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We had the subjective impression that many patients admitted for resection of their lung cancer had first presented several months previously. The numerous steps in diagnosis and preoperative staging inevitably entail some delay, but the delay seemed to be longer than necessary. The survival of patients with lung cancer is well known to be correlated with the stage.' Naturally there is concern that delay in diagnosis and treatment allows tumour progression and thus reduces survival. The patient may also require more extensive resection. This is in addition to the high levels of anxiety that any delay can generate in patients who realise that they have lung cancer which may require surgery.This study was undertaken to assess the length and cause of delay from the first presentation to surgery and to identify the stages at which such delay occurs. Methods A retrospective study was made of all patients with lung tumours referred for lung resection at Papworth Hospital from 1 January 1993 to 31 December 1993. The names of the relevant patients were found from the operating theatre audit information. Data were obtained from medical records at the cardiothoracic regional centre and also at the referring hospitals. General practitioners and the departments of radiology and pathology were contacted for further details when required. The data collected were the dates on which each consultation, investigation and referral occurred, and the date of operation. The time of onset of symptoms was not recorded, since this would be very inaccurate in such a retrospective study and since it is not germane to the study. The tumour type and stage were also identified. From these data it was possible to identify the delay incurred by each patient at each stage in the investigative process. The hospital records for one patient were not available for this retrospective study, and this patient has therefore been excluded from the analysis.The delays studied were: (1) from first presentation to chest radiography, and (2) to chest physician referral; (3) from chest physician referral to chest clinic appointment; delays for (4) bronchoscopy, (5) CT scanning and (6) percutaneous needle biopsy; (7) from chest physician referral to surgical referral; (8) from this referral to surgical outpatient appointment; (9) from surgical referral to operation; and (10) the total delay from presentation to 903 on 10 May 2018 by guest. Protected by copyright.

Background: Health related quality of life (HRQOL) after surgery is important, although very limited data are available on the QOL after lung cancer surgery. Methods: The effect of surgery on HRQOL was assessed in a prospective study of 110 patients undergoing potentially curative lung cancer surgery at Papworth Hospital, 30% of whom had borderline lung function as judged by forced expiratory volume in 1 second. All patients completed the EORTC QLQ-C30 and LC13 lung cancer module before surgery and again at 1, 3 and 6 months postoperatively. Results: On average, patients had high levels of functioning and low levels of symptoms. Global QOL had deteriorated significantly 1 month after surgery (p = 0.001) but had returned to preoperative levels by 3 months (p = 0.93). Symptoms had worsened significantly at 1 month after surgery but had returned to baseline levels by 6 months. Low values on the preoperative HRQOL scales were not significantly associated with poor surgical outcome. However, patients with low preoperative HRQOL functioning scales and high preoperative symptom scores were more likely to have poor postoperative (6 months) QOL. The only lung function measurement to show a marginally statistically significant association with quality of life at 6 months after surgery was percentage predicted carbon monoxide transfer factor (TLCO). Conclusion: Although surgery had short term negative effects on quality of life, by 6 months HRQOL had returned to preoperative values. Patients with low HRQOL functioning scales, high preoperative symptom scores, and preoperative percentage predicted TLCO may be associated with worse postoperative HRQOL.

