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Journal of Thoracic Oncology:
doi: 10.1097/JTO.0000000000000101
Letters to the Editor

Emerging Evidence of a Clinical Quality Registry as a Driver of Improvement in Lung Cancer Outcomes

Stirling, Rob G. BSc(Hons), MBBCh(Hons); Evans, Sue M. PhD; McNeil, John J. MBBS, PhD

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Department of Allergy Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Australia, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

Disclosure: The authors declare no conflict of interest.

Address for correspondence: Rob G. Stirling, MBBCh(Hons), Allergy Immunology and Respiratory Medicine, Alfred Hospital, Commercial Rd., Melbourne 3004, Australia. E-mail:

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To the Editor:

Improving outcomes such as diagnosis, staging, and survival in lung cancer is the objective of all stakeholders in what remains a disease that is largely treatment resistant. Our interest is usually drawn to announcements of development and innovation in the fields of diagnostics and therapeutics. Few perhaps might anticipate that the use of available data may have the potential to result in credible and substantial improvements in diagnosis and staging quality, care provision, and both short- and longer-term survival. This, however, is precisely what is offered in the recent report by Jakobsen et al.1 on the Danish Lung Cancer Registry.

The authors describe the establishment of a national quality management system stemming from the development of national guidelines, the creation of a high-quality integrated data system, frequent reports, and a process of audit evaluation and scrutiny that engages both stakeholder clinicians and institutions and regional and national health care authorities. Within the space of a decade, statistically and clinically important improvements are demonstrated in 1-, 2-, and 5-year survival, in addition to reduced waiting time, enhanced clinical and pathological staging concordance and reduction in regional variation in clinical outcomes.

During this timeframe there seems a substantial increase in active cancer treatment including surgical resection, chemotherapy, and radiotherapy. The rate of potentially curative therapy, however, including resection rate (15%–17%) and rate of combined chemo-radiotherapy (with likely curative intent, 10%–14%) remained unchanged. Improved subject selection, characterization, and treatment selection are likely to improve outcomes in those receiving potentially curative treatment; however, equally appealing, yet undescribed, is the possibility of enhanced survival in those receiving treatment with noncurative intent.

Clearly the success of the initiative rests on a sophisticated, informed, and interactive relationship between government, health authorities, and clinicians. Drivers to engagement are likely to include political demand and an important administrative recognition of the capability of the Danish Lung Cancer Registry to capture necessary core clinical data as a mechanism to enable feedback and closure of the quality cycle.2 The report of similar trends by the national Lung Cancer Audit in the United Kingdom may support these findings.3

The pursuit of quality and safety in health care demands definition of markers that describe the structure, quality, and outcomes of health care processes.4 Although governments and health care providers strive to develop disease-relevant and epidemiologically robust measures of quality there remains a major gap, with relatively few examples of nationwide, population-based systems established for such data collection.5 The peer-reviewed publication of outcomes attributable to clinical quality registry activity does much to promote registry science and demonstrates a potentially powerful role in advancing safety and quality in health care outcomes. The Danish Lung Cancer Group and Danish Government have provided significant leadership and demonstrate powerful survival impact through the use of a clinical quality registry. Our constituents may well ask, “Why aren’t we following?”

Rob G. Stirling, BSc(Hons), MBBCh(Hons)

Department of Allergy Immunology and

Respiratory Medicine

The Alfred Hospital

Melbourne, Australia

Department of Epidemiology and

Preventive Medicine

Monash University

Melbourne, Australia

Sue M. Evans, PhD

John J. McNeil, MBBS, PhD

Department of Epidemiology and

Preventive Medicine

Monash University

Melbourne, Australia

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1. Jakobsen E, Green A, Oesterlind K, et al. Nationwide quality improvement in lung cancer care: the role of the Danish Lung Cancer Group and Registry. J Thorac Oncol. 2013;8:1238–1247

2. Srigley J, Lankshear S, Brierley J, et al. Closing the quality loop: facilitating improvement in oncology practice through timely access to clinical performance indicators. J Oncol Pract. 2013;9:e255–e261

3. Beckett P, Woolhouse I, Stanley R, Peake MD. Exploring variations in lung cancer care across the UK—the “story so far” for the National Lung Cancer Audit. Clin Med. 2012;12:14–18

4. Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care. 2003;15:523–530

5. Evans SM, Scott IA, Johnson NP, Cameron PA, McNeil JJ. Development of clinical-quality registries in Australia: the way forward. Med J Aust. 2011;194:360–363

Copyright © 2014 by the European Lung Cancer Conference and the International Association for the Study of Lung Cancer.


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