Thoracic Surgery in the Real World: Does Surgical Specialty Affect Outcomes in Patients Having General Thoracic Operations?

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer

PURPOSE

The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care.

PATIENTS AND METHODS

Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes.

RESULTS

From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively.

CONCLUSION

Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Certified thoracic surgeons in Japan: a national database survey on risk-adjusted mortality associated with lung resection

PURPOSE

We investigated the association between the number of certified general thoracic surgeons (GTSs) and the mortality after lung cancer surgery, based on the data from the National Clinical Database (NCD).

METHODS

We analyzed the characteristics and operative and postoperative data of 120,946 patients who underwent lung cancer surgery in one of the 905 hospitals in Japan. The number of GTSs in each hospital was categorized as 0, 1-2, or 3 or more. Multivariable analysis was applied to adjust the patients' preoperative risk factors, as identified in a previous study. We calculated 95% confidence intervals (CI) for the mortality rate based on the odds ratios (ORs).

RESULTS

The patients' characteristics were distributed almost uniformly regardless of the number of GTSs. Crude mortality according to the number of GTSs of 0, 1-2, or 3 or more was 0.9%, 0.8%, and 0.7%, respectively (p = 0.03). However, after adjustment, the ORs for 1-2 and 3 or more GTSs (reference: 0) were 0.86 (p = 0.23, 95% CI: 0.67-1.10) and 0.84 (p = 0.18, 95% CI: 0.64-1.09), respectively. The number of GTSs did not have a significant association with mortality. Similar results were observed for patients in the lobectomy cohort.

CONCLUSION

Low surgical mortality was consistent, regardless of the number of GTSs in each hospital.

Video-assisted thoracoscopic surgery lobectomy might be a feasible alternative for surgically resectable pathological N2 non-small cell lung cancer patients

Background

The majority of previous studies of the clinical outcome of video‐assisted thoracoscopic surgery (VATS) versus open lobectomy for pathological N2 non‐small cell lung cancer (pN2 NSCLC) have been single‐center experiences with small patient numbers. The aim of this study was therefore to investigate these procedures but in a large cohort of Chinese patients with pathological N2 NSCLC in real‐world conditions.

Methods

Patients who underwent lobectomy for pN2 NSCLC by either VATS or thoracotomy were retrospectively reviewed from 10 tertiary hospitals between January 2014 and September 2017. Perioperative outcomes and overall survival of the patients were analyzed. Cox regression analysis was performed to identify potential prognostic factors. Propensity‐score analysis was performed to reduce cofounding biases and compare the clinical outcomes between both groups.

Results

Among 2144 pN2 NSCLC, 1244 patients were managed by VATS and 900 by open procedure. A total of 305 (24.5%) and 344 patients died during VATS and the thoracotomy group during a median follow‐up of 16.7 and 15.6 months, respectively. VATS lobectomy patients had better overall survival when compared with those undergoing the open procedure (P < 0.0001). Multivariate COX regression analysis showed VATS lobectomy independently favored overall survival (HR = 0.75, 95% CI: 0.621–0.896, P = 0.0017). Better perioperative outcomes, including less blood loss, shorter drainage time and hospital stay, were also observed in patients undergoing VATS lobectomy (P < 0.05). After propensity‐score matching, 169 patients in each group were analyzed, and no survival difference were found between the two groups. Less blood loss was observed in the VATS group, but there was a longer operation time.

Conclusions

VATS lobectomy might be a feasible alternative to conventional open surgery for resectable pN2 NSCLC.

Key points

Significant findings of the study: VATS lobectomy has comparative OS in pN2 NSCLC versus open procedure in resectable patients.

What this study adds: VATS lobectomy might be feasible for pN2 NSCLC.

Outcomes of Anatomic Lung Resection for Cancer Are Better When Performed by Cardiothoracic Surgeons

BACKGROUND

Anatomic lung resection (ALR) outcomes are superior for cardiothoracic surgeons (CTSs) by analysis of Medicare; National Inpatient Sample; South Carolina Office of Research and Statistics; and Surveillance, Epidemiology, and End Results databases. Similar findings have been reported for all noncardiac thoracic procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Our aim was to further delineate outcome differences between CTSs and general surgeons (GSs) specifically for ALR.

METHODS

A retrospective analysis of 15,574 nonemergent, nonpediatric ALR for lung cancer was conducted using the ACS-NSQIP 2013 to 2017 database. Included procedures were all ALR for lung cancer. Surgeons were classified as CTSs or GSs. Other specialties were excluded. Preoperative characteristics and 30-day outcomes were compared by bivariate (chi-square test) and multivariate analysis. Multivariate analysis was conducted by multiple logistic regression.

RESULTS

CTSs performed 14,172 (91.0%) of included procedures, and GSs performed 1402 (9.0%). A thoracoscopic approach was utilized at a similar rate (49.08% for CTSs vs 49.71% for GSs; P = .747). The extent of resection differed in a statistically, but not clinically, significant fashion. CTS patients had a higher rate of preoperative dyspnea (22.66% for CTSs vs 17.62% for GSs; P < .001). Procedures performed by CTSs had a lower risk-adjusted odds ratio of overall morbidity, pulmonary morbidity, sepsis or septic shock, bleeding requiring transfusion, and length of stay greater than the median (5 days).

