Patterns of Surgical Care of Lung Cancer Patients

Prospective risk-adjusted morbidity and mortality outcome analysis after therapeutic bronchoscopic procedures: results of a multi-institutional outcomes database

INTRODUCTION

Interest in databases is growing to allow for outcomes research, assess health-care quality, and determine best practices and resource allocation, and they are increasingly considered as a tool to potentially tie reimbursement to outcome parameters. Little is known about resource use and risk-adjusted morbidity and mortality after therapeutic bronchoscopic interventions.

METHODS

Data were extracted and reviewed from an ongoing prospective, multi-institutional outcomes database for therapeutic bronchoscopic interventions. All consecutive patients are entered into this database, and information on demographics, indications, procedures and anesthesia, comorbidities and general health status, urgency of intervention, morbidity and mortality to 30 days, increase in levels of care, and procedural resources is documented.

RESULTS

From December 2005 to May 2007, 554 therapeutic procedures were performed in four hospitals. Most procedures were done under general anesthesia (n = 362) and rigid bronchoscopy (n = 483), and the most common intervention was airway stent placement (n = 258). Forty-two percent of procedures were done urgently or emergently. Complications were common (19.8%), and 30-day mortality was 7.8%, correlating with underlying health status and urgency of intervention.

DISCUSSION

Prospective and ongoing data analysis for bronchoscopic procedures is feasible and valuable. Risk-adjusted and disease-specific outcomes can be documented and potentially used for quality assessment, benchmarking, and quality improvement initiatives. Appropriate use of resources and effect of interventions can be documented. Extending the number of participating centers as well as inclusion of quality of life tools and technical success are the next steps.

[Concordance between clinical and pathological staging in patients with stages I or II non-small cell lung cancer subjected to surgical treatment]

OBJECTIVE

To compare clinical and pathological staging in patients with non-small cell lung cancer submitted to surgical treatment, as well as to identify the causes of discordance.

METHODS

Data related to patients treated at the Department of Thoracic Surgery of the Pontifical Catholic University of Rio Grande do Sul São Lucas Hospital were analyzed retrospectively. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for clinical stages IA, IB, and IIB. The kappa index was used to determine the concordance between clinical and pathological staging.

RESULTS

Of the 92 patients studied, 33.7% were classified as clinical stage IA, 50% as IB, and 16.3% as IIB. The concordance between clinical and pathological staging was 67.5% for stage IA, 54.3% for IB, and 66.6% for IIB. The accuracy of the clinical staging was greater for stage IA, and a kappa of 0.74, in this case, confirmed a substantial association with pathological staging. The difficulty in evaluating nodal metastatic disease is responsible for the low concordance in patients with clinical stage IB.

CONCLUSIONS

The concordance between clinical and pathological staging is low, and patients are frequently understaged (in the present study, only one case was overstaged). Strategies are necessary to improve clinical staging and, consequently, the treatment and prognosis of patients with non-small cell lung cancer.

Temporal trends in the management of potentially resectable lung cancer

BACKGROUND

Standardized, evidence-based guidelines recommend lung resection for patients with stage I or II nonsmall-cell lung cancer (NSCLC), and select patients with stage IIIA disease. We hypothesized that the proportion of patients operated on would increase over time coincident with increasing adherence to practice guidelines and improved patient/provider education over time.

METHODS

This investigation was a cohort study of tumor-registry data linked to Medicare claims.

RESULTS

Between 1992 and 2002, 24,030 patients--mean age 75 +/- 6 years, 55% men--were diagnosed with NSCLC. In each stage, the proportion of patients undergoing resection was lower in 2002 compared with 1992: stage I (68% versus 80%, p < 0.001), II (59% versus 74%, p < 0.001), and IIIA (23% versus 35%, p < 0.001). The mean age and comorbidity index of the cohort was higher in 2002 compared with 1992 (76 versus 74 years, p < 0.001; and 0.47 and 0.82, p < 0.001, respectively). The unadjusted odds of resection decreased by 6% per year (odds ratio 0.94, 99% confidence interval: 0.93 to 0.95), and adjustment for age, comorbidity index, race, and stage resulted in a slightly smaller (4% per year) but significantly decreasing trend in operative management over time (odds ratio 0.96, 99% confidence interval: 0.95 to 0.97).

