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

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.

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.

Incidence and risk factors of pulmonary complications after lung cancer surgery: A systematic review and meta-analysis

Postoperative pulmonary complications (PPCs) are associated with high mortality rates after lung cancer surgery. Although some studies have discussed the different risk factors for PPCs, the relationship between these factors and their impact on PPCs remains unclear. Hence, this study aimed to systematically summarize the incidence and determine the risk factors for PPCs. We conducted a systematic search of five English and four Chinese databases from their inception to April 1, 2023. A total of 34 articles (8 cohort studies and 26 case-control studies) (n = 31696, 5833 with PPCs) were included in the analysis. The primary outcome was the incidence of PPC. The secondary outcome was the odds ratio (OR) of PPCs based on the identified risk factors calculated by RevMan 5.4. A narrative descriptive summary of the study results was presented when pooling the results or conducting a meta-analysis was not possible. The pooled incidence of PPCs was 18.4 %. This meta-analysis demonstrated that TNM staging (OR 4.29, 95 % CI 2.59-7.13), chronic obstructive pulmonary disease (COPD) (OR 2.47, 95 % CI 1.80-3.40), smoking history (OR 2.37, 95 % CI 1.33-4.21), poor compliance with respiratory rehabilitation (OR 1.64, 95 % CI 1.17-2.30), male sex (OR 1.62, 95 % CI 1.28-2.04), diabetes (OR 1.56, 95 % CI 1.07-2.27), intraoperative bleeding volume (OR 1.44, 95 % CI 1.02-2.04), Eastern Cooperative Oncology Group score (ECOG) > 1 (OR 1.37, 95 % CI 1.04-1.80), history of chemotherapy and/or radiotherapy (OR 1.32, 95 % CI 1.03-1.70), older age (OR 1.18, 95 % CI 1.11-1.24), and duration of surgery (OR 1.07, 95 % CI 1.04-1.10) were significantly associated with a higher risk of PPCs. In contrast, the peak expiratory flow rate (PEF) (OR 0.99, 95 % CI 0.98-0.99) was a protective factor. Clinicians should implement targeted and effective interventions to prevent the occurrence of PPCs.

Effectiveness of a computer-facilitated intervention on improving provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting: A pilot study

INTRODUCTION

Effective tobacco treatments are available but are often not delivered to individuals with an actual or potential diagnosis of thoracic malignancy. The specific aims of this study were to identify the prevalence of tobacco use and examine the effectiveness of the Clinical and community Effort Against Smoking and secondhand smoke Exposure (CEASE), a system-level computer-facilitated intervention, to improve provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting.

METHODS

A pre-post-test design was used to assess the effectiveness of CEASE. A 3-step approach was used to integrate tobacco treatment into routine care: ask about tobacco use, assist with cessation, and refer to a quitline. An end-of-visit survey was conducted to collect prevalence of tobacco use and delivery of tobacco treatment. Descriptive statistics and Fisher's exact test were used for analysis.

RESULTS

A total of 218 individuals were enrolled; 105 participants were in usual care (UC) and 113 were in the CEASE group. Of those who enrolled, 27.6% were never smokers in UC and 27.7% in CEASE, 60% were former smokers in UC and 50% in CEASE, and 12.4% were current smokers in UC and 21.4% in CEASE. Significant differences were noted in delivery of tobacco treatment with 15.4% having received tobacco treatment in UC compared to 62.5% in CEASE (p<0.004).

CONCLUSIONS

A computer-facilitated intervention increased provider delivery of tobacco treatment in a thoracic surgery and oncology outpatient setting. This intervention provided a low-resource approach that has the potential to be scaled and implemented more broadly.

The prognostic value and model construction of inflammatory markers for patients with non-small cell lung cancer

The aim of this study was to investigate and analyse the predictive value of systemic inflammatory markers based on peripheral blood biomarkers for the prognosis of non-small cell lung cancer (NSCLC) patients. Based on a retrospective monitoring cohort of 973 NSCLC patients from an Affiliated Tumor Hospital from 2012 to 2023. The log-rank test and Cox proportional risk regression model were used to identify independent prognostic inflammatory markers. Subsequently, a nomogram prediction model was constructed and evaluated. The results of multivariate Cox regression analysis showed that patients with high NLR group (HR = 1.238, 95% CI 1.015-1.510, P = 0.035), and high CAR group (HR = 1.729, 95% CI 1.408-2.124, P < 0.001) were risk factors affecting the prognosis of NSCLC patients. The nomogram that includes age, tumor stage, smoking history, BMI, NLR, and CAR can effectively predict the prognosis of NSCLC patients.The inflammatory markers NLR and CAR, which combine inflammatory and nutritional status, are effective predictors of the prognosis of NSCLC patients. The combination of clinical information and these easily accessible inflammatory markers has significant research value for prognostic assessment, clinical treatment, and follow-up monitoring of NSCLC patients.

