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Subramanian MP, Eaton DB, Labilles UL, Heiden BT, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Thomas TS, Meyers BF, Kozower BD, Puri V. Exposure to Agent Orange is associated with increased recurrence after surgical treatment of stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2024; 167:1591-1600.e2. [PMID: 37709166 DOI: 10.1016/j.jtcvs.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/31/2023] [Accepted: 09/02/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Approximately 3 million Americans served in the armed forces during the Vietnam War. Veterans have a higher incidence rate of lung cancer compared with the general population, which may be related to exposures sustained during service. Agent Orange, one of the tactical herbicides used by the armed forces as a means of destroying crops and clearing vegetation, has been linked to the development of several cancers including non-small cell lung cancer. However, traditional risk models of lung cancer survival and recurrence often do not include such exposures. We aimed to examine the relationship between Agent Orange exposure and overall survival and disease recurrence for surgically treated stage I non-small cell lung cancer. METHODS We performed a retrospective cohort study using a uniquely compiled dataset of US Veterans with pathologic I non-small cell lung cancer. We included adult patients who served in the Vietnam War and underwent surgical resection between 2010 and 2016. Our 2 comparison groups included those with identified Agent Orange exposure and those who were unexposed. We used multivariable Cox proportional hazards and Fine and Gray competing risk analyses to examine overall survival and disease recurrence for patients with pathologic stage I disease, respectively. RESULTS A total of 3958 Vietnam Veterans with pathologic stage I disease were identified (994 who had Agent Orange exposure and 2964 who were unexposed). Those who had Agent Orange exposure were more likely to be male, to be White, and to live a further distance from their treatment facility (P < .05). Tumor size distribution, grade, and histology were similar between cohorts. Multivariable Cox proportional hazards modeling identified similar overall survival between cohorts (Agent Orange exposure hazard ratio, 0.97; 95% CI, 0.86-1.09). Patients who had Agent Orange exposure had a 19% increased risk of disease recurrence (hazard ratio, 1.19; 95% CI, 1.02-1.40). CONCLUSIONS Veterans with known Agent Orange exposure who undergo surgical treatment for stage I non-small cell lung cancer have an approximately 20% increased risk of disease recurrence compared with their nonexposed counterparts. Agent Orange exposure should be taken into consideration when determining treatment and surveillance regimens for Veteran patients.
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Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
| | - Daniel B Eaton
- Veterans Affairs St Louis Health Care System, St Louis, Mo
| | | | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Yan Yan
- Veterans Affairs St Louis Health Care System, St Louis, Mo; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Martin W Schoen
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Mo
| | - Mayank R Patel
- Veterans Affairs St Louis Health Care System, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Theodore S Thomas
- Department of Medical Oncology, Washington University School of Medicine, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
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Yang Z, Bai YZ, Yan Y, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Kreisel D, Nava RG, Meyers BF, Kozower BD, Patterson GA, Hartwig MG, Heiden BT, Puri V. Validation of a novel donor lung scoring system based on the updated lung Composite Allocation Score. Am J Transplant 2024:S1600-6135(24)00242-9. [PMID: 38531429 DOI: 10.1016/j.ajt.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 03/28/2024]
Abstract
Lung transplantation (LTx) continues to have lower rates of long-term graft survival compared with other organs. Additionally, lung utilization rates from brain-dead donors remain substantially lower compared with other solid organs, despite a growing need for LTx and the significant risk of waitlist mortality. This study aims to examine the effects of using a combination of the recently described novel lung donor (LUNDON) acceptability score and the newly adopted recipient lung Composite Allocation Score (CAS) to guide transplantation. We performed a review of nearly 18 000 adult primary lung transplants from 2015-2022 across the US with retroactive calculations of the CAS value. The medium-CAS group (29.6-34.5) had superior 1-year posttransplant survival. Importantly, the combination of high-CAS (> 34.5) recipients with low LUNDON score (≤ 40) donors had the worst survival at 1 year compared with any other combination. Additionally, we constructed a model that predicts 1-year and 3-year survival using the LUNDON acceptability score and CAS values. These results suggest that caution should be exercised when using marginally acceptable donor lungs in high-priority recipients. The use of the LUNDON score with CAS value can potentially guide clinical decision-making for optimal donor-recipient matches for LTx.
