Impact of smoking cessation before resection of lung cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database study

Guidelines for preoperative pulmonary function assessment in patients with lung cancer who will undergo surgery (The Japanese Association for Chest Surgery)

This article translates the guidelines for preoperative pulmonary function assessment in patients with lung cancer who will undergo surgery, established by the Japanese Association of Chest Surgery on May 17, 2021, from Japanese to English. The last version of these guidelines was created on April 5, 2011. Over the past decade, changes in clinical practice have occurred that do not align with the current guidelines, prompting a revision in conjunction with the introduction of new evidence this time. This guideline was developed with reference to the internationally adopted GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. Extraction of evidence, systematic review, and quality assessment are entrusted to each guideline review committee and the Pulmonary Function Assessment Working Group. Committee members are also responsible for determining the selection of evidence and the extraction period, with a particular emphasis on adopting items considered to be of special importance. The recommended assessment and management is categorized into a general overview, pulmonary function assessment, cardiopulmonary exercise test, pulmonary function assessment for lung cancer with interstitial pneumonia, preoperative smoking cessation, and pulmonary rehabilitation. These are described by the strength of recommendation, the strength of evidence, and the consensus rate.

Postdiagnosis Smoking Cessation and Survival Outcomes of Head and Neck Cancer Patients

BACKGROUND

Post-diagnosis smoking remains prevalent among head and neck squamous cell carcinoma (HNSCC) patients. Smoking cessation may improve patient outcomes.

METHODS

A prospective longitudinal cohort study (2008-2014) included 835 newly diagnosed HNSCC patients and followed up for 7 years. Participants were categorized by smoking behavior (never smokers, former smokers, quitters, continuing smokers, and intermittent smokers). The primary outcomes were overall survival (OS) and recurrence-free survival (RFS).

RESULTS

Smoking cessation after diagnosis was associated with significantly improved OS. Quitters had a 61% reduction in mortality risk compared to continuing smokers (HR: 0.39, 95% CI: 0.22, 0.69), with the greatest benefit in oral cavity cancer patients (HR: 0.28, 95% CI: 0.12, 0.65). Intermittent smokers also showed improved survival (HR: 0.50, 95% CI: 0.31, 0.79). RFS did not significantly differ based on smoking behavior.

CONCLUSIONS

Smoking cessation post-diagnosis improves OS, particularly in oral cavity cancer patients, highlighting the importance of targeted smoking cessation interventions in HNSCC care.

The impact of smoking on postoperative complications following elective off-pump CABG in an ERAS setting

PURPOSE

This study investigates the impact of smoking on major postoperative complications following elective off-pump coronary artery bypass graft (CABG) surgery within an enhanced recovery after surgery (ERAS) program.

METHODS

A total of 3168 patients who underwent elective off-pump and minimally invasive direct CABG under ERAS between January 1, 2017, and December 31, 2020, were enrolled. Propensity score matching was applied to minimize potential confounders when comparing postoperative outcomes between smokers and non-smokers.

RESULTS

Multivariate logistic regression analyses showed no significant difference in 30-day postoperative mortality between smokers and non-smokers (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 0.40-1.56). However, smokers had a higher risk of 30-day major complications, including postoperative acute myocardial infarction (AMI) (aOR: 1.43, 95% CI: 1.02-1.99) and overall postoperative complications (aOR: 1.18, 95% CI: 1.04-1.48). Similarly, for the 31-90-day period, smokers had no significantly higher risk of mortality (aOR: 1.06, 95% CI: 0.49-1.19), but experienced higher rates of major complications, including postoperative AMI (aOR: 1.73, 95% CI: 1.17-2.55) and overall postoperative complications (aOR: 1.48, 95% CI: 1.13-1.92).

CONCLUSIONS

The ERAS program benefits patients undergoing CABG surgery, including smokers, by providing similar major postoperative outcomes to non-smokers, except for increased risks of postoperative AMI and overall complications.

Impact of smoking habits on postoperative outcomes following lung surgery for cancer: results from the Epithor database

OBJECTIVES

Smoking is a modifiable risk factor for lung resections but to what extent preoperative smoking cessation reduces that risk remains unclear. The study hypothesis was that the potential benefit of smoking cessation can be assessed by measuring the risk difference between active and former smokers in a large cohort of patients.

METHODS

Data were extracted from the French Society of Thoracic and Cardiovascular Surgeons (Société Française de Chirurgie Thoracique et Cardiovasculaire) database. The study cohort comprised patients who underwent lung resection for cancer from January 2002 to December 2020 and for which information on smoking status was available. The risk of overall and specific postoperative complications according to smoking status was defined by logistic regression models, and results were presented in terms of odds ratios (ORs) and relative 95% confidence intervals (CIs) adjusted for confounding factors.

RESULTS

Of the 7204 analysed patients at the time of their operations, 20.2% were active smokers, 60.7% were ex-smokers and 19.1% were never smokers. Compared to former smokers, active smokers experienced a higher rate of respiratory complications (OR 1.5, CI 1.2-1.7) and infections (OR 1.6, CI 1.3-1.9). Postoperative atelectasis was significantly reduced in former smokers (3%) compared to active smokers (6.9%, P < 0.01). In active smokers, the risk was related to the level of exposure, being higher for smokers of more than 40 pack-year.

CONCLUSIONS

After lung surgery, active smokers experience a higher risk of respiratory complications, infections and prolonged air leak compared to former smokers. This risk seems to be related to the level of exposure.

Smoking and Complications After Cancer Surgery: A Systematic Review and Meta-Analysis

Importance

Surgical cancer treatments may be delayed for patients who smoke over concerns for increased risk of complications. Quantifying risks for people who had recently smoked can inform any trade-offs of delaying surgery.

Objective

To investigate the association between smoking status or smoking cessation time and complications after cancer surgery.

Data Sources

Embase, CINAHL, Medline COMPLETE, and Cochrane Library were systematically searched for studies published from January 1, 2000, to August 10, 2023.

Study Selection

Observational and interventional studies comparing the incidence of complications in patients undergoing cancer surgery who do and do not smoke.

Data Extraction and Synthesis

Two reviewers screened results and extracted data according to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Data were pooled with a random-effects model and adjusted analysis was performed.

Main Outcomes and Measures

The odds ratio (OR) of postoperative complications (of any type) for people who smoke currently vs in the past (4-week preoperative cutoff), currently smoked vs never smoked, and smoked within shorter (2-week cutoff) and longer (1-year cutoff) time frames.

Results

The meta-analyses across 24 studies with a pooled sample of 39 499 participants indicated that smoking within 4 weeks preoperatively was associated with higher odds of postoperative complications compared with ceasing smoking for at least 4 weeks (OR, 1.31 [95% CI, 1.10-1.55]; n = 14 547 [17 studies]) and having never smoked (OR, 2.83 [95% CI, 2.06-3.88]; n = 9726 [14 studies]). Within the shorter term, there was no statistically significant difference in postoperative complications between people who had smoked within 2 weeks preoperatively and those who had stopped between 2 weeks and 3 months in postoperative complications (OR, 1.19 [95% CI, 0.89-1.59]; n = 5341 [10 studies]), although the odds of complications among people who smoked within a year of surgery were higher compared with those who had quit smoking for at least 1 year (OR, 1.13 [95% CI, 1.00-1.29]; N = 31 238 [13 studies]). The results from adjusted analyses were consistent with the key findings.

Conclusions and Relevance

In this systematic review and meta-analysis of smoking cessation and complications after cancer surgery, people with cancer who had stopped smoking for at least 4 weeks before surgery had fewer postoperative complications than those smoking closer to surgery. High quality, intervention-based evidence is needed to identify the optimal cessation period and inform clinicians on the trade-offs of delaying cancer surgery.