CONCLUSIONS

ALR outcomes are superior for CTSs when compared with GSs. This is consistent with prior studies looking at this specific subset of patients and studies looking at a different subset of patients using the ACS-NSQIP database.

Risk-Adjusted Margin Positivity Rate as a Surgical Quality Metric for Non-Small Cell Lung Cancer

BACKGROUND

Incomplete lung cancer resection connotes poor prognosis; the incidence varies with patient demographic, clinical, and institutional factors. We sought to develop a valid, survival impactful, facility-based surgical quality metric that adjusts for related patient demographic and clinical characteristics.

METHODS

Facilities performing resections for patients diagnosed with stage I to IIIA non-small cell lung cancer in the National Cancer Data Base between 2004 and 2011 were identified. Multivariate logistic regression modeling was used to estimate the expected number of margin-positive cases by adjusting for patient risk mix and calculate the observed-to-expected ratio for each facility. Facilities were categorized as outperformers (observed-to-expected ratio less than 1, p < 0.05), nonoutliers (p > 0.05), and underperformers (observed-to-expected ratio greater than 1, p < 0.05); and their characteristics across performance categories were compared by χ² tests. Multivariate Cox proportional hazard analyses were conducted, adjusting for patient demographic and clinical characteristics.

RESULTS

A total of 96,324 patients underwent surgery at 809 facilities. The overall observed margin-positive rate was 4.4%. Sixty-one facilities (8%) were outperformers, 644 (80%) were nonoutliers, and 104 (13%) were underperformers. One third (36%) of National Cancer Institute-designated facilities, 13% of academic comprehensive cancer programs, 5% of comprehensive community cancer programs, and 13% of "other" facilities achieved outperforming status but no community cancer programs did. Interestingly, 9% of National Cancer Institute-designated facilities and 11% of academic comprehensive cancer program facilities were underperformers. Adjusting for patient demographic and clinical characteristics, outperformers had a 5-year all-cause hazard ratio of 0.88 (95% confidence interval: 0.85 to 0.91, p < 0.0001) compared with nonoutliers, and 0.80 (95% confidence interval: 0.77 to 0.84, p < 0.0001) compared with underperformers.

CONCLUSIONS

Facility performance in lung cancer surgery can be captured by the risk-adjusted margin-positivity rate, potentially providing a valid quality improvement metric.

Impact of Surgeon Specialty on Perioperative Outcomes of Surgery for Benign Esophageal Diseases: A NSQIP Analysis

BACKGROUND

Surgery for benign esophageal disease is mostly performed either by general surgeons (GS) or cardiothoracic surgeons (CTS) in the United States. The purpose of this study was to evaluate the effect of surgeon specialty on perioperative outcomes of surgery for benign esophageal diseases.

MATERIALS AND METHODS

We have conducted a retrospective analysis using the ACS-NSQIP during the period of 2006-2013. Patients who underwent paraesophageal hernia (PEH) repair, gastric fundoplication, or Heller esophagomyotomy were divided into two groups according to the specialty of the surgeon (GS or CTS). Outcomes compared between the two groups using multivariable logistic regression included 30-day mortality, overall morbidity, discharge destination, hospital length of stay (LOS), and readmission rates.

RESULTS

Most of the surgeries were performed by general surgeons (PEH: 97.1%; fundoplication: 97.6%; Heller: 91.6%). Patients had lower comorbidities, better physical condition, and underwent a laparoscopic approach more frequently in the GS group. Regression analysis showed that GS group had a lower mortality rate (operating room, 0.44; 95% confidence interval [CI]: 0.23-0.86; P = .017), shorter LOS, and more home discharge for patients undergoing PEH repair. Mortality, morbidity, readmission, LOS, and home discharge were comparable between GS and CTS in fundoplication and Heller esophagomyotomy.

CONCLUSION

GS perform most of esophageal surgeries for benign diseases. GS group has better outcomes in PEH repair compared with CTS, whereas there is no difference in the overall outcomes between GS and CTS in fundoplication and Heller esophagomyotomy. These results show that specialization is not always the answer to better outcomes. Difference in outcomes, however, might be related to disease severity, approach needed, or case volume.

Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria

BACKGROUND

The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small cell lung cancer recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of three or more mediastinal nodal stations. We examined the survival impact of these criteria.

METHODS

A population-based observational study was done using patient-level data from all curative-intent, non-small cell lung cancer resections from 2004 to 2013 at 11 institutions in four contiguous Dartmouth Hospital referral regions in three US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines.

RESULTS

Of 2,429 eligible resections, 91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria; however, there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p < 0.001). Compared with patients whose surgery missed one or more criteria, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59 to 0.86, p < 0.001). Margin status and the nodal staging criteria were most strongly linked with survival.

CONCLUSIONS

Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the United States. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in non-small cell lung cancer care.