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Affiliation(s)
- Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, Saint Louis, Missouri, USA
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Subramanian MP, Eaton DB, Heiden BT, Brandt WS, Labilles UL, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Thomas T, Meyers BF, Kozower BD, Puri V. Lobe-specific lymph node sampling is associated with lower risk of cancer recurrence. JTCVS Open 2024; 17:271-283. [PMID: 38420561 PMCID: PMC10897676 DOI: 10.1016/j.xjon.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/06/2023] [Accepted: 11/13/2023] [Indexed: 03/02/2024]
Abstract
Objective Adequate intraoperative lymph node (LN) assessment is a critical component of early-stage non-small cell lung cancer (NSCLC) resection. The National Comprehensive Cancer Network and the American College of Surgeons Commission on Cancer (CoC) recommend station-based sampling minimums agnostic to tumor location. Other institutions advocate for lobe-specific LN sampling strategies that consider the anatomic likelihood of LN metastases. We examined the relationship between lobe-specific LN assessment and long-term outcomes using a robust, highly curated cohort of stage I NSCLC patients. Methods We performed a cohort study using a uniquely compiled dataset from the Veterans Health Administration and manually abstracted data from operative and pathology reports for patients with clinical stage I NSCLC (2006-2016). For simplicity in comparison, we included patients who had right upper lobe (RUL) or left upper lobe (LUL) tumors. Based on modified European Society of Thoracic Surgeons guidelines, lobe-specific sampling was defined for RUL tumors (stations 2, 4, 7, and 10 or 11) and LUL tumors (stations 5 or 6, 7, and 10 or 11). Our primary outcome was the risk of cancer recurrence, as assessed by Fine and Gray competing risks modeling. Secondary outcomes included overall survival (OS) and pathologic upstaging. Analyses were adjusted for relevant patient, disease, and treatment variables. Results Our study included 3534 patients with RUL tumors and 2667 patients with LUL tumors. Of these, 277 patients (7.8%) with RUL tumors and 621 patients (23.2%) with LUL tumors met lobe-specific assessment criteria. Comparatively, 34.7% of patients met the criteria for count-based assessment, and 25.8% met the criteria for station-based sampling (ie, any 3 N2 stations and 1 N1 station). Adherence to lobe-specific assessment was associated with lower cumulative incidence of recurrence (adjusted hazard ratio [aHR], 0.83; 95% confidence interval [CI], 0.70-0.98) and a higher likelihood of pathologic upstaging (aHR, 1.49; 95% CI, 1.20-1.86). Lobe-specific assessment was not associated with OS. Conclusions Adherence to intraoperative LN sampling guidelines is low. Lobe-specific assessment is associated with superior outcomes in early-stage NSCLC. Quality metrics that assess adherence to intraoperative LN sampling, such as the CoC Operative Standards manual, also should consider lobe-specific criteria.
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Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Daniel B Eaton
- Veterans Affairs St Louis Health Care System, St Louis, Mo
| | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Whitney S Brandt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | | | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Yan Yan
- Veterans Affairs St Louis Health Care System, St Louis, Mo
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Martin W Schoen
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Mo
| | - Mayank R Patel
- Veterans Affairs St Louis Health Care System, St Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Theodore Thomas
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
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Tohmasi S, Eaton DB, Heiden BT, Rossetti NE, Rasi V, Chang SH, Yan Y, Gopukumar D, Patel MR, Meyers BF, Kozower BD, Puri V, Schoen MW. Inhaled medications for chronic obstructive pulmonary disease predict surgical complications and survival in stage I non-small cell lung cancer. J Thorac Dis 2023; 15:6544-6554. [PMID: 38249867 PMCID: PMC10797395 DOI: 10.21037/jtd-23-1273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/20/2023] [Indexed: 01/23/2024]
Abstract