Ultra-short-period perioperative pulmonary rehabilitation on short-term outcomes after surgery in smoking patients with lung cancer: a randomized clinical trial

BACKGROUND

Pulmonary rehabilitation (PR) is essential for airway management after thoracic surgery. Most current PRs are composed of 2-4-week exercises, which require significant consumption of medical resources and concerns about disease progression.

MATERIALS AND METHODS

This single-center, prospective, randomized controlled trial enrolled smoking patients with pulmonary masses or nodules suitable for lobectomy, aged 18-80, with a smoking history (≥20 pack-years). Eligible patients were randomized in a 1:1 ratio into two groups. Patients in the intervention group underwent perioperative breathing exercises based on positive pressure vibration expectoration and 3-day preoperative lower limb endurance training. Patients in the control group received routine perioperative care. The primary outcome was in-hospital incidence of postoperative pulmonary complications. Secondary outcomes included postoperative hospital stay, total hospitalization cost, postoperative drainage time, drainage volume, semiquantitative cough strength score, pain score, Borg scale-assessed fatigue, and walking distance on postoperative days 1 and 2.

RESULTS

A total of 194 patients were included in the study, with 94 in the intervention group and 100 in the control group. Our ultrashort PR program potentially reduced pulmonary complications incidence (24.5 vs. 33.0%), but without statistical significance ( P =0.190). No significant differences were found in other perioperative outcomes, except for postoperative semiquantitative cough strength score (3 [interquartile range, 3-3.75] vs. 3 [interquartile range, 2-3], P <0.001) and change in walking distance from postoperative days 1 to 2 (60 [interquartile range, 40-82.5] vs. 30 [interquartile range, 10-60], P =0.003).

CONCLUSION

There were no significant differences in postoperative complications and other hospitalizations, but our ultrashort rehabilitation program improved patients' semiquantitative cough strength score and walking distance, indicating the potential for better outcomes. This treatment is a safe and effective means of airway management for thoracic surgery in the era of enhanced recovery (ClinicalTrials.gov Identifier: NCT03010033).

Relationship between gender and perioperative clinical features in lung cancer patients who underwent VATS lobectomy

OBJECTIVES

Compare the differences in perioperative clinical characteristics of lung cancer patients of different genders who have undergone VATS lobectomy, and explore the impact of these differences on the short-term prognosis of patients.

METHODS

A total of 338 consecutive patients with lung cancer who underwent VATS lobectomy in our hospital from August 2021 to August 2022 were retrospectively analyzed, they were divided into male group and female group. The perioperative characteristics and short-term prognosis of different groups were compared. The multivariate binary logistic regression analysis was used to analyze the risk factors.

RESULTS

There were statistically significant differences between male and female patients in age of onset, body surface area (BSA), smoking rate, alcohol consumption rate, hypertension incidence, pulmonary function and clinical stage. There were statistically significant differences between male and female patients in operation time and lymph node dissection. The probability of postoperative complications, such as pulmonary infection, persistent air leakage and severe subcutaneous emphysema, in male patients was significantly higher than that in female patients. The average daily postoperative thoracic drainage volume in male patients was considerably higher than that in female patients, and the postoperative duration of thoracic drainage tube and hospital stay in male patients were significantly longer than those in female patients. After multiple regression analysis, low FEVI values in males was found to be an independent risk factor for postoperative complications.

CONCLUSIONS

Compared with female patients, male patients with lung cancer are more likely to have unfavorable factors such as older age, higher smoking rate, poor pulmonary function and late clinical stage of tumors when they undergoing VATS surgery treatment. The appropriate thoracic drainage time can be selected according to gender differences to shorten the length of hospital stay. The incidence of postoperative complications is higher in male patients, especially those with poor pulmonary function, and active perioperative intervention is required to reduce the incidence of postoperative complications.

Timing effects of short-term smoking cessation on lung cancer postoperative complications: a systematic review and meta-analysis

BACKGROUND

Preoperative smoking cessation may reduce postoperative complications in patients with lung cancer. However, the optimal duration of short-term preoperative smoking cessation remains unclear.

METHODS

Three databases, PubMed, Embase, and the Cochrane Library, were searched for studies published up to April 5, 2024. The Newcastle-Ottawa scale was used to assess the risk of bias. The included studies compared the incidence of postoperative complications between patients with different preoperative smoking cessation times and those with persistent preoperative smoking. A meta-analysis of postoperative complications and events such as pneumonia was performed in patients with lung cancer.

RESULTS

Fourteen studies met the inclusion criteria and included a total of 50,741 patients who had undergone pulmonary resection. The meta-analysis showed that preoperative smoking cessation of > 2 weeks and < 1 month did not reduce the incidence of postoperative complications (odds ratio [OR] 1.05; 95% confidence interval [CI] 0.76-1.44; P = 0.78) and pneumonia (OR 0.98; 95% CI 0.60-1.61; P = 0.95). Moreover, preoperative smoking cessation for > 1 month was effective in reducing the incidence of postoperative complications (OR 0.72; 95% CI 0.63-0.83; P < 0.01) as well as pneumonia (OR 0.80; 95% CI 0.49-1.33; P = 0.40).

CONCLUSIONS

This meta-analysis suggests that preoperative smoking cessation for > 1 month is effective in reducing complications and pneumonia after pulmonary resection in patients with lung cancer, especially as video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery become more common.

Identification of the Prognostic Factors for Synchronous Multiple Primary Lung Cancer Treated With Staged Bilateral Surgery

INTRODUCTION

Staged bilateral surgery is widely used to treat synchronous multiple primary lung cancer (SMPLC); however, the prognostic factors for survival outcomes remain unclear. This study aimed to identify prognostic factors and construct a predictive model for overall survival (OS) and recurrence-free survival (RFS) in patients with SMPLC who underwent staged bilateral surgery.

METHODS

The study included 256 patients diagnosed with SMPLC and treated with staged bilateral surgery at our hospital between January 2010 and July 2017. Multivariate Cox proportional-hazard regression was used to identify prognostic factors for OS and RFS. Additionally, a predictive model was constructed using time-dependent receiver operating characteristic curves.

RESULTS

Among the 256 patients, 10 (3.95%) succumbed to the disease and 24 (9.41%) experienced recurrence. Smoking (hazard ratio [HR]: 5.128; 95% confidence interval [CI]: 1.442-18.233; p = 0.012) and most advanced pathological TNM (pTNM) stage (II + III) (HR: 12.938; 95% CI: 2.650-63.176; p = 0.002) were identified as significant predictors of poor OS. A prognostic model was developed for predicting OS, with a 5-year area under the curve (AUC) of 0.854. Furthermore, most advanced pTNM stage (II + III) was associated with poor RFS (HR: 5.964; 95% CI: 2.669-13.327; p < 0.001), and the predictive model exhibited a 5-year AUC of 0.718 for RFS.

CONCLUSION

This study revealed that smoking and most advanced pTNM stage were independent prognostic factors associated with poor OS in patients with bilateral SMPLC. Moreover, most advanced pTNM stage was also linked to unfavorable RFS. The developed predictive model demonstrated moderate prognostic performance for both OS and RFS.

Oncologists' communication about tobacco and alcohol use during treatment for esophagogastric cancer: a qualitative observational study of simulated consultations

PURPOSE

Tobacco and alcohol use influence cancer risk as well as treatment outcomes, specifically for esophageal and gastric cancer patients. Therefore, it is an important topic to discuss during consultations. This study aims to uncover medical, radiation, and surgical oncologists' communication about substance use, i.e., tobacco and alcohol use, in simulated consultations about curative and palliative esophagogastric cancer treatment.