CONCLUSIONS

Unexpectedly, the use of resection for lung cancer has decreased dramatically over time, and this decline is not fully accounted for by an older cohort with more comorbid conditions. Future investigations should determine whether increasing unmeasured contraindications to resection, barriers to accessing specialty care, an inadequate supply of thoracic surgeons, or bias against operative therapy are responsible.

Screening for lung cancer

OBJECTIVE

The purpose of our review is to discuss the current state of lung cancer screening using CT in the context of defined criteria for effective screening.

CONCLUSION

Although there are hopeful developments in lung cancer screening, a number of unresolved issues must be answered before adopting screening on a large scale. Currently no data exist to suggest that lung cancer screening with CT will result in a decrease in lung cancer mortality.

Is palpation of the nonresected pulmonary lobe(s) required for patients with non-small cell lung cancer? A prospective study

OBJECTIVE

Video-assisted lobectomy is an increasingly used technique to treat patients with non-small cell lung cancer but it does not usually afford lung palpation.

METHODS

A prospective study was conducted on patients with tumors amenable to video-assisted lobectomy (noncentral lesion and <5 cm) who underwent open lobectomy via thoracotomy. All patients underwent 64-slice helical computed tomographic scan with intravenous contrast at 5-mm intervals and had integrated 2-deoxy-2-18F-fluoro-D-glucose positron emission tomography computed tomography 30 days or less before thoracotomy. Unsuspected malignant pulmonary nodules that were palpated and removed (from a different lobe than the one resected) and that were not imaged preoperatively were defined as cancer that would have been missed by video-assisted lobectomy.

RESULTS

From January 2006 to February 2007, 166 patients had non-small cell lesions that were resected via thoracotomy, despite being amenable to video-assisted surgery, by one surgeon. Thirty-seven (22%) patients had pulmonary nodules that probably would have been missed by video-assisted lobectomy; 14 (8.4%) of these nodules were malignant. These were unsuspected M1 pulmonary lesions in 9 patients and unsuspected different types of primary non-small cell lung cancers in 5 patients. All missed lesions were less than 6 mm and in different lobes from the one resected. Nine (64%) of these 14 patients' primary known lesions were pathologic T1 lesions. Nine patients received adjuvant chemotherapy because of these unsuspected M1 nodules.

CONCLUSIONS

Open lobectomy that affords palpation of the rest of the lung may discover nonimaged malignant pulmonary nodules in different lobes in 8% to 9% of patients with non-small cell lung cancer despite preoperative fine-cut chest computed tomographic scan with contrast and integrated integrated 2-deoxy-2-18F-fluoro-D-glucose positron emission tomography computed tomographic scanning. The clinical impact of these findings is unknown.

Outcomes of risk-adapted fractionated stereotactic radiotherapy for stage I non-small-cell lung cancer

PURPOSE

High local control rates can be achieved using stereotactic radiotherapy in Stage I non-small-cell lung cancer (NSCLC), but reports have suggested that toxicity may be of concern. We evaluated early clinical outcomes of "risk-adapted" fractionation schemes in patients treated in a single institution.

METHODS AND MATERIALS

Of 206 patients with Stage I NSCLC, 81% were unfit to undergo surgery and the rest refused surgery. Pathologic confirmation of malignancy was obtained in 31% of patients. All other patients had new or growing 18F-fluorodeoxyglucose positron emission tomography positive lesions with radiologic characteristics of malignancy. Planning four-dimensional computed tomography scans were performed and fractionation schemes used (3 x 20 Gy, 5 x 12 Gy, and 8 x 7.5 Gy) were determined by T stage and risk of normal tissue toxicity.

RESULTS

Median overall survival was 34 months, with 1- and 2-year survivals of 81% and 64%, respectively. Disease-free survival (DFS) at 1 and 2 years was 83% and 68%, respectively, and DFS correlated with T stage (p = 0.002). Local failure was observed in 7 patients (3%). The crude regional failure rate was 9%; isolated regional recurrence was observed in 4%. The distant progression-free survival at 1 and 2 years was 85% and 77%, respectively. SRT was well tolerated and severe late toxicity was observed in less than 3% of patients.