Background Lung function is routinely assessed prior to surgical resection for non-small cell lung cancer (NSCLC). Further assessment of chronic obstructive pulmonary disease (COPD) using inhaled COPD medications to determine disease severity, a readily available metric of disease burden, may predict postoperative outcomes and overall survival (OS) in lung cancer patients undergoing surgery. Methods We retrospectively evaluated clinical stage I NSCLC patients receiving surgical treatment within the Veterans Health Administration from 2006-2016 to determine the relationship between number and type of inhaled COPD medications (short- and long-acting beta2-agonists, muscarinic antagonists, or corticosteroids prescribed within 1 year before surgery) and postoperative outcomes including OS using multivariable models. We also assessed the relationship between inhaled COPD medications, disease severity [measured by forced expiratory volume in 1 second (FEV1)], and diagnosis of COPD. Results Among 9,741 veterans undergoing surgery for clinical stage I NSCLC, patients with COPD were more likely to be prescribed inhaled medications than those without COPD [odds ratio (OR) =5.367, 95% confidence interval (CI): 4.886-5.896]. Increased severity of COPD was associated with increased number of prescribed inhaled COPD medications (P<0.0001). The number of inhaled COPD medications was associated with prolonged hospital stay [adjusted OR (aOR) =1.119, 95% CI: 1.076-1.165), more major complications (aOR =1.117, 95% CI: 1.074-1.163), increased 90-day mortality (aOR =1.088, 95% CI: 1.013-1.170), and decreased OS [adjusted hazard ratio (aHR) =1.061, 95% CI: 1.042-1.080]. In patients with FEV1 ≥80% predicted, greater number of prescribed inhaled COPD medications was associated with increased 30-day mortality (aOR =1.265, 95% CI: 1.062-1.505), prolonged hospital stay (aOR =1.130, 95% CI: 1.051-1.216), more major complications (aOR =1.147, 95% CI: 1.064-1.235), and decreased OS (aHR =1.058, 95% CI: 1.022-1.095). When adjusting for other drug classes and covariables, short-acting beta2-agonists were associated with increased 90-day mortality (aOR =1.527, 95% CI: 1.120-2.083) and decreased OS (aHR =1.087, 95% CI: 1.005-1.177). Conclusions In patients with early-stage NSCLC, inhaled COPD medications prescribed prior to surgery were associated with both short- and long-term outcomes, including in patients with FEV1 ≥80% predicted. Routine assessment of COPD medications may be a simple method to quantify operative risk in early-stage NSCLC patients.
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Affiliation(s)
- Steven Tohmasi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel B. Eaton
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
| | - Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Nikki E. Rossetti
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Valerio Rasi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yan Yan
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Deepika Gopukumar
- Department of Health and Clinical Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Mayank R. Patel
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
| | - Martin W. Schoen
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
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Heiden BT, Eaton DB, Brandt WS, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Development and Validation of the VA Lung Cancer Mortality (VALCAN-M) Score for 90-Day Mortality Following Surgical Treatment of Clinical Stage I Lung Cancer. Ann Surg 2023; 278:e634-e640. [PMID: 36250678 PMCID: PMC10106524 DOI: 10.1097/sla.0000000000005725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to develop and validate the Veterans Administration (VA) Lung Cancer Mortality (VALCAN-M) score, a risk prediction model for 90-day mortality following surgical treatment of clinical stage I nonsmall-cell lung cancer (NSCLC). BACKGROUND While surgery remains the preferred treatment for functionally fit patients with early-stage NSCLC, less invasive, nonsurgical treatments have emerged for high-risk patients. Accurate risk prediction models for postoperative mortality may aid surgeons and other providers in optimizing patient-centered treatment plans. METHODS We performed a retrospective cohort study using a uniquely compiled VA data set including all Veterans with clinical stage I NSCLC undergoing surgical treatment between 2006 and 2016. Patients were randomly split into derivation and validation cohorts. We derived the VALCAN-M score based on multivariable logistic regression modeling of patient and treatment variables and 90-day mortality. RESULTS A total of 9749 patients were included (derivation cohort: n=6825, 70.0%; validation cohort: n=2924, 30.0%). The 90-day mortality rate was 4.0% (n=390). The final multivariable model included 11 factors that were associated with 90-day mortality: age, body mass index, history of heart failure, forced expiratory volume (% predicted), history of peripheral vascular disease, functional status, delayed surgery, American Society of Anesthesiology performance status, tumor histology, extent of resection (lobectomy, wedge, segmentectomy, or pneumonectomy), and surgical approach (minimally invasive or open). The c statistic was 0.739 (95% CI=0.708-0.771) in the derivation cohort. CONCLUSIONS The VALCAN-M score uses readily available treatment-related variables to reliably predict 90-day operative mortality. This score can aid surgeons and other providers in objectively discussing operative risk among high-risk patients with clinical stage I NSCLC considering surgery versus other definitive therapies.