METHODS

Secondary analyses were performed on n = 40 standardized patient assessments (SPAs) collected in three Dutch clinical studies. Simulated patients with esophagogastric cancer were instructed to ask about smoking or alcohol use during treatment. The responses of the 40 medical, radiation, and surgical oncologists were transcribed verbatim, and thematic analysis was performed in MAXQDA.

RESULTS

Oncologists consistently advocated smoking cessation during curative treatment. There was more variation in their recommendations and arguments in the palliative compared to the curative setting and when addressing alcohol use instead of smoking. Overall, oncologists were less stringent regarding behavior change in the palliative than in the curative setting. Few oncologists actively inquired about the patient's perspective on the substance use behavior, the recommended substance use change, or the support offered.

CONCLUSION

Clear guidelines for oncologists on when and how to provide unequivocal recommendations about substance use behavior change and support to patients are needed. Oncologists might benefit from education on how to engage in a conversation about smoking or alcohol.

Smoking Status and Outcomes following Lung Resection

BACKGROUND

 Surgical resection is the gold standard treatment for the management of early-stage lung cancer. Several modifiable factors may significantly influence postoperative morbidity and mortality. We examined the outcomes of patients following lung resection based upon preoperative smoking status to quantify the impact on postoperative outcomes.

METHODS

 Data from consecutive lung resections from January 1, 2012 to June 11, 2021 were included. Biopsies for interstitial lung disease and resections for emphysematous lung or bullae were excluded. Patients were divided into three cohorts: current smokers (those who smoked within 4 weeks of surgery), ex-smokers (those who stopped smoking prior to 4 weeks leading up to surgery), and nonsmokers (those who have never smoked). Patient's preoperative variables, postoperative complications, length of stay, and mortality were examined.

RESULTS

 A total of 2,426 patients were included in the study. A total of 502 patients (20.7%) were current smokers, 1,445 (59.6%) were ex-smokers and 479 patients (19.7%) nonsmokers. Of those smoking immediately prior to surgery 36.9% developed postoperative complications. Lower respiratory tract infections (18.1%) and prolonged air leak (17.1%), in particular, were significant higher in smokers. 90-day mortality (5.8%) was higher in the current smokers when compared with ex- and nonsmokers (5.3 and 1%, respectively). Median length of hospital stay, readmissions, and cost of hospital stay was also higher in the current smoker cohort.

CONCLUSION

 Smoking immediately prior to surgery is associated with an increase in morbidity, mortality, and length of stay. Not only does this have a significant individual impact, but it is also associated with a significant financial burden to the National Health Service.

Assessment of the Functioning Profile of Patients with Lung Cancer Undergoing Lobectomy in Relation to the ICF Rehabilitation Core Set

Lung cancer often presents with pain and breathlessness, frequently necessitating surgical procedures, such as lung lobectomy. A pivotal component of postoperative care is rehabilitation, aimed not only at improving the clinical condition but also at influencing the patient's functional profile. In a study conducted at the Clinic of Thoracic Surgery and Respiratory Rehabilitation in the Regional Multispecialist Center for Oncology and Traumatology of the Nicolaus Copernicus Memorial Hospital in Lodz, the effectiveness of rehabilitation intervention was assessed in 50 patients (n = 27 M, n = 23 F) postlobectomy due to early stage nonsmall cell lung cancer (NSCLC). The International Classification of Functioning, Disability, and Health-ICF Rehabilitation Core Set was used to evaluate the functional profile, the modified Laitinen scale for pain assessment, and the modified Borg scale for breathlessness evaluation. Additionally, lung-expansion time was monitored. The significance level of the statistical tests in this analysis was set at α = 0.05. The study employed an analysis of the normality of the distributions of the numerical variables, reporting of variable distributions, estimation of differences between groups, estimation of differences within groups, estimation of the independence of categorical variables, and regression analysis. The research confirmed that rehabilitation partially improves the functional profile of patients and reduces the sensation of breathlessness postsurgery. The study highlighted the need for future research with a larger number of participants and an extended observation period to gain a deeper understanding of the impact of rehabilitation on patients after lung lobectomy procedures.

Association between duration of smoking abstinence before non-small-cell lung cancer diagnosis and survival: a retrospective, pooled analysis of cohort studies

BACKGROUND

The association between duration of smoking abstinence before non-small-cell lung cancer (NSCLC) diagnosis and subsequent survival can influence public health messaging delivered in lung-cancer screening. We aimed to assess whether the duration of smoking abstinence before diagnosis of NSCLC is associated with improved survival.

METHODS

In this retrospective, pooled analysis of cohort studies, we used 26 cohorts participating in Clinical Outcomes Studies of the International Lung Cancer Consortium (COS-ILCCO) at 23 hospitals. 16 (62%) were from North America, six (23%) were from Europe, three (12%) were from Asia, and one (4%) was from South America. Patients enrolled were diagnosed between June 1, 1983, and Dec 31, 2019. Eligible patients had smoking data before NSCLC diagnosis, epidemiological data at diagnosis (obtained largely from patient questionnaires), and clinical information (retrieved from medical records). Kaplan-Meier curves and multivariable Cox models (ie, adjusted hazard ratios [aHRs]) were generated with individual, harmonised patient data from the consortium database. We estimated overall survival for all causes, measured in years from diagnosis date until the date of the last follow-up or death due to any cause and NSCLC-specific survival.

FINDINGS

Of 42 087 patients with NSCLC in the COS-ILCCO database, 21 893 (52·0%) of whom were male and 20 194 (48·0%) of whom were female, we excluded 4474 (10·6%) with missing data. Compared with current smokers (15 036 [40·0%] of 37 613), patients with 1-3 years of smoking abstinence before NSCLC diagnosis (2890 [7·7%]) had an overall survival aHR of 0·92 (95% CI 0·87-0·97), patients with 3-5 years of smoking abstinence (1114 [3·0%]) had an overall survival aHR of 0·90 (0·83-0·97), and patients with more than 5 years of smoking abstinence (10 841 [28·8%]) had an overall survival aHR of 0·90 (0·87-0·93). Improved NSCLC-specific survival was observed in 4301 (44%) of 9727 patients who had quit cigarette smoking and was significant at abstinence durations of more than 5 years (aHR 0·87, 95% CI 0·81-0·93). Results were consistent across age, sex, histology, and disease-stage distributions.

INTERPRETATION

In this large, pooled analysis of cohort studies across Asia, Europe, North America, and South America, overall survival was improved in patients with NSCLC whose duration of smoking abstinence before diagnosis was as short as 1 year. These findings suggest that quitting smoking can improve overall survival, even if NSCLC is diagnosed at a later lung-cancer screening visit. These findings also support the implementation of public health smoking cessation strategies at any time.

FUNDING

The Alan B Brown Chair, The Posluns Family Fund, The Lusi Wong Fund, and the Princess Margaret Cancer Foundation.

A Secondary Analysis of a Preliminary Contingency Management Intervention for Presurgical Cancer Patients: Evaluating Individual Participant Data

INTRODUCTION

Contingency management (CM) interventions deliver monetary reinforcers contingent upon biochemically verified abstinence from smoking. CM has been found to be effective, however, individual participant, analyses are warranted to further elucidate how individual-level behavior patterns vary during the intervention period, both within and across treatment groups.

AIMS AND METHODS

This is a secondary analysis of a randomized controlled pilot trial of presurgical cancer patients who smoke (RCT N = 40). All participants were current everyday smokers and were enrolled in cessation counseling, offered nicotine replacement therapy, and submitted breath CO testing 3 times per week for 2-5 weeks. Participants randomized to CM received monetary reinforcers for breath CO ≤6 ppm on an escalating schedule of reinforcement with a reset for positive samples. Sufficient breath CO data exist for 28 participants (CM = 14; monitoring only [MO] = 14). Effect size was calculated for differences in negative CO tests. Time to first negative test was tested using survival analysis. Fisher's exact test was used to assess relapse.

