Changes in demographic and smoking history trends in patients referred to a London thoracic malignancy specialist centre between 2010-2021: The Guy's Cancer Centre experience

Background In the UK it is estimated that 10-15% of lung cancer cases occur in never-smokers. This study demonstrates the changes of the demographic characteristics, including the smoking status, of all the patients referred to the thoracic malignancy unit at Guy's Cancer Centre, South East London, between 2010 and 2021. Methods We included patients with a documented ICD10 diagnosis of bronchus and lung malignancy who were referred to Guy's thoracic malignancy unit from 2010 until 2021. A total of 6861 patients with a diagnosis of lung cancer were identified. We collected baseline demographic and clinical characteristics, including smoking status and socio-economic status for all the patients. Descriptive statistics were utilised to highlight the dynamic changes over the years of the referred patients. Results The number of referrals per year remained overall stable from 2010 until 2019, with a decrease in the number of referrals in 2020 and 2021, most likely due to the COVID-19 pandemic. We observed a gradual increase in the percentage of never smokers among the lung cancer patients: 5%, 8%, 10% and 13% of the referred patients were never smokers in the years 2010, 2015, 2018 and 2021 respectively. Median age remained stable across the years (range 68-71 years). Male percentage was 56%, 55%, 53% and 53% in 2010, 2015, 2018 and 2021 respectively. From the patients that we had a documented ethnic background the proportion of White/Black/Asian/Other or Mixed ethnicity remained stable across the years with a median 87%, 7%, 3%, and 3% respectively. The most common histological diagnosis was adenocarcinoma, followed by squamous cell carcinoma and small cell lung carcinoma. Conclusions The proportion of never-smoking to smoking related lung cancer has gradually increased between 2010 and 2021. There was little variability in age, sex and ethnic background. Never-smoking lung cancer is a distinct biological entity, therefore, further research should focus on the understanding of the aetiology and the risk factors leading to the development of lung cancer, in the absence of a history of tobacco exposure. Legal entity responsible for the study The authors. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc.

Difference in general practice telehealth utilisation associated with birth country during COVID-19 from two Australian states.

Objective: Telehealth has been an integral part of ensuring continued general practice access during the COVID-19 pandemic. Whether telehealth was similarly adopted across different ethnic, cultural, and linguistic groups in Australia is unknown. In this study, we assessed how telehealth utilisation differed by birth country. Methods: In this retrospective observational study, electronic health record data from 799 general practices across Victoria and New South Wales, Australia between March 2020 to November 2021 were extracted (12,403,592 encounters from 1,307,192 patients). Multivariate generalised estimating equation models were used to assess the likelihood of a telehealth consultation (against face-to-face consultation) by birth country (relative to Australia or New Zealand born patients), education index, and native language (English versus others). Results: Patients born in Southeastern Asia (aOR: 0.54; 95% CI: 0.52-0.55), Eastern Asia (aOR: 0.63; 95% CI: 0.60-0.66), and India (aOR: 0.64; 95% CI: 0.63-0.66) had a lower likelihood of having a telehealth consultation compared to those born in Australia or New Zealand. Northern America, British Isles, and most European countries did not present with a statistically significant difference. Additionally, higher education levels (aOR: 1.34; 95% CI: 1.26-1.42) was associated with an increase in the likelihood of a telehealth consultation, while being from a non-English-speaking country was associated with a reduced likelihood (aOR: 0.83; 95% CI: 0.81-0.84). Conclusions: This study provides evidence showing differences in telehealth use associated with birth country. Strategies to ensure continued healthcare access for patients, whose native language is not English, such as providing interpreter services for telehealth consultations, would be beneficial. Perspectives: Understanding cultural and linguistic differences may reduce health disparities in telehealth access in Australia and could present an opportunity to promote healthcare access in diverse communities.

General practice perspective on the use of telehealth during the COVID-19 pandemic in Australia using an Action Research approach: a qualitative study.

OBJECTIVES: Telehealth has emerged as a viable and safe mode of care delivery in Australia during the COVID-19 pandemic. However, electronic general practice data reveal differences in uptake and consultation mode, which we hypothesise may be due to potential barriers impacting on quality of care. We aimed to identify the benefits and barriers of telehealth use in general practice, using an 'Action Research' approach involving general practitioners (GPs) and general practice stakeholders. DESIGN: Qualitative focus group performed within a broader Action Research methodology. SETTING: A focus group was held in August 2021, with general practice participants from Victoria, Australia. PARTICIPANTS: The study consisted of a purposive sample of 11 participants, including GPs (n=4), representatives from three primary health networks (n=4) and data custodian representatives (n=3) who were part of a project stakeholder group guided by an Action Research approach. METHODS: Semistructured interview questions were used to guide focus group discussions via videoconference, which were recorded and transcribed verbatim for analysis. The transcript was analysed using an inductive thematic approach. RESULTS: Emerging themes included evolution of telehealth, barriers to telehealth (privacy, eligibility, technology, quality of care, sociodemographic and residential aged care barriers) and benefits of telehealth (practice, quality of care, sociodemographic and residential aged care benefits). CONCLUSION: The findings highlight a range of barriers to telehealth that impact general practice, but also provide justification for the continuation and development of telehealth. These results provide important context to support data-driven population-based findings on telehealth uptake. They also highlight areas of quality improvement for the enhancement of telehealth as a valuable tool for routine general practice patient care.