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Affiliation(s)
- Brendan T Heiden
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Whitney S Brandt
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, MO
- Department of Internal Medicine, Division of Hematology and Medical Oncology, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G Nava
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F Meyers
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
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Schoen MW, Pickett C, Eaton DB, Heiden BT, Chang SH, Yan Y, Subramanian MP, Puri V. Abstract 6741: Number of prescription drugs and overall survival in metastatic castrate resistant prostate cancer. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-6741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Background: Assessment of comorbid diseases is essential to clinical research and may risk-stratify patients for adverse events and death. Total number of prescription medications and drug classes could be an easy-to-use tool for estimating patient risk independent of established methods such as the Charlson Comorbidity Index (CCI) that is created from administrative data. Additionally, clinicians have access to prescription medication lists, facilitating assessment of comorbidities in clinical settings.
Methods: Retrospective observational study of US Veterans treated for metastatic castrate resistant prostate cancer in the Veterans Health Administration who received treatment with abiraterone or enzalutamide between May 2011-June 2, 2017. We determined number of unique drugs and anatomic therapeutic chemical (ATC) drug classes prescribed in the year prior up to 14 days before initiation of treatment. Multivariable logistic regression and Cox proportional hazard modeling was used to assess the association between number of drugs with all-cause 90-day mortality and overall survival (OS) while accounting for important covariates including age, CCI, body-mass index, prostate specific antigen, race, prior docetaxel, hemoglobin, albumin, bilirubin, and creatinine.
Results: Among 11,021 Veterans, a median (IQR) of 11 (6,18) unique medications and 10 (5,15) unique ATC medication classes were filled in the year prior to treatment. The median age was 75 years with median CCI of 3 and 2,550 were black (23.1%). Increasing age was associated with increased CCI across age strata with mean CCI of 3.7 in age <70, 4.2 in age 70-79, and 4.3 in age 80+ (p<0.001). Increased age was associated with decreased number of unique medicines with mean 14.7 in age <70, 12.7 in age 70-79, and 11.2 in age 80+ (p<0.001). Black race was associated with increased mean number of medications compared to white race (15.5 vs. 12.0, p<0.001). After adjusting for relevant patient, tumor, and treatment factors, the number of medications and drug classes were each independently associated with increased 90-day mortality with adjusted OR (95% CI) of 1.021 (1.011,1.030) and 1.024 (1.012,1.036) respectively. Both number of medications and number of classes were also associated with decreased OS with adjusted Hazard Ratio of 1.015 (1.013,1.018) and 1.018 (1.014,1.021) respectively. Within subgroups of patients with comparable CCI, increased number of medications was associated with increased risk of death.
Conclusion: The number of prescription medications and drug classes are independently associated with short- and long-term outcomes in patients undergoing treatment for metastatic castrate resistant prostate cancer, even after accounting for important covariates including age and CCI. Assessment of patient medications may provide a simple, yet reliable tool to assess comorbidities, risk of adverse events, and death.
Citation Format: Martin W. Schoen, Carley Pickett, Daniel B. Eaton, Brendan T. Heiden, Su-Hsin Chang, Yan Yan, Melanie P. Subramanian, Varun Puri. Number of prescription drugs and overall survival in metastatic castrate resistant prostate cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6741.
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Affiliation(s)
| | | | | | | | - Su-Hsin Chang
- 3Washington University in St. Louis, Saint Louis, MO
| | - Yan Yan
- 3Washington University in St. Louis, Saint Louis, MO
| | | | - Varun Puri
- 3Washington University in St. Louis, Saint Louis, MO
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Patel BG, Thomas TS, Meyers BF, Kozower BD, Puri V. Abstract 734: Comprehensive validation of high-risk clinicopathologic features in early-stage, node-negative non-small cell lung cancer. Cancer Res 2023. [DOI: 10.1158/1538-7445.am2023-734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Abstract
Objective: Current guidelines recommend adjuvant therapy for patients with completely resected non-small cell lung cancer (NSCLC) with high-risk clinical or pathologic features. Despite this, the relationship between these features and cancer recurrence is poorly elucidated.
Methods: We conducted a retrospective cohort study using a uniquely compiled dataset from the US Veterans Health Administration (VHA) including all Veterans with pathologic early-stage (≤5cm, N0) NSCLC receiving definitive surgical treatment (2010-2016). Based on National Comprehensive Cancer Network guidelines, we evaluated 6 high-risk features: tumor size, tumor grade, visceral-pleural invasion, lymphovascular invasion, non-anatomic wedge resection, and adequacy of nodal sampling. We developed a score reflecting the relationship between these high-risk features and recurrence, using a multivariable competing risk model (death as competing event). The score performance was then tested in an external cohort from the National Cancer Database (NCDB).