CONCLUSIONS

SRT is well tolerated in patients with extensive comorbidity with high local control rates and minimal toxicity. Early outcomes are not inferior to those reported for conventional radiotherapy. In view of patient convenience, such risk-adapted SRT schedules should be considered treatment of choice in patients presenting with medically inoperable Stage I NSCLC.

Surgical assessment and intraoperative management of mediastinal lymph nodes in non-small cell lung cancer

Mediastinal lymph node status has important prognostic and therapeutic implications for nonsmall cell lung cancer patients. Consequently, an accurate pathologic assessment of mediastinal lymph nodes for metastasis is essential. Despite the significance of nodal assessment, practice patterns among surgeons vary widely. Therefore we reviewed the literature to provide evidence-based recommendations regarding the ideal means and extent of preoperative and intraoperative pathologic mediastinal lymph node staging in non-small cell lung cancer patients. We found that the most sensitive and accurate intraoperative method is a complete mediastinal lymph node dissection. Pathologic evaluation of at least 10 mediastinal lymph node from at least three stations should be performed at the time of surgery.

Commonly encountered difficulties in pathologic staging of lung cancer

CONTEXT

Lung cancer is the leading cause of cancer mortality worldwide. Despite technological, therapeutic, and scientific advances, most patients present with incurable disease and a poor chance of long-term survival. For those with potentially curable disease, lung cancer staging greatly influences therapeutic decisions. Therefore, surgical pathologists determine many facets of lung cancer patient care.

OBJECTIVE

To present the current lung cancer staging system and examine the importance of mediastinal lymph node sampling, and also to discuss particularly confusing and/or challenging areas in lung cancer staging, including assessment of visceral pleura invasion, bronchial and carinal involvement, and the staging of synchronous carcinomas.

DATA SOURCES

Published current and prior staging manuals from the American Joint Committee on Cancer and the International Union Against Cancer as well as selected articles pertaining to lung cancer staging and diagnosis accessible through PubMed (National Library of Medicine) form the basis of this review.

CONCLUSIONS

Proper lung cancer staging requires more than a superficial appreciation of the staging system. Clinically relevant specimen gross examination and histologic review depend on a thorough understanding of the staging guidelines. Common sense is also required when one is confronted with a tumor specimen that defies easy assignment to the TNM staging system.

Open lobectomy for patients with stage I non-small cell lung cancer

Until additional multi-institutional, randomized, controlled trials provide evidence to the contrary, open lobectomy with mediastinal lymphadenectomy should be considered the gold standard for treating patients with stage I NSCLC with sufficient cardiopulmonary reserve, including older patients. It is the operation with which alternative pulmonary resections, including video-assisted thoracoscopic lobectomy and sublobar resection, should be compared. In treating stage I NSCLC patients, sublobar resection should be reserved for patients with inadequate physiologic reserve to tolerate lobectomy and for those enrolled in clinical trials.

Risk factors for 30-day mortality after resection of lung cancer and prediction of their magnitude

BACKGROUND

There is considerable variability in reported postoperative mortality and risk factors for mortality after surgery for lung cancer. Population-based data provide unbiased estimates and may aid in treatment selection.

METHODS

All patients diagnosed with lung cancer in Norway from 1993 to the end of 2005 were reported to the Cancer Registry of Norway (n = 26 665). A total of 4395 patients underwent surgical resection and were included in the analysis. Data on demographics, tumour characteristics and treatment were registered. A subset of 1844 patients was scored according to the Charlson co-morbidity index. Potential factors influencing 30-day mortality were analysed by logistic regression.

RESULTS

The overall postoperative mortality rate was 4.4% within 30 days with a declining trend in the period. Male sex (OR 1.76), older age (OR 3.38 for age band 70-79 years), right-sided tumours (OR 1.73) and extensive procedures (OR 4.54 for pneumonectomy) were identified as risk factors for postoperative mortality in multivariate analysis. Postoperative mortality at high-volume hospitals (> or = 20 procedures/year) was lower (OR 0.76, p = 0.076). Adjusted ORs for postoperative mortality at individual hospitals ranged from 0.32 to 2.28. The Charlson co-morbidity index was identified as an independent risk factor for postoperative mortality (p = 0.017). A prediction model for postoperative mortality is presented.