RESULTS

The CM group achieved abstinence more quickly (p < .05), had a lower percentage of positive tests (h = 0.80), and experienced fewer lapses following abstinence (p = .00). While 11 of 14 participants in the CM group achieved and sustained abstinence by their third breath test, this was only true for 2 of the 14 MO participants.

CONCLUSIONS

Those in CM achieved abstinence quicker and with fewer lapses than those engaged in MO speaking to the efficacy of the schedule of financial reinforcement. This is particularly important within presurgical populations given the potential benefits to postoperative cardiovascular and wound infection risk.

IMPLICATIONS

While the efficacy of CM as an intervention is well established, this secondary analysis provides insight into the individual behavior patterns underlying successful abstinence. Those assigned to CM were not only more likely to achieve abstinence, but did so more quickly and with fewer instances of relapse. This is of particular importance to those scheduled for surgery where achieving abstinence as early as possible impacts on the risk of postoperative complications. CM interventions may be particularly well suited for critical windows in which timely and sustained abstinence is advantageous.

A survey exploring the practices of smoking cessation support among hospital-based healthcare providers

BACKGROUND

Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs.

METHODS

HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis.

RESULTS

All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs.

CONCLUSION

Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

Smoking Cessation for Preoperative Optimization

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Postoperative Respiratory Failure and Advanced Ventilator Settings

Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.

Prehabilitation and Rehabilitation for Patients with Lung Cancer: A Review of Where we are Today

Lung cancer is the third most common type of cancer in the UK, with nearly 50 000 new cases diagnosed a year. Treatments for lung cancer have improved in recent years with the advent of new surgical and radiotherapy techniques and the increased use of immunotherapies. These advances have resulted in increasing numbers of patients surviving beyond the completion of their treatment. Lung cancer patients are now not dying from their cancer diagnosis, but from other co-existing pathologies. Lung cancer patients commonly present with multiple comorbidities. Mitigating the effects of poor lifestyles and changing behaviours may improve the efficacy of treatments, reduce side-effects and improve the quality of life for lung cancer patients. Published evidence supports the use of interventions to manage behavioural habits, to optimise the health of patients. There is no consensus as to what, when or how to embed these into the patient pathway. Supporting patients before, during and after their cancer treatments to increase activity, eat well and stop smoking have been seen to decrease side-effects and improve patient outcomes and wellbeing. The challenge is to provide a package of interventions that is acceptable to patients and fits within the patient pathway so as not to conflict with diagnostic and therapeutic activities. This article reviews where we are today with providing behavioural support to optimise the health of lung cancer patients undergoing treatment.

Smoking cessation by combined medication and counselling: a feasibility study in lung cancer patients

PURPOSE

Smoking cessation in patients with diagnosed lung cancer has positive effects on cancer therapy and overall prognosis. Despite this, knowledge on smoking cessation in lung cancer patients is sparse.

METHODS

This is an observational single centre, 12-week, prospective, single-arm trial at a tertiary lung cancer centre. Responsive patients were enrolled following confirmed lung cancer diagnosis. Smoking cessation intervention included counselling as well as pharmacotherapy. The primary endpoint was the point prevalence abstinence rate at week 12 based on biochemical verification. Secondary endpoints were the abstinence rate at week 26, quality of life and side effects.

RESULTS

80 patients were enrolled. Mean age was 62.6 ± 7.9 years. Most patients (63%) were treated with chemotherapy or radiochemotherapy. 39 patients used nicotine replacement therapy, 35 varenicline whereas six patients did not use pharmacotherapy. During the study period 13 patients died. Data were available in 72 patients after 12 weeks and 57 patients at week 24. Point prevalence abstinence rates were 37.5% (95% CI 26.4-49.7%) at week 12 and 32.8% (95% CI 21.8-45.4%) at week 26, respectively. Quality of life and side effects were not significantly affected by pharmacotherapy.

CONCLUSION

In conclusion, our results suggest that smoking cessation is feasible in patients with newly diagnosed lung cancer. The observed abstinence rate is comparable to other patient cohorts. Furthermore, pharmacotherapy in addition to cancer therapy was safe and did not show novel side effects in these seriously ill patients. Thus, smoking cessation should be an integral part of lung cancer treatment. Trial registration The study was conducted in accordance with good clinical practice standards (GCP) and approved by the local ethics committee (16/3/14), the European PAS registry (EUPAS8748) and the German BfArM (NIS-Studien-Nr. 5508). All patients provided written informed consent before study enrollment.

Impact of smoking status and chronic obstructive pulmonary disease on pulmonary complications post lung cancer surgery

Introduction

Smoking and chronic obstructive pulmonary disease (COPD) are associated with an increased risk of post-operative pulmonary complications (PPCs) following lung cancer resection. It remains unclear whether smoking cessation reduces this risk.

Methods

Retrospective review of a large, prospectively collected database of over 1000 consecutive resections for lung cancer in a quaternary lung cancer centre over a 23-year period.

Results

One thousand and thirteen patients underwent curative-intent lobectomy or pneumonectomy between 1995 and 2018. Three hundred and sixty-two patients (36%) were ex-smokers, 314 (31%) were current smokers and 111 (11%) were never smokers. A pre-operative diagnosis of COPD was present in 57% of current smokers, 57% of ex-smokers and 20% of never smokers. Just over 25% of patients experienced a PPC. PPCs were more frequent in current smokers compared to never smokers (27% vs 17%, p = 0.036), however, no difference was seen between current and ex-smokers (p = 0.412) or between never and ex-smokers (p = 0.113). Those with a diagnosis of COPD, independent of smoking status, had a higher frequency of both PPCs (65% vs 35%, p<0.01) and overall complications (60% vs 40%, p<0.01) as well as a longer length of hospital stay (10 vs 9 days, p<0.01).

Conclusion

Smoking and COPD are both associated with a higher rate of PPCs post lung cancer resection. COPD, independent of smoking status, is also associated with an increased overall post-operative complication rate and length of hospital stay. An emphasis on COPD treatment optimisation, rather than smoking cessation in isolation, may help improve post-operative outcomes.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Development and psychometric testing of the self-regulatory questionnaire for lung cancer screening (SRQ-LCS)

BACKGROUND

Research implicates psychological factors in low uptake of lung cancer screening. We developed and psychometrically tested a standardised measure of these psychological determinants in preparation for a prospective, longitudinal cohort study of screening uptake.

METHODS

Leventhal's Common-Sense Model of Self-Regulation of Health and Illness provided the theoretical framework to generate the initial item pool. Items were refined during expert review and cognitive interviews which tested for face validity, redundancy, acceptability and comprehensibility. An online survey piloted the refined pool with 1500 current and former (quit ≤ 15 years) smokers aged 55-80. The response distributions, internal reliability and factor structure determined the final retained constructs. Regression analyses examined these constructs' associations with screening intention, smoking status and demographics.

RESULTS

The final measure included seven factor-derived subscales (consequences, personal control, treatment control, illness coherence, emotional representation, behavioural response and appraisal, risk perception) with Cronbach's alphas ranging from 0.59 to 0.91 and four single-item questions (response efficacy for smoking cessation, treatment intention, perceived stigma and lung cancer survival). Most constructs were associated with smoking status and screening intention (p's < .05).

CONCLUSIONS

The Self-Regulatory Questionnaire for Lung Cancer Screening (SRQ-LCS) is an acceptable, reliable and valid measure for investigating the psychological determinants of screening uptake.

