (23.8 percent in Victoria, 2003) and for England and Wales (21.9 percent, 2012)[5, 6].
- Chemotherapy drugs dispensed following diagnosis of lung cancer
Chemotherapy is the primary mode of treatment for small cell tumours and may be curative when used in combination with radiotherapy for early stage/localised disease. In NSCLC it may be used with radiotherapy in early stage disease but is most often used as part of a palliative treatment regimen in locally advanced or metastatic disease, where it prolongs survival and improves quality of life.
a) NSCLC patients
- Overall, 20.1 percent NSCLC patients were dispensed chemotherapy drugs (2008–12).
- The three-year rolling average dispensing rates increased from 18.7 percent (2008–10) to 22.2 percent (2010–12).
- Māori had a higher chemotherapy dispensing rate (22.7 percent) than non-Māori (19.6 percent).
- Dispensing rates decreased with age from 44 percent for people aged 40-59 years to 1.3 percent for people aged 80 years and older.
- Dispensing rates were lower for males than females than males (18.7 percent vs 21.8 percent).
- The dispensing rates varied from 10.6–29 percent for DHBs with little variation for RCNs (19.1–22.3 percent).
- The chemotherapy rate for New Zealand NSCLC patients is lower than in Australia (39.4 percent in Victoria, 2003).
b) SCLC patients
- Overall, 66.2 percent of SCLC patients were dispensed chemotherapy drugs (2008–12).
- The dispensing three-year rolling average rates increased from 64.4 percent (2008–10) to 68.8 percent (2010–12).
- Māori had a higher chemotherapy dispensing rate (73.9 percent) than non-Māori.
- Dispensing rates decreased with age from 82.9 percent for people aged 40-59 years to 28.0 percent for people aged 80 years and older.
- Male dispensing rates were lower than for females (62.9 percent vs 69.4 percent).
- The dispensing rates for SCLC patients showed wide variation for DHBs (48.6–85.1 percent) and for RCNs (59.2–75.3 percent).
- The percentage of New Zealand SCLC patients receiving chemotherapy drugs was similar to England and Wales (67.5 in 2012).
- Radiotherapy treatment following diagnosis (2012 only)
Lung cancer patients may receive radiotherapy on its own or in combination with other treatments.
- Overall, 42.3 percent of patients received radiotherapy.
- Radiotherapy rates decreased with age from 56.7 percent of 40–59-year-olds to 25.5 percent of over-80-year-olds.
- Māori had a higher rate (46.9 percent) than non-Māori (41.2 percent).
- Male and female radiotherapy rates were similar (42.0 percent and 42.7 percent).
- The radiotherapy rates showed some variation between DHBs (35.9–51.5 percent) and insignificant variation between RCNs (41.8–43 percent).
- The New Zealand radiotherapy rate was higher than England and Wales (30 percent) in 2012.
It is pleasing to note that within New Zealand there was limited regional variation in treatment; however international comparisons highlight possible areas for investigation and review. Questions to explore include:
- what role does stage at diagnosis play in determining intervention rates?
- to what extent does comorbidity, performance status or personal choice determine whether patients receive anti-cancer treatment?
- why are New Zealand’s referral rates to surgery and chemotherapy lower?
Even with improvements in treatment, many lung cancer patients will continue to present with incurable disease. Early diagnosis is critical to improved outcomes for patients and tobacco control remains a key strategy to reduce the overall incidence of the disease.
National Lung Cancer Working Group. 2011. Standards of Service Provision for Lung Cancer Patients in New Zealand. Wellington: Ministry of Health.
- Ministry of Health. 2015. Cancer Patient Survival 1994–2011. Wellington: Ministry of Health.
- Ministry of Health. 2014. Cancer: New registrations and deaths 2011. Wellington: Ministry of Health.
- Ferlay, J, et al. 2013. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. 2012: Lyon: International Agency for Research on Cancer.
- Walters, S, et al. 2013. Lung cancer survival and stage at diagnosis in Australia, Canada, Denmark, Norway, Sweden and the UK: a population-based study, 2004–2007. Thorax 68(6): 551–64.
- Health and Social Care Information Centre. 2013. National Lung Cancer Audit Report 2013. Leeds: Health and Social Care Information Centre. URL: http://www.hscic.gov.uk/catalogue/PUB16019/clin-audi-supp-prog-lung-nlca-2014-rep.pdf (accessed July 2015).
- Mitchell, P.L., et al., Lung cancer in Victoria: are we making progress? Med J Aust, 2013. 199(10): p. 674-9.