The impact of certification of general thoracic surgeons on lung cancer mortality: a survey by The Japanese Association for Thoracic Surgery

OBJECTIVES

The Japanese Board of General Thoracic Surgery and the annual survey by the Japanese Association for Thoracic Surgery (JATS) of certified hospitals began in 2005; since then, over 1300 specialists and 650 hospitals have been certified by this system. To evaluate how this system contributes to improving the outcomes of general thoracic surgery, the effects of the number of certified general thoracic surgeons (GTSs) and hospital volume on 30-day mortality or hospital mortality were evaluated.

METHODS

Using data from the annual survey of JATS from 2005 to 2012, the outcomes of 211 619 patients who underwent lung resection for lung cancer were evaluated. The patients were divided into four groups by the level of surgery: first level, partial resection; second level, segmentectomy and lobectomy; third level, sleeve segmentectomy and lobectomy; and fourth level, pneumonectomy, sleeve pneumonectomy and pleuro-pneumonectomy. Multiple logistic regression analysis was used to examine the associations between operative mortality and the number of GTSs, hospital volume and level of surgical procedure.

RESULTS

Overall 30-day and hospital mortality rates were 0.40 and 0.77%, respectively. The 30-day and hospital mortality rates for each surgical level were 0.20 and 0.35% for the first level, 0.36 and 0.73% for the second level, 1.02 and 1.81% for the third level and 2.42 and 4.26% for the fourth level, respectively. The number of GTSs was associated with lower 30-day and hospital mortality rates (P < 0.0001). On logistic analysis, number of GTSs (<3 vs ≥3), hospital volume (<50 vs ≥50) and level of procedure (1 vs 2, 3 vs 2, 4 vs 2) were significantly associated with 30-day and hospital mortality rates. For 30-day mortality, the odds ratios were 0.688 (P < 0.0001) for higher number of GTSs and 0.856 (P = 0.0510) for higher volume hospitals. In the subgroup analysis by surgical level, low 30-day and hospital mortality rates in the second and fourth surgical levels were correlated with a higher number of GTSs.

CONCLUSIONS

The current decrease in overall 30-day mortality rates from the JATS data showed greater dependence on the number of GTSs than on the hospital volume. We believe that the certification system in Japan is useful for the establishment of GTS status.

Improving lung cancer outcomes by improving the quality of surgical care

Surgical resection remains the most important curative treatment modality for non-small cell lung cancer, but variations in short- and long-term surgical outcomes jeopardize the benefit of surgery for certain patients, operated on by certain types of surgeons, at certain types of institutions. We discuss current understanding of surgical quality measures, and their role in promoting understanding of the causes of outcome disparities after lung cancer surgery. We also discuss the use of minimally invasive surgical resection approaches to expand the playing field for surgery in lung cancer care, and end with a discussion of the future role of surgery in a world of alternative treatment possibilities.

Lung cancer surgery: an up to date

According to the International Agency for Research on Cancer (IARC) GLOBOCAN World Cancer Report, lung cancer affects more than 1 million people a year worldwide. In Greece according to the 2008 GLOBOCAN report, there were 6,667 cases recorded, 18% of the total incidence of all cancers in the population. Furthermore, there were 6,402 deaths due to lung cancer, 23.5% of all deaths due to cancer. Therefore, in our country, lung cancer is the most common and deadly form of cancer for the male population. The most important prognostic indicator in lung cancer is the extent of disease. The Union Internationale Contre le Cancer (UICC) and the American Joint Committee for Cancer Staging (AJCC) developed the tumour, node, and metastases (TNM) staging system which attempts to define those patients who might be suitable for radical surgery or radical radiotherapy, from the majority, who will only be suitable for palliative measures. Surgery has an important part for the therapy of patients with lung cancer. "Lobectomy is the gold standard treatment". This statement may be challenged in cases of stage Ia cancer or in patients with limited pulmonary function. In these cases an anatomical segmentectomy with lymph node dissection is an acceptable alternative. Chest wall invasion is not a contraindication to resection. En-bloc rib resection and reconstruction is the treatment of choice. N2 disease represents both a spectrum of disease and the interface between surgical and non-surgical treatment of lung cancer Evidence from trials suggests that multizone or unresectable N2 disease should be treated primarily by chemoradiotherapy. There may be a role for surgery if N2 is downstaged to N0 and lobectomy is possible, but pneumonectomy is avoidable. Small cell lung cancer (SCLC) is considered a systemic disease at diagnosis, because the potential for hematogenous and lymphogenic metastases is very high. The efficacy of surgical intervention for SCLC is not clear. Lung cancer resection can be performed using several surgical techniques. Video-assisted thoracoscopic surgery (VATS) lobectomy is a safe, efficient, well accepted and widespread technique among thoracic surgeons. The 5-year survival rate following complete resection of lung cancer is stage dependent. Incomplete resection rarely is useful and cures the patient.

Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined.

METHODS

The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians.

RESULTS

Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (&lt; 3 cm) peripheral NSCLC that are clinical stage I.