Implementation strategies for integrating tobacco cessation treatment in cancer care: A qualitative study

Purpose

The objective of this study was to determine how to optimize implementation of tobacco cessation treatment interventions in cancer care by (1) investigating the feasibility and acceptability of a multi-level approach to tobacco cessation treatment intervention, (2) identifying barriers and facilitators to implementation, and (3) eliciting additional strategies to improve implementation of the intervention.

Methods

We conducted qualitative interviews with oncologists (n = 15) from one large academic health center in the Southeastern United States. We asked about their knowledge, attitudes, and current practices regarding tobacco use screening and treatment. We also asked about two proposed strategies to support implementation of tobacco cessation treatment: (1) developing a registry of tobacco users in collaboration with the state-run tobacco cessation program, and (2) providing on-site tobacco cessation counseling from trained professionals.

Results

Oncologists saw addressing tobacco use as valuable; however, they felt restricted from consistently addressing tobacco use by multi-level barriers such as workload, electronic health record (EHR) design, patient anxiety, and low self-efficacy for treating tobacco dependence. Oncologists responded positively to on-site treatment and felt this strategy would increase treatment accessibility and enhance engagement. Reaction to developing a registry of tobacco users was mixed, with concerns regarding lack of oncologist involvement and patient privacy expressed. Other suggested strategies for supporting implementation of tobacco cessation treatment included reducing referral complexity, establishing financial or quality incentives for oncologists, and leveraging existing EHR tools to facilitate integration of cessation interventions into clinic workflows.

Conclusion

We identified several challenges to implementing tobacco use treatment in cancer care; however, we considered strategies to overcome these barriers that were viewed as feasible and acceptable. Our work highlights the importance of engaging stakeholders in implementation efforts. Future work should explore the impact of the implementation strategies identified in this study.

Offering lung resection to current smokers: An opportunity for more equitable care

OBJECTIVE

Minority patients with lung cancer are less likely to undergo surgical resection and experience worse survival than non-Hispanic White patients. Currently, 40% of thoracic surgeons require smoking cessation before surgery, which may disproportionately affect minority patients. Our objective was to assess the risk of smoking status on postoperative morbidity and mortality among patients with lung cancer.

METHODS

A prospectively maintained institutional database was queried for all patients who underwent surgical resection of a primary lung malignancy between 2006 and 2020. Operative mortality, major morbidity, and a composite of morbidity and mortality were compared between current smokers and prior smokers.

RESULTS

A total of 601 patients underwent resection, and 236 (39.3%) were current smokers. Current smokers were more likely to be younger (P < .01), to have a greater pack-years history (P = .03), and to have worse pulmonary function test results (P < .01). Pretreatment stage, surgical approach, and extent of resection were similar between groups. There was no difference in operative mortality (0.9% vs 1.9%, P = .49), major morbidity (12.7% vs 9.3%, P = .19), or composite major morbidity and mortality between groups (13.1% vs 9.3%, P = .14). After adjusting for pulmonary function status, current smoking status was not associated with mortality or major morbidity on multivariable logistic regression (odds ratio, 1.51; 95% confidence interval, 0.76-3.03, P = .24).

CONCLUSIONS

Current smokers experienced similar rates of mortality and major morbidity as prior smokers. In the context of continued racial and ethnic disparities in lung cancer survival, in particular decreased resection rates among minorities, smoking cessation requirements should not delay or prevent operative intervention for lung cancer.

Long-term Outcomes After Lung Cancer Resection in Smokers: Analysis of the National Lung Screening Trial

BACKGROUND

Smoking is a known risk factor for perioperative complications after lung resection; however, little data exists looking at the impact of smoking status (current versus former) on long-term oncologic outcomes after lung cancer surgery. We sought to compare overall survival (OS), progression-free survival (PFS), and cancer-specific mortality (CSM) in current and former smokers using data from the National Lung Screening Trial (NLST). Additionally, we performed subset analysis in current smokers in order to evaluate the effect of modern surgical techniques on long-term outcomes.

METHODS

Patients with clinical stage IA or IB NSCLC who underwent upfront resection within 180 days of diagnosis were identified in the NLST database. Cox proportional hazard regression models were used to assess differences in patient and treatment characteristics with respect to OS and PFS, with a cause-specific hazard model used for CSM.

RESULTS

A total of 593 patients were included in the study (269 former smokers, 324 current smokers). Lobar resection (LR) was performed more often than sublobar resection (SLR) (481 vs. 112), and thoracotomy was performed more often than thoracoscopy (482 vs. 86). Comparison of current versus former smokers showed no difference in OS or PFS after resection. Higher CSM was seen in current smokers (p = 0.049). Subset analysis of current smokers revealed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Although higher CSM was associated with thoracoscopy versus thoracotomy in this group, this finding was limited by a relatively small thoracoscopy sample size of 44 patients (p = 0.026).

CONCLUSION

Our analysis of the NLST database shows no significant difference in OS and PFS when comparing current and former smokers undergoing resection for stage I NSCLC. Active smoking status was associated with higher CSM. Subset analysis of current smokers showed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Higher CSM was seen in current smokers who underwent thoracoscopy compared to thoracotomy; however, this finding was limited by a small sample size.

Concordance Between Electronic Health Record and Tumor Registry Documentation of Smoking Status Among Patients With Cancer

PURPOSE

Patients with cancer who use tobacco experience reduced treatment effectiveness, increased risk of recurrence and mortality, and diminished quality of life. Accurate tobacco use documentation for patients with cancer is necessary for appropriate clinical decision making and cancer outcomes research. Our aim was to assess agreement between electronic health record (EHR) smoking status data and cancer registry data.

MATERIALS AND METHODS

We identified all patients with cancer seen at University of Florida Health from 2015 to 2018. Structured EHR smoking status was compared with the tumor registry smoking status for each patient. Sensitivity, specificity, positive predictive values, negative predictive values, and Kappa statistics were calculated. We used logistic regression to determine if patient characteristics were associated with odds of agreement in smoking status between EHR and registry data.

RESULTS

We analyzed 11,110 patient records. EHR smoking status was documented for nearly all (98%) patients. Overall kappa (0.78; 95% CI, 0.77 to 0.79) indicated moderate agreement between the registry and EHR. The sensitivity was 0.82 (95% CI, 0.81 to 0.84), and the specificity was 0.97 (95% CI, 0.96 to 0.97). The logistic regression results indicated that agreement was more likely among patients who were older and female and if the EHR documentation occurred closer to the date of cancer diagnosis.

CONCLUSION

Although documentation of smoking status for patients with cancer is standard practice, we only found moderate agreement between EHR and tumor registry data. Interventions and research using EHR data should prioritize ensuring the validity of smoking status data. Multilevel strategies are needed to achieve consistent and accurate documentation of smoking status in cancer care.

Prognostic factors of patients with small cell lung cancer after surgical treatment

Background

The current National Comprehensive Cancer Network guidelines recommend surgical treatment for patients with stages I–IIA small cell lung cancer (SCLC), but it still cannot deny the effect of surgical treatment on other limited-stage SCLC. Although more advanced diagnostic methods are now used for the diagnosis and classification of SCLC, the selection of surgical candidates is still arbitrary.

Methods

Data were collected from patients with SCLC who underwent surgery at the First Affiliated Hospital of Zhengzhou University from January 2011 to January 2021. Kaplan-Meier method was used to calculate cumulative survival curves, and log-rank test was used to evaluate differences among different subgroups. The Cox proportional hazard regression model was used to assess the predictive power of the variables for prognosis and survival.