A simplified frailty index and nomogram to predict the postoperative complications and survival in older patients with upper urinary tract urothelial carcinoma

Purpose

This study was designed to investigate the clinical value of a simplified five-item frailty index (sFI) for predicting short- and long-term outcomes in older patients with upper urinary tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU).

Method

This retrospective study included 333 patients (aged ≥65 years) with UTUC. Patients were classified into five groups: 0, 1, 2, 3, and 3+, according to sFI score. The variable importance and minimum depth methods were used to screen for significant variables, and univariable and multivariable logistic regression models applied to investigated the relationships between significant variables and postoperative complications. Survival differences between groups were analyzed using Kaplan-Meier plots and log-rank tests. Cox proportional hazards regression was used to evaluate risk factors associated with overall survival (OS) and cancer-specific survival (CSS). Further, we developed a nomogram based on clinicopathological features and the sFI. The area under the curve (AUC), Harrel's concordance index (C-index), calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram.

Result

Of 333 cases identified, 31.2% experienced a Clavien-Dindo grade of 2 or greater complication. Random forest-logistic regression modeling showed that sFI significantly influenced the incidence of postoperative complications in older patients (AUC= 0.756). Compared with patients with low sFI score, those with high sFI scores had significantly lower OS and CSS (p < 0.001). Across all patients, the random survival forest-Cox regression model revealed that sFI score was an independent prognostic factor for OS and CSS, with AUC values of 0.815 and 0.823 for predicting 3-year OS and CSS, respectively. The nomogram developed was clinically valuable and had good ability to discriminate abilities for high-risk patients. Further, we developed a survival risk classification system that divided all patients into high-, moderate-, and low-risk groups based on total nomogram points for each patient.

Conclusion

A simple five-item frailty index may be considered a prognostic factor for the prognosis and postoperative complications of UTUC following RNU. By using this predictive model, clinicians may increase their accuracy in predicting complications and prognosis and improve preoperative decision-making.

Surgeon behaviors related to engaging patients in smoking cessation at the time of elective surgery

BACKGROUND

Despite the abundance of evidence supporting smoking cessation before elective surgery, there is wide variation in surgeon adherence to these best practices.

METHODS

This qualitative study used convenience sampling to recruit General Surgery trained surgeons. Surgeons participated in semi-structured interviews based on domains from the Theoretical Domains Framework (TDF). Content analysis was guided by the TDF.

RESULTS

Of the 14 TDF domains, social or professional role/identity, memory, attention and decision processes, environmental context and resources, and beliefs about consequences emerged most frequently. Mapping these domains to the Behavior Change Wheel identified education, enablement, and incentivization as effective intervention functions.

CONCLUSIONS

Using the TDF, this study identified a widespread sense of responsibility among surgeons to engage patients in perioperative smoking cessation despite workplace barriers and lacking resources. These findings provide valuable insight to facilitate surgeon participation in health promotion through targeted, theory-based interventions informed by surgeon identified barriers to perioperative smoking cessation.

Identification of preoperative risk factors associated with prolonged length of stay after lobectomy

Objective

To examine the association between length of stay (LOS) after lobectomy and operative adverse events and define the best predictors and risk factors associated with prolonged LOS after lobectomy.

Methods

Data from patients undergoing thoracoscopic lobectomy in the Thoracic Surgery Department of our center between January 2015 and December 2021 were retrospectively analyzed. The association between operative adverse events and LOS after lobectomy was explored using receiver operating characteristic (ROC) curves, and multivariate logistic regression analyses were used to identify preoperative risk factors associated with prolonged LOS after lobectomy.

Results

Prolonged LOS after lobectomy was defined as a LOS after lobectomy that is > 3.5 days based on an optimal diagnostic value for operative adverse events (AUC = 0.882). Of the included patients, 20.9% (91/435) exceeded this threshold, of whom 52.7% (48/91) exhibited operative adverse events. The preoperative risk factors associated with prolonged LOS after lobectomy were age≥60 years old (OR = 9.632, 95%CI 1.126-75.66, p = 0.03), being a current smoker (OR = 2.702, 95%CI 1.547-4.72, P < 0.001), an American Society of Anesthesiology (ASA) classification of 2 or higher (OR = 1.845, 95%CI 1.06-3.211, P = 0.03), ASA = 3 (OR = 9.133, 95%CI 3.281-25.425, P < 0.001), and Stage IIIA disease (OR = 6.565, 95%CI 2.823-15.271, P < 0.001). Prolonged LOS after lobectomy was significantly associated with the incidence of different operative adverse events, including conversion to thoracotomy, an operative duration of ≥300 min, blood transfusion events, chest tube drainage time, postoperative complications, and postoperative interventions (P < 0.001).

Conclusion

The risk of prolonged LOS after lobectomy is higher in patients that are ≥60 years old, current smokers, exhibit an ASA classification of 2 or higher, and have a stage IIIA disease. Early identification of these risk factors can enhance the treatment offered to high-risk patients, thereby reducing the rates of operative adverse events and optimizing resource utilization.