High Flow Nasal Cannula Oxygen in COVID-19;still an important role to play

Introduction: High flow nasal cannula oxygen (HFNC) has a firm evidence base in the management of hypoxaemic respiratory failure. It has been shown to reduce mortality and increase ventilator free days when compared with use of standard oxygen or continuous positive airway pressure (CPAP), and it has been shown to reduce intubation rates in patients with a P: F ratio of <200mmHg.1 However, provisional data from the use of HFNC in COVID-19 suggest no significant reduction in intubation rates and no mortality benefit over conventional oxygen therapy or CPAP.2 These contradictory findings complicate our understanding of any potential role for HFNC in COVID-19. In our organisation, all patients with COVID-19 who remained hypoxic despite standard oxygen therapy were initially managed with HFNC and only if they failed this modality were then trialled on CPAP or intubated for invasive mechanical ventilation. HFNC was provided on our physician led Respiratory Support Unit (RSU) with daily critical care input. Our approach differs to that employed in the most recent multicentre randomised controlled trial of respiratory support in COVID-19 and therefore offers the opportunity to understand how HFNC may be of benefit in patients with COVID-19. Objectives: To explore the potential role and safety for HFNC in COVID-19. Methods: Retrospective analysis of all patients with COVID-19 admitted to a single NHS acute Trust between March 2020 and February 2021, who required escalation of respiratory support to HFNC with or without subsequent CPAP or intubation. Data collected included patient demographics, comorbidities, respiratory support requirements, ceiling of treatment and outcomes. Logistic regression analysis was used to compare mortality rates for patients who did or did not receive HFNC. Results: One hundred and forty-seven patients met inclusion criteria of whom fifty-five (37%) were managed solely on the Respiratory Support Unit (RSU). Nineteen patients (13%) had HFNC as their ceiling of care, of whom nine died. Of those patients deemed appropriate for full escalation, fifty-four (37%) received only HFNC and thirty-two (22%) subsequently required intubation after a trial of HFNC. The relative risk of mortality for patients who received HFNC prior to intubation compared to those who were intubated without HFNC was 0.48 (95% CI 0.26-0.89). There were no safety concerns associated with HFNC. Conclusion: Our data suggests that HFNC may offer survival benefit in those with care limitations in organ support, as demonstrated by our survival rate of 53% in this patient cohort. HFNC is generally well tolerated and is associated with fewer adverse events than other forms of non-invasive respiratory support. HFNC can be employed as a safe tool for assessing patients' respiratory support requirements and monitoring trajectory in RSUs, sparing ICU capacity in healthcare systems under strain. Furthermore, it is associated with a favourable mortality profile in those who subsequently require intubation (34% mortality), particularly when compared with the UK national average for mortality in COVID-19 ventilated patients (50%). HFNC may therefore still have a role in the management of patients with COVID-19 with acute hypoxaemic respiratory failure and this warrants further examination.

Real-world outcomes with nivolumab for pre-treated malignant mesothelioma in the UK

Introduction: There are limited options for the treatment of malignant mesothelioma (MM) following progression with pemetrexed-platinum chemotherapy. Recently, nivolumab showed a survival benefit over placebo in this setting. In the UK, since April 2020, nivolumab has been funded through the interim national COVID-19 cancer plan. We assessed the real-world efficacy and toxicity outcomes in MM patients treated with nivolumab at Guy’s Cancer Centre.Methods: We identified all chemotherapy-pre-treated patients administered single-agent nivolumab for MM. Baseline characteristics, treatment, response, survival and treatment-related adverse events (TRAEs) were assessed. Best responses – disease control or progression – were derived from radiologic and clinical documentation. Results: Twenty patients were identified. Median age was 72 years (range 45 – 85), 80% male and 95% had epithelioid (5% sarcomatoid) disease. Programmed death-ligand 1 (PD-L1) measurements were unavailable. Nineteen (95%) had pleural and one peritoneal MM. ECOG PS was 0, 1 or 2 in 1 (5%), 16 (80%) and 3 (15%) patients respectively. All were previously exposed to pemetrexed-platinum chemotherapy, and 4 (20%) had received rechallenge. Median time from prior treatment to commencement of nivolumab was 6 months. Median follow-up was 10.8 months. Median number of two-weekly 240mg equivalent cycles administered was twelve. Best response was disease control in 17 (85%) patients and progressive disease in 3 (15%). Median progression-free survival was 5.0 months (95% CI 3.7 – 6.2). Six patients (30%) had died by time of analysis, with median overall survival not reached. Twenty TRAEs were seen among 14 patients (70%), all except one graded 1/2 (Table 1). Conclusions: Nivolumab proved a safe and effective way to deliver non-myelosuppressive anticancer therapy at a favourable dosing schedule to a vulnerable population during the COVID-19 pandemic. These real-world outcomes corroborate findings from the CONFIRM trial, although limited by small sample size and retrospective nature.