Results

Smoking index, surgical resection method, TNM stage of postoperative pathology, and postoperative chemotherapy were significantly correlated with postoperative survival (P<0.05), which were independent predictors for postoperative survival. Patients with a smoking index >800 had a higher risk of death after surgery [hazard ratio (HR): 7.050, 95% confidence interval (CI): 3.079–16.143, P<0.001]. Compared with patients who underwent pulmonary lobectomy, those who underwent other pneumoresections (e.g., wedge resection, segmental resection, sleeve resection) had an increased risk of death (HR: 2.822, 95% CI: 1.030–7.734, P=0.044). Compared with stage I patients, stage II and stage III patients had an increased risk of death, with HRs of 6.039 and 3.145, respectively. Compared with those who received ≤4 courses of postoperative chemotherapy, those who received >4 courses of postoperative chemotherapy had reduced postoperative mortality risk (HR: 0.211, 95% CI: 0.097–0.459, P<0.001).

Conclusions

A high smoking index suggests worse prognosis; therefore, patients who smoke should be advised to quit smoking. Compared with stage II and stage III patients, surgical treatment is recommended for stage I SCLC patients. TNM staging, especially N staging, should be evaluated prior to surgery. Pulmonary lobectomy with mediastinal lymph node dissection should be the preferred surgical treatment for patients with SCLC. Patients should receive at least 5 courses of adjuvant chemotherapy after surgery.

Sarcopenia on preoperative chest computed tomography predicts cancer-specific and all-cause mortality following pneumonectomy for lung cancer: A multicenter analysis

Background

Mortality risk prediction in patients undergoing pneumonectomy for non‐small cell lung cancer (NSCLC) remains imperfect. Here, we aimed to assess whether sarcopenia on routine chest computed tomography (CT) independently predicts worse cancer‐specific (CSS) and overall survival (OS) following pneumonectomy for NSCLC.

Methods

We included consecutive adults undergoing standard or carinal pneumonectomy for NSCLC at Massachusetts General Hospital and Heidelberg University from 2010 to 2018. We measured muscle cross‐sectional area (CSA) on CT at thoracic vertebral levels T8, T10, and T12 within 90 days prior to surgery. Sarcopenia was defined as T10 muscle CSA less than two standard deviations below the mean in healthy controls. We adjusted time‐to‐event analyses for age, body mass index, Charlson Comorbidity Index, forced expiratory volume in 1 second in % predicted, induction therapy, sex, smoking status, tumor stage, side of pneumonectomy, and institution.

Results

Three hundred and sixty‐seven patients (67.4% male, median age 62 years, 16.9% early‐stage) underwent predominantly standard pneumonectomy (89.6%) for stage IIIA NSCLC (45.5%) and squamous cell histology (58%). Sarcopenia was present in 104 of 367 patients (28.3%). Ninety‐day all‐cause mortality was 7.1% (26/367). After a median follow‐up of 20.5 months (IQR, 9.2–46.9), 183 of 367 patients (49.9%) had died. One hundred and thirty‐three (72.7%) of these deaths were due to lung cancer. Sarcopenia was associated with shorter CSS (HR 1.7, p = 0.008) and OS (HR 1.7, p = 0.003).

Conclusions

This transatlantic multicenter study confirms that sarcopenia on preoperative chest CT is an independent risk factor for CSS and OS following pneumonectomy for NSCLC.

Modern Perioperative Practices May Mitigate Effects of Continued Smoking Among Lung Cancer Patients

BACKGROUND

Though smokers are at an increased risk for postoperative pulmonary complications following thoracic surgery, the relationship between cessation timing and postoperative pulmonary complications has not been explored in an era of enhanced recovery protocols and active tobacco cessation programs. Because a strong preference exists among thoracic surgeons to delay surgery to continued smokers, we sought to evaluate this relationship in a modern era.

METHODS

Patients undergoing lung resection for a diagnosis of non-small cell lung cancer from 2012-2017 were identified. Multivariable logistic regression was used to evaluate preoperative tobacco cessation timing to determine the impact upon postoperative pulmonary complications.

RESULTS

1038 ever-smokers were identified. Patients were current smokers in 30 (3%) instances, and among former smokers, the preoperative cessation interval was 0-14 days in 10% (104), >14 days-1 month in 6% (62), >1 month-1 year in 18% (189), >1-5 years in 10% (107), and >5 years in 53% (546). Pulmonary complications were experienced by 269 (26%) patients. Multivariable analysis revealed that no group of recent or long-term quitters experienced superior outcomes in terms of pulmonary complications, when evaluating various periods of abstinence in comparison to continued smokers and active quitters.

CONCLUSIONS

In an era of enhanced recovery protocols, minimally invasive surgery, and active tobacco cessation programs which may help patients to cut back, our data do not support the practice of delaying or denying surgery to patients who have difficulty quitting completely. Perioperative cessation counseling should be aimed at long-term benefits, including reduction of disease recurrence and secondary malignancies.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

When Is It Safe to Operate for Lung Cancer? Selection of Fiscally Responsible Cardiopulmonary Function Tests for Limited Resection (Wedge Resection and Segmentectomy), Standard Lobectomy, Sleeve Lobectomy, and Pneumonectomy

Pulmonary function testing remains the central determinant of candidacy for pulmonary resection and indicator of perioperative risk. For patients with borderline pulmonary function, exercise testing can help determine surgical candidacy either via stair climbing or by obtaining a maximum oxygen consumption. The Thoracic Revised Cardiac Risk Index should be used to select patients for further cardiac testing. Patient comorbidities, medications, functional limitations, and smoking status are also requisite assessments of the preoperative evaluation that influence perioperative outcomes. A minimally invasive approach to pulmonary resection reduces perioperative risk and may be of most benefit to patients with borderline pulmonary function.

Variability in Smoking Status for Lobectomy Among Society of Thoracic Surgeons Database Participants

BACKGROUND

Current smokers undergoing lobectomy are at greater risk of complications than are former smokers. The Society of Thoracic Surgeons (STS) composite score for rating program performance for lobectomy adjusts for smoking status, a modifiable risk factor. This study examined variability in the proportion of current smokers undergoing lobectomy among STS database participants. Additionally, the study determined whether each participant's rating changed if smoking was excluded from the risk adjustment model.

METHODS

This is a retrospective analysis of the STS cohort used to develop the composite score for rating program performance for lobectomy. The study summarized the variability among STS database participants for performing lobectomy on current smokers and compared star ratings developed from models with and without smoking status.

RESULTS

There were 24,912 patients with smoking status data: 23% current smokers, 62% former smokers, and 15% never smokers. There was significant variability among participants in the proportion of current smokers undergoing lobectomy (3% to 48.6%; P < .001). Major morbidity or mortality (composite) was greater in current smokers (12.1%) than in former smokers (8.6%) and never smokers (4.2%) (P < .001). Using the current risk adjustment model, participant star ratings were as follows: 1 star, n = 6 (3.2%); 2 stars, n = 170 (91.4%); and 3 stars, n = 10 (5.4%). When smoking status was excluded from the model, 1 participant shifted from a 2-star to a 3-star program.

CONCLUSIONS

There is substantial variability among STS database participants with regard to the proportion of current smokers undergoing lobectomy. However, exclusion of smoking status from the model did not significantly affect participant star rating.

Care to Quit: a stepped wedge cluster randomised controlled trial to implement best practice smoking cessation care in cancer centres

BACKGROUND

Cigarette smoking in people with cancer is associated with negative treatment-related outcomes including increased treatment toxicity and complications, medication side effects, decreased performance status and morbidity. Evidence-based smoking cessation care is not routinely provided to patients with cancer. The purpose of this study is to determine the effectiveness of a smoking cessation implementation intervention on abstinence from smoking in people diagnosed with cancer.

