Investigation and management of lung cancer in older adults.

BACKGROUND: The average age of patients with lung cancer is increasing, but there is little data of the management and outcomes of this common cancer in the elderly. METHODS: Data were collected from our hospital lung cancer database, medical, radiology and pathology records, for all patients with a new diagnosis of lung cancer from Jan 2002 to Dec 2004. The investigation, treatment and outcomes of these patients were analysed, and the younger (<75 years old) and elderly (75 years+) populations were compared. RESULTS: Data on 367 were analysed. Median age at diagnosis was 72 years and median survival was 5.2 months. Elderly patients were less likely to be fully investigated i.e. have histological confirmation (88.2% vs. 66.4%; p<0.001), stage recorded (88.6% vs. 78.1%; p=0.001) and performance status recorded (88.6% vs. 75.3%; p=0.003). They had poorer performance status. The older patients were less likely to receive active treatment (surgery 11.6% vs. 6.4%; p<0.001, chemotherapy or radiotherapy 50.9% vs. 26.2% p<0.001). Improved survival was independently associated with younger age (p<0.001), better performance status (p<0.001), early stage (p<0.001) and active treatment (p=0.005). Hazard ratios for death for poor PS vs. good PS was 1.88 (p<0.001), for late stage vs. early stage was 2.01 (p=0.011), for BSC vs. active treatment was 1.46 (p=0.005) and for 75 years+ patients vs. under 75 years was 1.36 (p=0.069). When comparing elderly with younger patients, median survival remained better in patients who were actively treated, had good PS and early stage (p<0.001). CONCLUSIONS: Elderly patients are less likely to be fully investigated and actively treated than younger patients with lung cancer. The causes of this difference are unclear but may include patient and clinicians' more conservative approach in the elderly. Predictors of improved outcome are the same in older and younger populations, and the elderly derive a similar survival advantage if actively treated. These data show that elderly patients are managed differently to younger patients, though the clinical basis for this is not clear. SUMMARY: Lung cancer is common in the older population and has a poor prognosis. We reviewed the investigation, treatment and survival of all patients with a new diagnosis of lung cancer over a three-year period. We compared the management of our younger (under 75 years) population with those aged 75 years or older. In our population, people over 75 years with lung cancer are less completely investigated. They were less likely to have full staging investigations, a histological or cytological diagnosis, or have their performance status recorded. Our over 75-year olds are less likely to receive active treatment (chemotherapy, radiotherapy or surgery) for lung cancer. Our older patients who received active treatment for lung cancer had similar survival advantages to younger patients.

Pulmonary hypertension in pregnancy: two cases and review of the literature.

Pulmonary arterial hypertension (PAH) in pregnancy carries a mortality of 30-56%. There are few published data to guide clinicians in its management. Two pregnant women with severe PAH have been treated at Royal Perth Hospital with a successful result in both. Their presentation and management are described. We review the physiological changes in pregnancy, pathophysiology in PAH, and review the literature describing treatment of PAH in pregnancy.

Do junior doctors take sick leave?

Nosocomial infections place a heavy burden on overstretched health services. An audit of junior doctors' sick leave behaviour was undertaken in 1993 and again in 2001. The object was to ascertain the level of common infectious illness and to investigate whether junior doctors were remaining at work inappropriately. The doctors were asked if any factors had influenced their decision to take sick leave or not. Between the two audits several initiatives have been introduced to improve the working conditions of junior doctors, including the New Deal to reduce hours of work. Eighty one junior doctors in a large teaching hospital participated in 1993 and 110 in 2001. The number reporting an infectious illness in the previous six months was similar (61.7% in 1993, 68.2% in 2001). There had been a significant increase in the percentage of infectious illness episodes for which the doctors took sick leave (15.1% in 1993, 36.8% in 2001, p < 0.001). The most common reason for taking less sick leave than was felt necessary was concern about colleagues having to do extra work (72% in 1993, 68% in 2001). Consultant pressure was cited by 26% (1993) and 20% (2001). Use of the staff occupational health unit was minimal, with none of the ill doctors contacting the department in 1993 and only three in 2001. Overall, despite the reduction in the number of infectious doctors not taking sick leave, the majority remained at work. Fundamental changes are needed if potentially infected doctors are not to present a risk of iatrogenic infection.