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Introduction: The organ-specific Danish cancer patient pathways (CPPs) including standard time frames were introduced in 2008-2009 securing fast tracks for cancer diagnosis and treatment. Previous studies of the CPPs have focussed on patients getting the suspected cancer diagnosis, whereas little is known about patients not getting the cancer diagnosis for which they were examined. We aimed to describe the characteristics of patients who completed a lung cancer CPP (LCPP) without getting a LC diagnosis. Furthermore, to assess the proportion of patients who had invasive procedures performed during the LCPP and radiographic examinations of the chest conducted 30 days prior to the LCPP and during the LCPP. Moreover, we aimed to describe the proportion of patients being diagnosed with any other cancer-type than LC or with non-malignant pulmonary diseases (NMPDs) during the LCPP. Methods: The study was a retrospective population-based cohort study based on Danish national registers. Patients completing a LCPP between 1 January 2013 and 31 December 2016 without being diagnosed with LC and who were registered as initiating and completing the LCPP, a total of 35,809, were included in the study. Results: Invasive procedures were performed in 12,986 patients (37.4%) and almost all patients had CT-scans of thorax and lungs conducted 30 days prior to or during the LCPP. During the LCPP other cancer-types than LC were diagnosed in 1,537 patients (4.3% of the study population), including other primary thoracic malignancies in 312 patients, while 6,826 patients (19.1%) were diagnosed with NMPDs, most often infections or chronic respiratory diseases of lower airways. Conclusion: Besides diagnosing LC the LCPP may contribute significantly in diagnosing other primary and secondary cancers as well as non-malignant diseases.

Introduction: Recurrence of cancer is not routinely registered in Danish national health registers. This study aimed to develop and validate a register-based algorithm to identify patients diagnosed with recurrent lung cancer and to estimate the accuracy of the identified diagnosis date. Material and Methods: Patients with early-stage lung cancer treated with surgery were included in the study. Recurrence indicators were diagnosis and procedure codes recorded in the Danish National Patient Register and pathology results recorded in the Danish National Pathology Register. Information from CT scans and medical records served as the gold standard to assess the accuracy of the algorithm. Results: The final population consisted of 217 patients; 72 (33%) had recurrence according to the gold standard. The median follow-up time since primary lung cancer diagnosis was 29 months (interquartile interval: 18– 46). The algorithm for identifying a recurrence reached a sensitivity of 83.3% (95% CI: 72.7– 91.1), a specificity of 93.8% (95% CI: 88.5– 97.1), and a positive predictive value of 87.0% (95% CI: 76.7– 93.9). The algorithm identified 70% of the recurrences within 60 days of the recurrence date registered by the gold standard method. The positive predictive value of the algorithm decreased to 70% when the algorithm was simulated in a population with a recurrence rate of 15%. Conclusion: The proposed algorithm demonstrated good performance in a population with 33% recurrences over a median of 29 months. It can be used to identify patients diagnosed with recurrent lung cancer, and it may be a valuable tool for future research in this field. However, a lower positive predictive value is seen when applying the algorithm in populations with low recurrence rates. [ABSTRACT FROM AUTHOR]

• Two thirds of Danish stage I lung cancer patients are surgically treated. • Differences in outcome according to curative treatment were due to age and performance status. • Treatment registration in the Danish Lung Cancer Registry can be improved. • Histology, high-risk alcohol and comorbidity were associated with not undergoing treatment. Stage I lung cancer is curable with surgery as the treatment of choice. Other effective and curative treatments exist. Nevertheless, some patients only receive palliative treatment and some receive no treatment at all. Using the Danish Lung Cancer Registry (DLCR), we assessed treatment distribution for a population-based Danish cohort of stage I lung cancer patients diagnosed from 2011 to 2014. We assessed one-year mortality according to treatment. Furthermore, in a nested case-control study based on data from medical records, we assessed the reason for not undergoing treatment among patients in favourable performance status (PS) with no treatment registration in the DLCR. We identified 2985 patients, 68% (n = 2021) were treated surgically and 17% (n = 508) were managed with curative oncological therapy. The unadjusted odds ratio (OR) for death within one year was 2.5 (95% CI, 1.8–3.3) for the oncologically managed vs. the surgically treated. After adjusting for age, lung function and PS, the OR was 1.2 (95% CI, 0.8–1.9). Among 129 patients with a PS of 0–1 and no treatment registration, we established the reason for not undergoing treatment in 122 (95%). The majority (70%) were misclassified and did either not have lung cancer, had more advanced disease or were curatively treated. The 36 (30%) patients that did not undergo treatment, had a lower prevalence of adenocarcinomas (17 vs. 51%, p = 0.003), more comorbidites (median Charlson comorbidity index score 2 vs. 1, p < 0.001) and high alcohol intake (19 vs. 7%, p = 0.04) as compared to surgically treated controls. The primary reasons for no treatment were; comorbidity, patient decision and disease progression. Difference in outcome between the two major treatment groups was confounded by age, lung function and PS. Comorbidity, high alcohol intake and histology were associated with not undergoing curative treatment in spite of a favourable PS. [ABSTRACT FROM AUTHOR]