Results: The study included 3,799 Veterans. The median follow-up was 7.1 years. Recurrence was detected in 800 (21.1%) patients. The association between high-risk features and cancer recurrence were as follows: tumor size (e.g., 31-40mm vs. 0-10mm, multivariable-adjusted hazard ratio, aHR 1.676, 95% CI 1.229-2.285, p=0.001), tumor grade (e.g., III vs. I, aHR 1.884, 95% CI 1.448-2.449, p<0.001), visceral-pleural invasion (aHR 1.096, 95% CI 0.905-1.329, p=0.35), lymphovascular invasion (aHR 1.747, 95% CI 1.441-2.117, p<0.001), non-anatomic wedge resection (aHR 1.335, 95% CI 1.101-1.619, p=0.003), and adequacy of nodal sampling (e.g., 1-4 lymph nodes vs. ≥10 lymph nodes, aHR 1.392, 95% CI 1.149-1.687, p<0.001). Using these parameters, a score was created reflecting the association between high-risk features and recurrence. The score ranged from 0-36, with higher scores reflecting higher cumulative incidence of recurrence. The score was further divided into low- (0-11, n=1,263, 33.3%; 5-yr recurrence risk 13.0%), moderate- (12-15, n=1,134, 29.9%; 5-yr recurrence risk 19.0%), and high-risk (16-36, n=1,402, 36.9%; 5-yr recurrence risk 27.1%) categories. Higher scores were also associated with diminished overall survival (median OS, low-risk: 9.0 yrs; moderate-risk: 7.3 yrs; high-risk: 5.4 yrs). The score was further tested in a cohort of 63,232 patients from the NCDB and higher scores remained associated with worse overall survival (median OS, low-risk: 9.4 yrs; moderate-risk: 8.0 yrs; high-risk: 6.3 yrs).
Conclusions: High-risk clinicopathologic features are associated with dramatically higher risk of recurrence and worse overall survival. Multivariable assessment of these features using a comprehensive yet pragmatic score may help to standardize adjuvant treatment eligibility following curative intent resection.
Citation Format: Brendan T. Heiden, Daniel B. Eaton, Su-Hsin Chang, Yan Yan, Martin W. Schoen, Bindiya G. Patel, Theodore S. Thomas, Bryan F. Meyers, Benjamin D. Kozower, Varun Puri. Comprehensive validation of high-risk clinicopathologic features in early-stage, node-negative non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 734.
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Affiliation(s)
| | | | | | - Yan Yan
- 1Washington University In St. Louis, St. Louis, MO
| | | | | | | | | | | | - Varun Puri
- 1Washington University In St. Louis, St. Louis, MO
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Heiden BT, Yang Z, Bai YZ, Yan Y, Chang SH, Park Y, Colditz GA, Dart H, Hachem RR, Witt CA, Vazquez Guillamet R, Byers DE, Marklin GF, Pasque MK, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Development and validation of the lung donor (LUNDON) acceptability score for pulmonary transplantation. Am J Transplant 2023; 23:540-548. [PMID: 36764887 PMCID: PMC10234600 DOI: 10.1016/j.ajt.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/04/2023]
Abstract
There is a chronic shortage of donor lungs for pulmonary transplantation due, in part, to low lung utilization rates in the United States. We performed a retrospective cohort study using data from the Scientific Registry of Transplant Recipients database (2006-2019) and developed the lung donor (LUNDON) acceptability score. A total of 83 219 brain-dead donors were included and were randomly divided into derivation (n = 58 314, 70%) and validation (n = 24 905, 30%) cohorts. The overall lung acceptance was 27.3% (n = 22 767). Donor factors associated with the lung acceptance were age, maximum creatinine, ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, mechanism of death by asphyxiation or drowning, history of cigarette use (≥20 pack-years), history of myocardial infarction, chest x-ray appearance, bloodstream infection, and the occurrence of cardiac arrest after brain death. The prediction model had high discriminatory power (C statistic, 0.891; 95% confidence interval, 0.886-0.895) in the validation cohort. We developed a web-based, user-friendly tool (available at https://sites.wustl.edu/lundon) that provides the predicted probability of donor lung acceptance. LUNDON score was also associated with recipient survival in patients with high lung allocation scores. In conclusion, the multivariable LUNDON score uses readily available donor characteristics to reliably predict lung acceptability. Widespread adoption of this model may standardize lung donor evaluation and improve lung utilization rates.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yun Zhu Bai
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yan Yan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Graham A Colditz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hank Dart
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St. Louis, Missouri, USA
| | | | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Chen LS, Smock N, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Assessment of Duration of Smoking Cessation Prior to Surgical Treatment of Non-small Cell Lung Cancer. Ann Surg 2023; 277:e933-e940. [PMID: 34793352 PMCID: PMC9114169 DOI: 10.1097/sla.0000000000005312] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To define the relationship between the duration of smoking cessation and postoperative complications for patients with lung cancer undergoing surgical treatment. BACKGROUND Smoking increases the risk of postoperative morbidity and mortality in patients with lung cancer undergoing surgical treatment. Although smoking cessation before surgery can mitigate these risks, the ideal duration of preoperative smoking cessation remains unclear. METHODS Using a uniquely compiled Veterans Health Administration dataset, we performed a retrospective cohort study of patients with clinical stage I non-small cell lung cancer undergoing surgical treatment between 2006 and 2016. We characterized the relationship between duration of preoperative smoking cessation and risk of postoperative complications or mortality within 30-days using multivariable restricted cubic spline functions. RESULTS The study included a total of 9509 patients, of whom 6168 (64.9%) were smoking at the time of lung cancer diagnosis. Among them, only 662 (10.7%) patients stopped smoking prior to surgery. Longer duration between smoking cessation and surgery was associated with lower odds of major complication or mortality (adjusted odds ratio [aOR] for every additional week, 0.919; 95% confidence interval [CI], 0.850-0.993; P = 0.03). Compared to nonsmokers, patients who quit at least 3 weeks before surgery had similar odds of death or major complication (aOR, 1.005; 95% CI, 0.702-1.437; P = 0.98) whereas those who quit within 3 weeks of surgery had significantly higher odds of death or major complication (aOR, 1.698; 95% CI, 1.203-2.396; P = 0.003). CONCLUSION Smoking cessation at least 3 weeks prior to the surgical treatment of lung cancer is associated with reduced morbidity and mortality. Providers should aggressively encourage smoking cessation in the preoperative period, since it can disproportionately impact outcomes in early-stage lung cancer.
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Affiliation(s)
- Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Martin W. Schoen
- VA St. Louis Health Care System, St. Louis, MO
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - Li-Shiun Chen
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO
| | - Nina Smock
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G. Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Thomas TS, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Association between imaging surveillance frequency and outcomes following surgical treatment of early-stage lung cancer. J Natl Cancer Inst 2023; 115:303-310. [PMID: 36442509 PMCID: PMC9996218 DOI: 10.1093/jnci/djac208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/14/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Recent studies have suggested that more frequent postoperative surveillance imaging via computed tomography following lung cancer resection may not improve outcomes. We sought to validate these findings using a uniquely compiled dataset from the Veterans Health Administration, the largest integrated health-care system in the United States. METHODS We performed a retrospective cohort study of veterans with pathologic stage I non-small cell lung cancer receiving surgery (2006-2016). We assessed the relationship between surveillance frequency (chest computed tomography scans within 2 years after surgery) and recurrence-free survival and overall survival. RESULTS Among 6171 patients, 3047 (49.4%) and 3124 (50.6%) underwent low-frequency (<2 scans per year; every 6-12 months) and high-frequency (≥2 scans per year; every 3-6 months) surveillance, respectively. Factors associated with high-frequency surveillance included being a former smoker (vs current; adjusted odds ratio [aOR] = 1.18, 95% confidence interval [CI] = 1.05 to 1.33), receiving a wedge resection (vs lobectomy; aOR = 1.21, 95% CI = 1.05 to 1.39), and having follow-up with an oncologist (aOR = 1.58, 95% CI = 1.42 to 1.77), whereas African American race was associated with low-frequency surveillance (vs White race; aOR = 0.64, 95% CI = 0.54 to 0.75). With a median (interquartile range) follow-up of 7.3 (3.4-12.5) years, recurrence was detected in 1360 (22.0%) patients. High-frequency surveillance was not associated with longer recurrence-free survival (adjusted hazard ratio = 0.93, 95% CI = 0.83 to 1.04, P = .22) or overall survival (adjusted hazard ratio = 1.04, 95% CI = 0.96 to 1.12, P = .35). CONCLUSIONS We found that high-frequency surveillance does not improve outcomes in surgically treated stage I non-small cell lung cancer. Future lung cancer treatment guidelines should consider less frequent surveillance imaging in patients with stage I disease.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, MO, USA
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Theodore S Thomas
- VA St. Louis Health Care System, St. Louis, MO, USA
- Divisions of Hematology and Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- VA St. Louis Health Care System, St. Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- VA St. Louis Health Care System, St. Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- VA St. Louis Health Care System, St. Louis, MO, USA