METHODS

A stepped wedge cluster randomised design will be used. All sites begin in the control condition providing treatment as usual. In a randomly generated order, sites will move to the intervention condition. Based on the Theoretical Domains Framework, implementation of Care to Quit will include (i) building the capability and motivation of a critical mass of key clinical staff and identifying champions; and (ii) identifying and implementing cessation care models/pathways. Two thousand one hundred sixty patients with cancer (diagnosed in the prior six months), aged 18+, who report recent combustible tobacco use (past 90 days or in the 30 days prior to cancer diagnosis) and are accessing anti-cancer therapy, will be recruited at nine sites. Assessments will be conducted at baseline and 7-month follow-up. The primary outcome will be 6-month abstinence from smoking. Secondary outcomes include biochemical verification of abstinence from smoking, duration of quit attempts, tobacco consumption, nicotine dependence, provision and receipt of smoking cessation care, mental health and quality of life and cost effectiveness of the intervention.

DISCUSSION

This study will implement best practice smoking cessation care in cancer centres and has the potential for wide dissemination.

TRIAL REGISTRATION

The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN ( ACTRN12621000154808 ) prior to the accrual of the first participant and will be updated regularly as per registry guidelines.

Correlation Between Smoking Status and Short-term Outcome of Thoracoscopic Surgery for Lung Cancer

BACKGROUND

Smoking has a major role in the risk of postoperative pulmonary complications. This study aimed to elucidate the correlation between smoking status and pulmonary complications after thoracoscopic surgery for lung cancer.

METHODS

A total of 1751 patients who underwent thoracoscopic lobectomy or segmentectomy for lung cancer between April 2011 and March 2020 were assessed. The rate of pulmonary complications was evaluated according to smoking status and preoperative duration of smoking cessation. Univariate and multivariate logistic regression analyses were performed.

RESULTS

Pulmonary complications were observed in 50 patients (2.9%), whereas 3 (0.2%) died within 90 days of surgery. The rate of pulmonary complications was higher in smokers than in nonsmokers (4.6% vs 0.9%; P < .001), and smoking history was an independent risk factor for pulmonary complications (odds ratio, 3.31; P = .007). The complication rate in patients with a cessation period of more than 2 months was significantly lower than that in patients who ceased smoking within 2 months (4.0% vs 8.5%; P = .043), but it was still higher than that in nonsmokers (4.0% vs 0.9%; P < .001). In the multivariable analysis for smokers, preoperative short-term smoking cessation within 2 months, male sex, histologic type, tumor size, and cardiopulmonary comorbidities were associated with pulmonary complications instead of pack-year smoking history.

CONCLUSIONS

Smoking habits and preoperative smoking cessation were independently associated with pulmonary complications after thoracoscopic surgery for lung cancer. A preoperative smoking cessation period of 2 months or more is preferable for reducing the risk of such complications.

Our current understanding of and approach to the management of lung cancer with pulmonary hypertension

INTRODUCTION

Lung cancer is a frequent pathology for which the best curative treatment is pulmonary resection. Pulmonary arterial hypertension is a rare disease but pulmonary hypertension associated with parenchymal disease or left heart disease is frequently observed in these patients. The diagnosis of pulmonary hypertension before lung resection makes the perioperative management of these patients more difficult and sometimes leads to rejecting patients for surgery.

AREAS COVERED

We performed a review of literature on PubMed on Pulmonary hypertension associated lung resection, preoperative assessment of lung resection and perioperative management of PH patients, including guidelines and clinical trials.In this review, we summarize the current state of knowledge regarding the pre and perioperative management of patients with suspected or confirmed PH who can benefit from surgical treatment of lung cancer.

EXPERT OPINION

Management of PH patients before lung resection should include a very careful workup including at least right heart catheterization with evaluation of the targeted PH treatment in an expert center and evaluation of other comorbidities. Perioperative management must be carried out in a specialized center.

Preoperative Cumulative Smoking Dose on Lung Cancer Surgery in a Japanese Nationwide Database

BACKGROUND

Smoking is a known risk factor for postoperative mortality and morbidity. However, the significance of cumulative smoking dose in preoperative risk assessment has not been established. We examined the influence of preoperative cumulative smoking dose on surgical outcomes after lobectomy for primary lung cancer.

METHODS

A total of 80,989 patients with primary lung cancer undergoing lobectomy from 2014 to 2016 were enrolled. Preoperative cumulative smoking dose was categorized by pack-years (PY): nonsmokers, PY = 0; light smokers, 0 < PY < 10; moderate smokers, 10 ≤ PY < 30; and heavy smokers, 30 ≤ PY. The risk of short-term outcomes was assessed according to PY by multivariable analysis adjusted for other covariates.

RESULTS

Postoperative 30-day mortality, as well as pulmonary, cardiovascular, and infectious complications, increased with preoperative PY. Multivariable analysis revealed that the odds ratios (ORs) for postoperative mortality compared with nonsmokers were 1.76 for light smokers (P = .044), 1.60 for moderate smokers (P = .026), and 1.73 for heavy smokers (P = .003). The ORs for pulmonary complications compared with nonsmokers were 1.20 for light smokers (P = .022), 1.40 for moderate smokers (P < .001), and 1.72 for heavy smokers (P < .001). Heavy smokers had a significantly increased risk of postoperative cardiovascular (OR, 1.26; P = .002) and infectious (OR, 1.39; P = .007) complications compared with nonsmokers.

CONCLUSIONS

The risk of mortality and morbidity after lung resection could be predicted according to preoperative cumulative smoking dose. These findings contribute to the development of strategies in perioperative management of lung resection patients.

Engagement and Effectiveness of a Smoking Cessation Quitline Intervention in a Thoracic Surgery Clinic

Importance

Smoking quitline programs effectively promote smoking cessation in outpatient primary care settings.

Objective

To examine the factors associated with smoking quitline engagement and smoking cessation among patients undergoing thoracic surgery who consented to a quitline electronic referral.

Design, Setting, and Participants

A retrospective cohort study was conducted from January 1, 2014, to December 31, 2018, among 111 active smoking patients referred to the quitline from a thoracic surgery outpatient clinic visit. Patients were divided into operative and nonoperative cohorts.

Main Outcomes and Measures

Primary outcomes were engagement rates in the quitline program and successful smoking cessation. Secondary outcomes were self-reported point prevalence abstinence at 1 month and 6 months after the smoking quit date.

Results

Of 111 patients (62 men; mean [SD] age, 61.8 [11.2] years) who had a quitline referral, 58 (52%) underwent surgery, and 32 of these 58 patients (55%) participated in the program. Of the 53 nonoperative patients (48%), 24 (45%) participated in the program. In the operative cohort, there was no difference in the smoking cessation rate between quitline participants and nonparticipants (21 of 32 [66%] vs 16 of 6 [62%]; P = .79) or in point prevalence abstinence at 1 month (23 of 32 [72%] vs 14 of 25 [56%]; P = .27) or 6 months (14 of 28 [50%] vs 6 of 18 [33%]; P = .36). Similarly, in the nonoperative cohort, there was no difference in the smoking cessation rate between quitline participants and nonparticipants (8 of 24 [33%] vs 11 of 29 [38%]; P = .78) or in point prevalence abstinence at 1 month (7 of 24 [29%] vs 8 of 27 [30%]; P = .99) or 6 months (6 of 23 [26%] vs 6 of 25 [24%]; P = .99). Regardless of quitline participation, operative patients had a 1.8-fold higher proportion of successful smoking cessation compared with nonoperative patients (37 of 58 [64%] vs 19 of 53 [36%]; P = .004) as well as a 2.2-fold higher proportion of 1-month point prevalence abstinence (37 of 57 [65%] vs 15 of 51 [29%]; P < .001) and a 1.8-fold higher proportion of 6-month point prevalence abstinence (20 of 45 [44%] vs 12 of 48 [25%]; P = .05). Having surgery doubled the odds of smoking cessation (odds ratio, 2.44; 95% CI, 1.06-5.64; P = .04) and quitline engagement tripled the odds of remaining smoke free at 6 months (odds ratio, 3.57; 95% CI, 1.03-12.38; P = .04).

