The diagnostic pathway in lung cancer patients with best supportive care decisions: are there lessons to be learnt?

Introduction: A proportion of patients with lung cancer will not be suitable for anti-cancer treatment and are managed with best supportive care (BSC). The aim of this retrospective case series analysis was to critically review the use of diagnostic and staging investigations in patients who were ultimately managed with BSC.

Methods: A retrospective review of all lung cancer patients with a multidisciplinary team outcome of BSC from 01 June 2018 to 01 June 2019 was performed. Patients were categorised into those with an early BSC decision and those that underwent further investigations prior to a BSC decision (investigations beyond initial computed tomography (CT)). Patient demographics, clinical characteristics and outcomes were collated and analysed.

Results: Seventy-seven lung cancer patients managed with BSC were identified. Patients were elderly (average age 79 years), functionally limited (80% World Health Organization performance status ≥3), frail (70% clinical frailty score ≥6) and had advanced stage disease (90% stage III/IV). Thirty-one (40%) underwent further investigations beyond the initial CT prior to the BSC decision. The most common types of further investigations were endobronchial ultrasound-guided transbronchial needle aspiration (27/31; 74%), positron emission tomography - CT (18/31; 45%) and CT-guided lung biopsy (7/31; 23%). This is despite high levels of consultant chest physician review at first assessment (71%), cancer nurse specialist involvement (97%), specialist palliative care involvement (65%), a high pathological confirmation rate of sampling procedures (89%) and adequacy of molecular testing. The most common reason for a BSC recommendation was a lack of fitness for systemic therapy (17/31; 55%). Six out of thirty-one (19%) patients deteriorated rapidly and died on the cancer pathway and 5/31 (16%) patients had inadequate renal function for systemic anti-cancer treatment. There was low utilisation of serum epidermal growth factor receptor mutation testing across the study cohort (2/77; 3%).

Discussion: In an older, functionally limited and frail patient with lung cancer, there is a risk of over-investigation. Impaired renal function is an important clinical factor to identify early to support discussions in this cohort. There will always be an unavoidable proportion of patients that undergo further investigations (often in search of rare targetable mutations) and are then ultimately recommended for best supportive care; such cases could form the basis of specific review and learning for lung cancer services.