Improving chemotherapy for patients with advanced non-small cell lung cancer

Lung cancer is the third most common mortal disease in industrialised countries and the prognosis has been slow to improve. The largest subgroup has locally advanced or metastatic non-small cell lung cancer (NSCLC). Unfortunately, these patients can usually not be cured and the main treatment option is palliative chemotherapy. Given the palliative intention of the chemotherapy, it is clinically highly relevant to establish the optimal treatment duration. While chemotherapy prolongs survival and improves quality of life (QoL), it also has side effects and only a minority of patients achieve an objective treatment response. Clinicians need guidance on treatment duration from controlled trials to balance these aspects. Improvements of the conditions under which chemotherapy is given can increase patient and staff satisfaction and increase system performance. This is especially relevant to incurable patients who spend a lot of their limited time at oncology outpatient clinics. Staffing, infrastructure and organisation of these units are often suboptimal to serve patients with palliative needs and reports of improvement projects can inspire and guide clinicians in improving their microsystems of care. Clinicians, health care administrators and the public need knowledge about the outcomes of palliative chemotherapy in unselected patient populations. The efficacy of palliative chemotherapy for advanced NSCLC has been amply documented in controlled clinical trials. Meanwhile, the elderly and patients with higher performance status have usually been under-represented in these trials and population studies of the effectiveness of chemotherapy are needed.

(i) To establish the optimal duration of platinum-based first line chemotherapy for advanced NSCLC; (ii) To improve the care processes at an oncology outpatient clinical microsystem; (iii) To describe the use of chemotherapy in a national population and investigate associations between chemotherapy use and survival; and (iv) To explore approaches to improve the system of chemotherapy from the macro perspective of a whole country.

The thesis combines methods from different knowledge domains. In a randomised trial, we compared three with six courses of platinum-based chemotherapy for advanced NSCLC. In a quality improvement study, we used logistic improvement tools, qualitative and quantitative patient and staff satisfaction measurements. Finally using data from the Norwegian cancer and chemotherapy registries, we investigated temporary and geographical variations of chemotherapy use and correlations with the survival of patients with advanced NSCLC. Methods and findings from the three studies were explored to inform a national improvement strategy for the chemotherapy of advanced NSCLC.

Survival and QoL were equal with three or six courses of chemotherapy for advanced NSCLC. Systematic process changes at the outpatient clinic led to increased patient and staff satisfaction. Furthermore, the study illustrates the application of established process improvement and evaluation tools in a clinical microsystem. In the registry study, we found delays of the introduction of palliative chemotherapy in Norway and significant associations between the use of chemotherapy and the survival of patients with advanced NSCLC. The general section of the thesis describes approaches to system-wide improvements and introduces a quality improvement matrix.

We conclude from our randomised trial and related research that chemotherapy beyond three courses is not beneficial for patients with advanced NSCLC. The report from the oncology outpatient clinic illustrates the value of the clinical microsystem approach for quality improvement at the front line of care. Patient feedback through a focus group, simple methods of assessing and simplifying processes of care, as well as measuring results over time were effective tools in our project. The description of the experiences can serve as an example for the improvement of microsystems in settings with similar problems. Finally, in the registry study of Norwegian patients with lung cancer, we found significant geographical and temporal variations of the utilisation of chemotherapy that were related to survival. Potential areas of improvement in the system of care for lung cancer are recruitment of patients in clinical studies, standardisation of the processes of care in outpatient clinics, definition of strategic aims of quality, development of balanced quality indicators, as well as measuring and reporting of outcomes by means of a quality registry.