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Are Clinical Guidelines Applied in Routine Daily Practice? A French Regional Survey of Physicians' Clinical Practices in Lung Cancer Management (EPOTRA).

In 2003 the French government initiated a large cancer plan. This program requested the latest edition of local guidelines in each of France's administrative regions. Since their creation, none of these guidelines has been assessed in the conditions of daily clinical practice.

Method: A survey was performed to assess physicians' integrated knowledge of local guidelines in the Rhône-Alpes region in France. It included 4 patient cases with accompanying multiple-choice questions. Responses were judged as appropriate or inappropriate according to the 2007 edition of local guidelines.

Results: Four hundred one physicians were contacted. The response rate was 56%. Among the responding physicians, 71 were eligible for analysis (those who were board certified in oncology and pulmonology and practiced thoracic oncology only). The rate of physicians who applied guidelines was 55%, 54%, 63%, and 25% for cases 1 to 4, respectively. There were no major differences in the responses between oncologists and pulmonologists. However significant differences were noted between physicians working in public health centers (cases 1 and 2) and those who practiced in private centers (cases 3 and 4) (appropriate response rate, 68% [case 3] vs. 36% [case 1] [P = .0494] for case 1; 28% [case 4] vs. 9% [case 2] (P = .0022)). Finally, no differences in physician responses were found in the administrative departments within the administrative region.

Conclusion: The results of the survey illustrate that regional guidelines are not routinely applied in daily clinical practice. This nonapplication of regional guidelines by physicians may be due to either a lack of knowledge of updates to guidelines or a lack of agreement with them.

Factors associated with adherence to chemotherapy guidelines in patients with non-small cell lung cancer.

Evidence-based guidelines recommend chemotherapy for medically fit patients with stages II-IV non-small cell lung cancer (NSCLC).

Adherence to chemotherapy guidelines has rarely been studied among large populations, mainly because performance status (PS), a key component in assessing chemotherapy appropriateness, is missing from claims-based datasets. Among a large cohort of patients with known PS, we describe first line chemotherapy use relative to guideline recommendations and identify patient factors associated with guideline concordant use.

PATIENTS AND METHODS: Insured patients, ages 50+, with stages II-IV NSCLC between 2000 and 2007 were identified via tumor registry (n=406). Chart abstracted PS, automated medical claims, Census tract information, and travel distance were linked to tumor registry data. Chemotherapy was considered appropriate for patients with PS 0-2. Multivariate logit models were fit to evaluate patient characteristics associated with chemotherapy over- and under-use per guideline recommendations. Tests of statistical significance were two sided.

RESULTS: Overall compliance with first line chemotherapy guidelines was 71%. Significant (p<0.05) predictors of chemotherapy underuse (19%) included increasing age (odds ratio [OR], 1.09), higher income (OR, 1.02), diagnosed before 2003 (OR, 2.05), and vehicle access (OR, 6.96) in the patient's neighborhood. Significant predictors of chemotherapy overuse (10%) included decreasing age (OR, 0.92), diagnosed after 2003 (OR, 3.24), and higher income (OR, 1.05) in the patient's neighborhood. Among NSCLC patients 29% do not receive guideline recommended chemotherapy treatment missing opportunities for cure or beneficial palliation, or receiving chemotherapy with more risk of harm than benefit.

Care concordant with guidelines is influenced by age, economic considerations such as income and transportation barriers.

European and North American lung cancer screening experience and implications for pulmonary nodule management.

The potential for low dose computed tomography (LDCT) to act as an effective tool in screening for lung cancer is currently the subject of several randomised control trials.

It has recently been given prominence by interim results released by the North American National Lung Screening Trial (NLST). Several other trials assessing LDCT as a screening tool are currently underway in Europe, and are due to report their final results in the next few years. These include the NELSON, DLSCT, DANTE, ITALUNG, MILD and LUSI trials. Although slow to instigate a trial of its own, the UK Lung Screen (UKLS) trial will shortly commence. The knowledge gained from the newer trials has mostly reinforced and refined previous concepts that have formed the basis of existing nodule management guidelines.

This article takes the opportunity to summarise the main aspects and initial results of the trials presently underway, assess the status of current collaborative efforts and the scope for future collaboration, and analyse observations from these studies that may usefully inform the management of the indeterminate pulmonary nodule.

Key Points

• Low dose CT screening for lung cancer is promising.
• The effect of LDCT screening on mortality is still uncertain.
• Several European randomised controlled trials for LDCT are underway.
• The trials vary in methodology but most compare LDCT to no screening.
• Preliminary results have reinforced existing nodule management concepts.

A roundup of recently published articles relevant to thoracic oncology.

We selected six publications for the "best of the month," published recently in peer-reviewed journals, covering a broad range of topics including second-hand smoking, intensive care unit admissions for patients with lung cancer, role of aspirin in preventing lung cancer, bleeding events in patients undergoing treatment with bevacizumab and requiring full anticoagulation, level of evidence used to support the National Comprehensive Cancer Network guidelines, and the use of prophylactic cranial irradiation in patient with locally advanced non-small cell lung cancer.

Spontaneous pneumothorax: remaining controversies.

Despite many guidelines issued by national and professional societies, a detailed literature survey between the late 1940s and 2010 clearly demonstrates that several aspects of pneumothorax pathogenesis and treatment still remain controversial.

Related to pathogenesis of primary pneumothorax, the current manuscript highlights why further studies are needed to explain

  1. mechanism of the oxygenation impairment in presence of a large pneumothorax;
  2. oxygenation differences between age and sex-matched patients with a pneumothorax of the same size;
  3. and sequence of events in tension pneumothorax.

Concerning the overall therapeutic approach, video-assisted technology provides a minimally invasive operative treatment. For this reason methods of recurrence prevention are now shared between interventional pulmonologists and thoracic surgeons. Although a significantly higher recurrence rates was reported in patients with primary spontaneous pneumothorax after simple pleural drainage versus thoracoscopic talc poudrage, (34% and 5% respectively), such a policy is still not widely adopted. Certain concerns that relate to the use of talc in relapse prevention are also discussed, showing that they are mostly dependent on the type of the talc used.

Concerning secondary pneumothorax, specificities of different forms related to diagnostics and therapeutic approach are also pointed out. Lung tuberculosis as the underlying cause is particularly addressed, due to the challenge of the timely recognition of specific lesions and prompt initiation of the antituberculous medical treatment . Similarly, lung cancer is mentioned as a possible underlying cause in patients with delayed lung expansion.

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