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Tian R, Wiley B, Liu J, Zong X, Truong B, Zhao S, Uddin MM, Niroula A, Miller CA, Mukherjee S, Heiden BT, Luo J, Puri V, Kozower BD, Walter MJ, Ding L, Link DC, Amos CI, Ebert BL, Govindan R, Natarajan P, Bolton KL, Cao Y. Clonal Hematopoiesis and Risk of Incident Lung Cancer. J Clin Oncol 2023; 41:1423-1433. [PMID: 36480766 PMCID: PMC9995101 DOI: 10.1200/jco.22.00857] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 09/08/2022] [Accepted: 10/07/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To prospectively examine the association between clonal hematopoiesis (CH) and subsequent risk of lung cancer. METHODS Among 200,629 UK Biobank (UKBB) participants with whole-exome sequencing, CH was identified in a nested case-control study of 832 incident lung cancer cases and 3,951 controls (2006-2019) matched on age and year at blood draw, sex, race, and smoking status. A similar nested case-control study (141 cases/652 controls) was conducted among 27,975 participants with whole-exome sequencing in the Mass General Brigham Biobank (MGBB, 2010-2021). In parallel, we compared CH frequency in published data from 5,003 patients with solid tumor (2,279 lung cancer) who had pretreatment blood sequencing performed through Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets. RESULTS In UKBB, the presence of CH was associated with increased risk of lung cancer (cases: 12.5% v controls: 8.7%; multivariable-adjusted odds ratio [OR], 1.36; 95% CI, 1.06 to 1.74). The association remained robust after excluding participants with chronic obstructive pulmonary disease. No significant interactions with known risk factors, including polygenic risk score and C-reactive protein, were identified. In MGBB, we observed similar enrichment of CH in lung cancer (cases: 15.6% v controls: 12.7%). The meta-analyzed OR (95% CI) of UKBB and MGBB was 1.35 (1.08 to 1.68) for CH overall and 1.61 (1.19 to 2.18) for variant allele frequencies ≥ 10%. In Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets, CH with a variant allele frequency ≥ 10% was enriched in pretreatment lung cancer compared with other tumors after adjusting for age, sex, and smoking (OR for lung v breast cancer: 1.61; 95% CI, 1.03 to 2.53). CONCLUSION Independent of known risk factors, CH is associated with increased risk of lung cancer.
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Affiliation(s)
- Ruiyi Tian
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
- Brown School, Washington University in St Louis, St Louis, MO
| | - Brian Wiley
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Jie Liu
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Xiaoyu Zong
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Buu Truong
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology (MIT), Cambridge, MA
| | - Stephanie Zhao
- School of Medicine, Washington University School of Medicine, St Louis, MO
| | - Md Mesbah Uddin
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology (MIT), Cambridge, MA
| | - Abhishek Niroula
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology (MIT), Cambridge, MA
- Department of Laboratory Medicine, Lund University, Lund, Sweden
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Christopher A. Miller
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Semanti Mukherjee
- Department of Medicine, Weill Cornell Medical College, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Jingqin Luo
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Matthew J. Walter
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Li Ding
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
- Department of Genetics, Washington University School of Medicine, St Louis, MO
| | - Daniel C. Link
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Christopher I. Amos
- Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Benjamin L. Ebert
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA
- Howard Hughes Medical Institute, Dana-Farber Cancer Institute, Boston, MA
| | - Ramaswamy Govindan
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and Massachusetts Institute of Technology (MIT), Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Kelly L. Bolton
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, MO
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Heiden BT, Eaton DB, Chang SH, Yan Y, Baumann AA, Schoen MW, Tohmasi S, Rossetti NE, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Association Between Surgical Quality Metric Adherence and Overall Survival Among US Veterans With Early-Stage Non-Small Cell Lung Cancer. JAMA Surg 2023; 158:293-301. [PMID: 36652269 PMCID: PMC9857796 DOI: 10.1001/jamasurg.2022.6826] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/16/2022] [Indexed: 01/19/2023]
Abstract