Emergency Remote Learning in Higher Education in Cyprus during COVID-19 Lockdown: A Zoom-Out View of Challenges and Opportunities for Quality Online Learning

This study provides a zoom-out perspective of higher education students' experiences related to the emergency remote learning (ERL) following the first lockdown due to the COVID-19 pandemic as captured by a national, in-depth survey administered to all higher education institutions in Cyprus (different fields of study and educational levels). Quantitative and qualitative analyses of the data collected from 1051 students provide valuable information and insights regarding learners' prior technology background and level of preparedness for online learning, the challenges and benefits of ERL and how they would like their online learning experience to be improved in case of future ERL. The results underline that students' knowledge of and self-efficacy in using e-learning tools do not directly equate to being a digital learner equipped with necessary digital skills such as self-regulation to fully benefit from online learning. The educational disparities caused by inequalities in access and accessibility to high-quality education laid bare by the pandemic stressed the need for online environments that would afford quality learning for all learners. Online learning demands are discussed in the article, as well as implications for research, practice and policy making.

Real-world safety of the 6-weekly pembrolizumab regimen in cancer patients treated in South East London

Background: Pembrolizumab (pembro) is a PD-1 inhibitor indicated for the treatment (tx) of a several malignancies. Most clinical trials used a 3-weekly tx (Q3W) but a 6-weekly 400mg regimen (Q6W) is now approved, based on pharmacokinetic data, also supported by the KEYNOTE-555 trial. The real world tolerability of the Q6W remains unknown. The COVID-19 pandemic led to rapid adoption of the Q6W tx, usually in patients (pts) previously receiving Q3W tx, as it facilitates less hospital visits. We report the toxicity profile of pts treated with Q6W pembro and the comparison of the preceding Q3W tx. Methods: We retrospectively analysed adverse events for non-small cell lung cancer (NSCLC), urothelial cancer (UC) and melanoma pts, who received at least 1 cycle of Q6W pembro. Pts that received pembro in combination tx were excluded. Previous Q3W monotherapy was permitted. Toxicity was graded as per CTCAE v5.0. Results: We included 94 pts (melanoma=39, NSCLC=38, UC=17). Median number of Q6W cycles received was 3 (range 1-6). 71% received the Q3W regimen (median 7 cycles, range 1-32) prior to switching to Q6W. New toxicity of any severity was recorded in 52% (49/94) during Q6W versus 70% (47/67) during Q3W tx. G 3/4 toxicities occurred in 15% (15) during Q6W versus 0% during previous Q3W tx. Of the 27 who started de novo with Q6W, 4 (15%) developed G 3/4 toxicities. G 3/4 toxicities were: GI (4% [colitis = 2, gastritis =1, oral lichen planus = 1]), nephritis (3%), arthralgia (2%), skin (2%), myositis/CK rise (2%), anaemia (1%), myocarditis (1%). Steroids for management of toxicity were initiated in 22% (21) pts, including 8 with G2 toxicity. Three (3%) pts switched back to Q3W administration. None of them received Q6W again. In total 9% of pts in Q6W discontinued tx due to toxicity. Conclusions: In our cohort of pts, the majority were previously treated with the Q3W regimen without significant toxicity. Switch to Q6W or de novo Q6W pembro led to a 15% rate of G 3/4 toxicity and 9% discontinuation rate. In pts pre-treated with Q3W, we cannot distinguish whether this was due to cumulative toxicity or due to switch to Q6W. More studies are required to ascertain the safety of the Q6W schedule. In the COVID-19 context, any Q6W toxicity concern should be weighed against the advantages of fewer hospital visits. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Reply to John spry on stay-at home orders and COVID-19 hospitalizations

This short note is a response to John Spry’s critique of our research letter “Association of Stay-at-Home Orders With COVID-19 Hospitalizations in 4 States,” which appeared in Journal of the American Medical Association in 2020. We also provide an example from a state that did not have a stay-at-home order that is consistent with the findings of our original paper. © 2020, Fraser Institute. All rights reserved.