Highlights • Denmark has high rates of smoking, alcohol drinkers and lung cancer mortality. • Being a never-smoker is associated with a good prognosis. • High alcohol intake in surgically treated is associated with early death. • There is little emphasis on smoking cessation in the follow-up program. Abstract Introduction In addition to the highest incidence rate of lung cancer among the Nordic countries, Denmark has the highest mortality rate. Moreover, rates of tobacco and alcohol consumption are among the highest in these countries. Method In a population-based matched case/control study, we aimed to assess the association between one-year all-cause mortality and a number of smoking-related parameters, high-risk alcohol intake, and nutritional status in clinical stage I lung cancer patients. Results We included 221 patients who died within one year after diagnosis (early death) and 410 matched controls who survived more than one year (survivor). The odds ratio (OR) for early death among never-smokers was 0.3 (CI 95%: 0.1–0.9). There was no significant difference between patients who died early and survivors in proportions of current smokers (49 vs. 45%), number of cumulated pack-years (45 vs. 46), daily tobacco consumption (15 vs. 14 cigarettes/day), patients who quit smoking after diagnosis (25 vs. 40%) and the prevalence of chronic obstructive pulmonary disease (COPD) (43 vs. 38%). Patients that died early received more medications for COPD (p = 0.03) and smoked more after diagnosis, 14 vs. 10 cigarettes per day (p = 0.03). The unadjusted OR for high-risk alcohol intake was 2.2 (CI 95% 1.3–3.7) in the early death group vs. the survivors. However, in a treatment-stratified analysis this was observed only for surgically treated patients (OR, 3.2; CI 95% 1.7–6.1). Low nutritional status was associated with early death, unadjusted (OR 2.3; CI 95% 1.4–3.7), while OR was 1.8 (95% CI 1.0–2.3) adjusted for high-risk alcohol intake and COPD. Treatment selection according to and interventions against these factors before and after lung cancer diagnosis may improve outcomes. [ABSTRACT FROM AUTHOR]

Background:The Nordic countries are similar in terms of demographics and health care organization. Yet there are marked differences in lung cancer mortality, for which Denmark historically has had the poorest outcome. One of several possible reasons for these differences could have to do with how lung cancer is diagnosed and treated in the different Nordic countries. However, among the four most populous Nordic countries: Sweden, Denmark, Norway and Finland, there is a paucity of knowledge about differences and similarities in recommendations in the national guidelines for non-small cell lung cancer (NSCLC) and the methodology by which the guidelines are developed. Methods:We identified and evaluated the development and content of the available clinical care guidelines for NSCLC in the four countries. Moreover, we compared the integrated cancer pathways in these countries. We have used case examples to illustrate areas with clear differences in clinical care recommendations. Results:There are notable differences in the methodology by which the guidelines are developed, published and updated to comply with international recommendations. The Norwegian guidelines are developed and updated according to the most rigorous methodology and have so far been updated most frequently. We found that on the basis of recommendations patients with NSCLC are treated differently with regard to bevacizumab therapy and radiation dosing regimens. Cerebral imaging practices in patients with locally advanced NSCLC also differ. There is, moreover, a marked difference with regard to efforts to help patients to quit smoking. All except Finland have integrated cancer pathways for fast track diagnosis and treatment. Guidelines for follow-up of lung cancer patients also differ, with the Danish follow-up regimen as the most comprehensive. To obtain consensus on optimal clinical care, areas with differences in recommendations or where recommendations are based on a low level of evidence should be subjected to further studies. [ABSTRACT FROM AUTHOR]