CONCLUSIONS

Even though improvements in postoperative mortality have been observed in recent years, these findings indicate a further potential to optimise the surgical treatment of lung cancer. Hospital treatment results varied but a significant volume effect was not observed. Prognostic models may identify patients requiring intensive postoperative care.

Risk-adjusted morbidity and mortality models to compare the performance of two units after major lung resections

OBJECTIVE

We sought to develop risk-adjusted morbidity and mortality models to compare the performance of 2 different thoracic surgery units in patients submitted to major lung resections.

METHODS

Seven hundred forty-three patients (551 male and 192 female patients) who underwent lobectomy (n = 611) or pneumonectomy (n = 132) from January 2000 through August 2004 at 2 European thoracic units (519 patients in unit A and 224 patients in unit B) were analyzed. Risk-adjusted models of 30-day or in-hospital cardiopulmonary morbidity and mortality were developed by using stepwise logistic regression analyses and validated by means of bootstrap analysis. Preoperative and operative variables were initially screened by using univariate analysis. Those with a P value of less than .10 were used as independent variables in the regression analyses. The regression equations were then used to estimate the risk of outcome, and the observed and predicted outcome rates of the 2 units were compared by using the z test for comparison of proportions.

RESULTS

The following regression models were developed. Predicted morbidity: lnR/1-R=-2.4+0.03Xage-0.02XppoFEV1+0.6Xcardiaccomorbidity (Hosmer-Lemeshow statistic = 6.1 [P = .6], c index = 0.65). Predicted mortality: lnR/1-R=-6.97+0.095Xage-0.042XppoFEV1 (Hosmer-Lemeshow statistic = 2.99 [P = .9], c index = 0.77). The models proved to be stable at bootstrap analyses. No differences were noted between observed and predicted outcome rates within each unit, despite an apparent unadjusted better performance of unit B.

CONCLUSIONS

The use of risk-adjusted outcome models avoided misleading information derived from the unadjusted analysis of performance. Risk modeling is essential for the evaluation of the quality of care.

Postoperative respiratory failure

This analysis differentiates the causes of postoperative respiratory failure. Respiratory failure in thoracic patients is broken down into two distinct groups, aspiration and pneumonia, promoting actions to prevent respiratory failure. The goal is to develop different strategies to avoid postoperative respiratory failure using an active approach (what can be done in the management of patients undergoing lung resection to prevent problems) rather than passive approach (what patient factors caused problems after surgery). Before that analysis, the operative risks after lung resections (lobectomies, pneumonectomies, elderly patients) and esophagectomies are reviewed to understand the data.

Nine-year single center experience with cervical mediastinoscopy: complications and false negative rate

BACKGROUND

Mediastinoscopy is a valuable tool for evaluating mediastinal pathology and is essential for establishing treatment strategies in most patients with lung cancer. We sought to determine the complication and false negative rate for mediastinoscopy in an institution that routinely performs this procedure.

METHODS

We performed a retrospective review of 2,145 consecutive mediastinoscopies at a single institution between April 1996 and April 2005. Demographics and complications were analyzed. In patients with lung cancer who underwent subsequent resection, the false negative rate was calculated.

RESULTS

Mean patient age was 61 +/- 0.4 years, and 58% (n = 1,253) were male. Pathology included lung cancer (n = 1,459), metastatic disease (n = 78), lymphoma (n = 51), and other benign disease (n = 557). Twenty-three patients (1.07%) experienced complications including hemorrhage (n = 7, 0.33%), vocal cord dysfunction (n = 12, 0.55%), tracheal injury (n = 2, 0.09%), and pneumothorax (n = 2, 0.09%). There was 1 death (0.05%) after pulmonary artery injury. Five of the 7 vascular injuries occurred during biopsy of level 4R. Three hundred and forty-three patients (23.5%) with lung cancer had positive mediastinoscopies. The false negative rate was 56 of 1,019 (5.5%) among lung cancer patients undergoing resection. Thirty-two (57%) of the false negatives were due to metastatic disease in lymph nodes not normally biopsied during cervical mediastinoscopy (levels 5, 6, 8, or 9).

CONCLUSIONS

Although invasive, mediastinoscopy identified locally advanced disease in a significant percentage of this lung cancer population and was associated with a low false negative rate. Complications after mediastinoscopy were uncommon. These results support the continued routine use of mediastinoscopy.