Background-Surgical resection is the recognised treatment of choice for patients with stage I or II non-small cell lung cancer (NSCLC). In the UK surgical resection rates have remained far lower (<10%) than those achieved in Europe and the USA (>20%), despite the recent introduction of fast access investigation units. It remains unclear therefore why UK surgical resection rates lag so far behind those of other countries. Methods-A new quick access two stop investigation service was established at Papworth in November 1995 to investigate all patients presenting to any of three surrounding health districts with suspected lung cancer. Once staging was complete, all patients with confirmed lung cancer were reviewed by a multidisciplinary team which included an oncologist and a thoracic surgeon. Time from presentation to definitive treatment and surgical resection rates were reviewed. Results-Two hundred and nine (76%) of a total of 275 consecutive patients investigated had confirmed lung cancer (28 small cell, 181 non-small cell). Of the remainder, eight patients (2%) had metastatic disease, four (1%) had other thoracic malignancy (thymoma, mesothelioma), four patients (1%) had benign thoracic tumours, and 50 (18%) had other non-malignant diseases. Of the 181 patients with non-small cell primary lung cancer, 47 (25%) underwent successful surgical resection, of whom 59% had stage I and 21% stage II disease. The failed thoracotomy rate was 11%. Median time from presentation at the peripheral clinic to surgical resection was 5 weeks (range 1-13). Conclusion-Quick access investigation, high histological confirmation rates, routine CT scanning, and review of every patient with confirmed lung cancer by a thoracic surgeon led to a substantial increase in the successful surgical resection rate. These results support the growing concern that many patients with operable tumours are being denied the chance of curative surgery in our present system. (Thorax 1998;53:445-449)

Standards for best practice in mitral valve repair were defined by multidisciplinary consensus. This study gives centres undertaking mitral valve repair an opportunity to benchmark their care against agreed standards that are challenging but achievable. Working towards these standards should act as a stimulus towards improvements in care.

Mitral valve repair is superior to replacement. The greatest survival advantage is in reduced mortality from myocardial failure. Repair should be the operation of choice for degenerative mitral regurgitation.

The British Thoracic Society and American College of Chest Physician guidelines outline criteria for investigating patients for lung cancer surgery. However, the guidelines are based on relatively old studies. Therefore, the relationship between pulmonary function test results and surgical outcome were studied prospectively in a large cohort of lung cancer patients.From January 2001 to December 2003, 110 patients underwent surgery for lung cancer. All underwent full lung function testing in order to predict post-operative lung function.The hospital mortality rate was 3% and major complication rate 22%. There was poor overall outcome in 13%. Mean pre-operative lung function values were: forced expiratory volume in one second (FEV1) 2.0 L (79.4% of the predicted value), and carbon monoxide diffusing capacity of the lung (DL,CO) 73.6% pred. The mean post-operative lung function values were: FEV1 1.4 L (55.6% pred), and DL,CO 51.3% pred. All lung function values were better predictors of poor surgical outcome when expressed as a percentage of the predicted value. Using a threshold of preoperative FEV1 of 47% pred resulted in the most useful positive and negative predictive probabilities, 0.90 and 0.67, respectively.Lung function values expressed as a percentage of the predicted value are more useful predictors of post-operative outcome than absolute values. The threshold of predicted forced expiratory volume in one second for surgical intervention could be lower (45-50% pred) than is currently accepted without increased mortality.KEYWORDS: Lung carcinoma, lung function, lung function tests, surgical resection S urgical resection remains the treatment of choice for anatomically resectable nonsmall cell lung cancer [1,2], offering the best prospect of long-term survival. However, many patients have coexisting chronic airflow limitation [3], which is associated with an increased risk from surgery. Loss of lung tissue may grossly impair post-operative ventilatory function in such patients, predisposing to cardiopulmonary complications, including death. The British Thoracic Society (BTS) and American College of Chest Physician guidelines [4,5] outline criteria for investigating patients with borderline lung function. However, many of the studies on which the guidelines are based are relatively old, and often based on predominantly male patients who were significantly younger than patients currently being considered for surgery.The latest BTS guidelines suggest that further investigation is unnecessary if a patient has a forced expiratory volume in one second (FEV1) of .2.0 L for pneumonectomy or .1.5 L for lobectomy. This is because studies have shown a mortality rate of ,5% using these criteria. However, these figures are based mainly on studies involving males, and it is likely that lower values would be more appropriate for females. It is possible that a figure based on a value expressed as a percentage of the predicted value would be better still, since this would also take into account the patient's age, s...

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