Conclusions and Relevance

Patients undergoing thoracic surgery were nearly twice as likely to quit smoking as those who did not have an operation, and smoking quitline participation further augmented point prevalence abstinence. Improved smoking cessation rates, even among nonoperative patients, were associated with appropriate outpatient counseling and intervention.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

The influence of tobacco load versus smoking status on outcomes following lobectomy for lung cancer in a statewide quality collaborative

BACKGROUND

Collaborative quality consortia can facilitate implementation of quality measures arising from clinical databases. Our statewide general thoracic surgery (GTS) collaborative investigated the influences of cigarette smoking status on mortality and major morbidity following lobectomy for lung cancer.

METHODS

Society of Thoracic Surgeons General Thoracic Surgery Database records were identified from 14 institutions participating in a statewide thoracic surgical quality collaborative between 2012 and 2017. We excluded patients with nonelective procedures, stage 0 tumors, American Society of Anesthesiologists class VI disease, and missing clinical characteristics. Outcomes analysis included the combined mortality and major postoperative morbidity rates and the influence of patient characteristics, including smoking status, on composite rate and on postoperative complications.

RESULTS

The study cohort included 2267 patient records for analysis. Overall combined mortality and major morbidity rate was 10.2% (n = 231). Postoperative 30-day mortality was 1.5%, and major morbidity 9.6%. Significant predictors of the combined outcome included male sex (P = .004), body mass index (P < .001), Zubrod score (P = .02), smoking pack-years (P = .03), and thoracotomy (P < .001). Higher American Society of Anesthesiologists disease class and advanced tumor stage were marginally associated with worse combined outcome (P = .06). Smoking status; that is, current, past (no smoking within 30 days), or never smoked, was not associated with worse combined outcome (P = .56) and had no significant influence on major complications.

CONCLUSIONS

Smoking status was not associated with worse outcomes; however, smoking dose (pack-years) was associated with worse combined mortality and major morbidity. A statewide quality collaborative provides constructive feedback for participating institutions and surgeons, promoting quality improvement in perioperative patient care strategies and improved outcomes.

Pre-operative patient optimization to prevent postoperative pulmonary complications-Insights and roles for the respiratory therapist: A narrative review

Background

The preoperative period has gained recognition as a crucial time to identify and manage preoperative medical conditions for preventing perioperative complications. Consequently, preoperative clinics have now become an essential component of perioperative care at many large hospitals. As the prevalence of preoperative clinics continues to grow, and the field of perioperative medicine progresses, respiratory therapists (RTs) will inevitably find a growing role to participate in preoperative patient optimization to mitigate pulmonary complications.

Methods

Keyword searches on perioperative pulmonary complications were conducted on the Medline database via PubMed and identified over 2000 candidate articles for review. Articles were included if they were English only and resulted with one or more of the following search terms; pulmonary complications, postoperative complications, postoperative pulmonary complications (PPCs), prehabilitation, incentive spirometry, smoking cessation, noninvasive ventilation. Preference was given for meta-analyses, randomized controlled trials, and systematic reviews. Publications within the past two decades were given additional preference toward final inclusion. The authors discussed eligible articles in group meetings over the span of multiple years to assess relevance and quality of data for narrowing eligible articles to the final selection of publications for the review.

Findings

The following narrative review examines preoperative optimization strategies to prevent PPCs and highlight areas where RTs may play a key role. After examining challenges in defining PPCs, the review examines key risk models available to predict PPCs and their implications for subsequent discussion on preventive measures that RTs may assist with in a multidisciplinary team.

Conclusion

RTs can reduce the health care burden of PPCs by assisting fellow perioperative clinicians in providing respiratory care for patients with premorbid conditions. While much of our review focused on pre-existing pulmonary pathologies and both the pharmacological and nonpharmacological optimization of these pathologies, there are other factors contributing to PPCs deserving future exploration.

Does short-term cessation of smoking before lung resections reduce the risk of complications?

Background

Smoking cessation is a highly important preparation before thoracic surgery. We examined the effects of short-term smoking cessation intervention before pulmonary resection on postoperative pulmonary complications (PPCs).

Methods

A retrospective analysis of prospectively collected data was performed for 753 patients who underwent curative surgical resection for thoracic malignancy at 3 institutions. Patients with a smoking history were instructed to quit smoking. After confirming smoking cessation by at least four weeks before surgery, surgical resection was performed. Subjects were classified into three groups based on their smoking status: abstainers (anyone who had stopped smoking for at least 4 weeks but less than 2 months), former smokers (anyone who had abstained from smoking for more than two months prior to surgery), and never smokers (those who had never smoked). We examined the relationship between the preoperative smoking status and PPCs.

Results

Surgery was performed for 660 primary lung cancers and 93 metastatic lung tumors. The smoking statuses were classified as follows: abstainers (n=105, 14%), former smokers (n=361; 48%) and never smokers (n=287, 38%). The incidence of PPCs among abstainers, former smokers and never smokers was 15%, 8% and 6%, respectively (P=0.01). The mean duration of post-operative chest tube drainage among abstainers, former smokers and never smokers was 3.2, 2.2 and 2.2 days, respectively (P=0.04). The mean post-operative hospital stay among abstainers, former smokers and never smokers was 12.1, 10.6 and 10.2 days, respectively (P=0.07). There was no 30-day mortality in the cohort.

Conclusions

Short-term smoking cessation intervention did not enough reduce the PPCs as much as in former or never smokers.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

[Approaches to the pre-operative functional assessment of patients with lung cancer and preoperative rehabilitation]

Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.

Rural-urban differences in health-related quality of life: patterns for cancer survivors compared to other older adults

PURPOSE

Health-related quality of life (HRQOL) among older cancer survivors can be impaired by factors such as treatment, comorbidities, and social challenges. These HRQOL impairments may be especially pronounced in rural areas, where older adults have higher cancer burden and more comorbidities and risk factors for poor health. This study aimed to assess rural-urban differences in HRQOL for older cancer survivors and controls.

METHODS

Data came from Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS), which links cancer incidence from 18 U.S. population-based cancer registries to survey data for Medicare Advantage Organization enrollees (1998-2014). HRQOL measures were 8 standardized subscales and 2 global summary measures. We matched (2:1) controls to breast, colorectal, lung, and prostate cancer survivors, creating an analytic dataset of 271,640 participants (ages 65+). HRQOL measures were analyzed with linear regression models including multiplicative interaction terms (rurality by cancer status), controlling for sociodemographics, cohort, and multimorbidities.

RESULTS

HRQOL scores were higher in urban than rural areas (e.g., global physical component summary score for breast cancer survivors: urban mean = 38.7, standard error [SE] = 0.08; rural mean = 37.9, SE = 0.32; p < 0.05), and were generally lower among cancer survivors compared to controls. Rural cancer survivors had particularly poor vitality (colorectal: p = 0.05), social functioning (lung: p = 0.05), role limitation-physical (prostate: p < 0.01), role limitation-emotional (prostate: p < 0.01), and global mental component summary (prostate: p = 0.02).

CONCLUSION

Supportive interventions are needed to increase physical, social, and emotional HRQOL among older cancer survivors in rural areas. These interventions could target cancer-related stigma (particularly for lung and prostate cancers) and/or access to screening, treatment, and ancillary healthcare resources.