Raz, Natural history of stage I Non-Small Cell Lung Cancer: implications for early detection, Chest. 2007 May 15, 2007.

Background Concern has been raised that early detection of lung cancer may lead to the treatment of clinically indolent cancers. No population-based study has examined the natural history of patients with stage I NSCLC who receive no surgery, chemotherapy, or radiation therapy. Our hypothesis is that long-term survival in patients with untreated stage I NSCLC is uncommon. Methods 101,844 incident cases of NSCLC in the California Cancer Center registry between 1989 and 2003 were analyzed. 19,702 had stage I disease, of which 1432 did not undergo surgical resection or receive treatment with chemotherapy or radiation. Five-year overall survival (OS) and lung cancer specific survival were determined for this untreated group, for subsets of patients who were recommended but refused surgical resection, and for T1 tumors. Results Only 42 patients with untreated stage I NSCLC were alive 5 years after diagnosis. Five-year OS for untreated stage I NSCLC was 6% overall, 9% for T1 tumors, and 11% for patients who refused surgical resection. Five-year lung cancer specific survival was 16%, 23%, and 22% respectively. Among these untreated patients, median survival was 9 months overall, 13 months for patients with T1 disease, and 14 months for patients who refused surgical resection. Conclusion Long-term survival with untreated stage I NSCLC is uncommon and the vast majority of untreated patients die of lung cancer. Given that median survival is only 13 months in patients with T1 disease, surgical resection or other ablative therapies should not be delayed even in patients with small lung cancers.

Kern, Medicolegal Analysis of the Delayed Diagnosis of Cancer in 338 Cases in the United States
Arch Surg. 1994;129(4):397-404.
To define the frequency, clinical characteristics, and legal outcomes of the delayed diagnosis of cancer leading to negligence litigation. Retrospective review of 338 jury verdict reports from 42 states in the United States.
Of 338 cancers divided into 13 major organ sites, breast (38%, n=127), gastrointestinal (15%, n=51), lung (15%, n=50), and head and neck cancers (10%, n=33) accounted for 80% (270/338) of lawsuits. The average diagnostic delay for 212 cases was 17 months. The median age of patients with delays was 15 years younger than the age of patients presenting with cancer in the general population. For cancers in nine major organ sites, the ratio of mortality for patients filing lawsuits to that for patients with cancer in the general population averaged 3.4:1. The total known indemnity payout was $140.2 million, with an average payout per case of $64 600. At 1 to 3 months of diagnostic delay, jury verdicts largely favored the defense (seven of 11 [65%] defense verdicts); after 6 months of delay, jury verdicts were almost evenly divided between defense verdicts, plaintiff verdicts, and out-of-court settlements.

The delayed diagnosis of cancer leading to negligence litigation is associated with significant indemnity payments, often involves middle-aged patients far younger than the expected age in the general cancer population.  The extent of diagnostic delay impacts outcome.
keywords, delayed diagnosis of cancer, medical malpractice, claim, lawyer, evaluation of delayed diagnosis of cancer claims.

Christensen, The impact of delayed diagnosis of lung cancer on the stage at the time of operation,  European Journal of Cardio-Thoracic Surgery
Volume 12, Issue 6, December 1997, Pages 880-884

The purpose of this investigation was to study the correlation between diagnostic delay and the stage of the lung cancer at the time of operation. A second objective was to study differences in symptoms between the patients grouped according to stage. Methods:  Two groups of patients were compared, one group with good prognosis (patients in Stages I and II) and one group with poor prognosis (patients in Stages III and IV). The time-spans studied were: (1) interval from the patient's perception of the first symptom to operation; and (2) the time from first contact with the healthcare-system to operation. The median delay between the patient-groups was compared est. To compare the symptoms which brought the patients in contact with the healthcare-system, the χ2-test was used. Results: In the time interval between appearance of the first symptom and operation, a significantly shorter median delay was found for patients with Stages I and II compared to Stages III and IV (P=0.037). Concerning the interval from first contact with the healthcare system to operation a significantly shorter median delay was found for the group of patients in Stage I and II compared to the patients-group in Stage III and IV (P=0.017). It was found that the cancer was an accidental finding, significantly more often in patients in Stages I or II compared to patients in Stages III or IV (P=0.0002). Conclusions: A few months delay before final treatment of a non-small-cell lung cancer seems to have an impact on the perioperative stage of the cancer, and thereby on the patients prognosis. A screening of asymptomatic risk-group patients will result in recognition of early lung cancer.

Author Keywords: Lung cancer; Diagnostic delay; Stage; Surgery; medical malpractice, missed diagnosis, lawyer, delay. 

Billing, Delays in the diagnosis and surgical treatment of lung cancer,  Volume 51, Issue 9, Thorax 1996, 51: 903-906

Patients admitted for resection of lung tumors frequently experience lengthy delays in diagnosis and preoperative investigations. This study was conducted to quantify this delay between presentation and definitive treatment and to assess the factors responsible for such a delay. METHODS: All patients undergoing lung resection for a tumour at a single surgical unit in 1993 were studied. The date of each consultation, investigation, and referral was identified, and the extent of any delay determined. RESULTS: The mean total delay from presentation to operation was 109 days. Within this period an average of one month occurred before referral to a respiratory specialist who then spent two months investigating the patient. After referral to a surgeon, surgery took place within a mean interval of 24 days. Delays to definitive treatment appear unacceptable. Points at which the efficiency of the diagnostic process could be improved are discussed. The length of delay did not correlate with tumor stage in this study.

Singh, Characteristics and Predictors of Missed Opportunities in Lung Cancer Diagnosis: An Electronic Health Record–Based Study

Purpose Understanding delays in cancer diagnosis requires detailed information about timely recognition and follow-up of signs and symptoms. This information has been difficult to ascertain from paper-based records.
We used an integrated electronic health record (EHR) to identify characteristics and predictors of missed opportunities for earlier diagnosis of lung cancer.
Using a retrospective cohort design, we evaluated 587 patients of primary lung cancer at two tertiary care facilities. Two physicians independently reviewed each case, and disagreements were resolved by consensus.
Type I missed opportunities were defined as failure to recognize predefined clinical clues (ie, no documented follow-up) within 7 days. Type II missed opportunities were defined as failure to complete a requested follow-up action within 30 days.  Results Reviewers identified missed opportunities in 222 (37.8%) of 587 patients.  Median time to diagnosis in cases with and without missed opportunities was 132 days and 19 days, respectively (P < .001). Abnormal chest x-ray was the clue most frequently associated with type I missed opportunities (62%). Follow-up on abnormal chest x-ray (odds ratio [OR], 2.07; 95% CI, 1.04 to 4.13) and completion of first needle biopsy (OR, 3.02; 95% CI, 1.76 to 5.18) were associated with type II missed opportunities. Patient adherence contributed to 44% of patients with missed opportunities.

Conclusion Preventable delays in lung cancer diagnosis arose mostly from failure to recognize documented abnormal imaging results and failure to complete key diagnostic procedures in a timely manner. Potential solutions include based strategies to improve recognition of abnormal imaging and track patients with suspected cancers.


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Lung Cancer and Mesothelioma is a comprehensive overview of lung cancer treatment and research comprising 41 chapters and over 480 pages. The book reviews chemotherapy, gene therapy, radiation, experimental treatments and other topics, with excerpts available below.      
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