Importance Surgical resection remains the preferred treatment for functionally fit patients diagnosed with early-stage non-small cell lung cancer (NSCLC). Process-based intraoperative quality metrics (QMs) are important for optimizing long-term outcomes following curative-intent resection. Objective To develop a practical surgical quality score for patients diagnosed with clinical stage I NSCLC who received definitive surgical treatment. Design, Setting, and Participants This retrospective cohort study used a uniquely compiled data set of US veterans diagnosed with clinical stage I NSCLC who received definitive surgical treatment from October 2006 through September 2016. The data were analyzed from April 1 to September 1, 2022. Based on contemporary treatment guidelines, 5 surgical QMs were defined: timely surgery, minimally invasive approach, anatomic resection, adequate lymph node sampling, and negative surgical margin. The study developed a surgical quality score reflecting the association between these QMs and overall survival (OS), which was further validated in a cohort of patients using data from the National Cancer Database (NCDB). The study also examined the association between the surgical quality score and recurrence-free survival (RFS). Exposures Surgical treatment of early-stage NSCLC. Main Outcomes and Measures Overall survival and RFS. Results The study included 9628 veterans who underwent surgical treatment between 2006 and 2016. The cohort consisted of 1446 patients who had a mean (SD) age of 67.6 (7.9) years and included 9278 males (96.4%) and 350 females (3.6%). Among the cohort, 5627 individuals (58.4%) identified as being smokers at the time of surgical treatment. The QMs were met as follows: timely surgery (6633 [68.9%]), minimally invasive approach (3986 [41.4%]), lobectomy (6843 [71.1%]) or segmentectomy (532 [5.5%]), adequate lymph node sampling (3278 [34.0%]), and negative surgical margin (9312 [96.7%]). The median (IQR) follow-up time was 6.2 (2.5-11.4) years. An integer-based score (termed the Veterans Affairs Lung Cancer Operative quality [VALCAN-O] score) from 0 (no QMs met) to 13 (all QMs met) was constructed, with higher scores reflecting progressively better risk-adjusted OS. The median (IQR) OS differed substantially between the score categories (score of 0-5 points, 2.6 [1.0-5.7] years of OS; 6-8 points, 4.3 [1.7-8.6] years; 9-11 points, 6.3 [2.6-11.4] years; and 12-13 points, 7.0 [3.0-12.5] years; P < .001). In addition, risk-adjusted RFS improved in a stepwise manner between the score categories (6-8 vs 0-5 points, multivariable-adjusted hazard ratio [aHR], 0.62; 95% CI, 0.48-0.79; P < .001; 12-13 vs 0-5 points, aHR, 0.39; 95% CI, 0.31-0.49; P < .001). In the validation cohort, which included 107 674 nonveteran patients, the score remained associated with OS. Conclusions and Relevance The findings of this study suggest that adherence to intraoperative QMs may be associated with improved OS and RFS. Efforts to improve adherence to surgical QMs may improve patient outcomes following curative-intent resection of early-stage lung cancer.
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Affiliation(s)
- Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Su-Hsin Chang
- VA St Louis Healthcare System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Yan Yan
- VA St Louis Healthcare System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ana A. Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Martin W. Schoen
- VA St Louis Healthcare System, St Louis, Missouri
- Division of Hematology and Medical Oncology, Department of Internal Medicine, St Louis University School of Medicine, St Louis, Missouri
| | - Steven Tohmasi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Nikki E. Rossetti
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
- VA St Louis Healthcare System, St Louis, Missouri
| | - Ruben G. Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
- VA St Louis Healthcare System, St Louis, Missouri
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
- VA St Louis Healthcare System, St Louis, Missouri
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Comparison Between Veteran and Non-Veteran Populations With Clinical Stage I Non-small Cell Lung Cancer Undergoing Surgery. Ann Surg 2023; 277:e664-e669. [PMID: 34550662 PMCID: PMC8581073 DOI: 10.1097/sla.0000000000004928] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC). BACKGROUND Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the VHA. We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population. METHODS We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB). RESULTS The unmatched cohorts included 9981 VHA and 176,304 NCDB patients. The VHA had more male, non-White patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, P = 0.011) and median overall survival (69.0 vs 88.7 months, P < 0.001). In the propensity matched cohort of 6792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, P < 0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, P = 0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, P < 0.001) but similar readmission rates (7.7% vs 7.0%, P = 0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, P < 0.001) and median overall survival (71.4 vs 65.2 months, P < 0.001). CONCLUSIONS Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.
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Affiliation(s)
- Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO
- Division of Public Health Sciences, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Martin W. Schoen
- VA St. Louis Health Care System, St. Louis, MO
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G. Nava
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery,
Washington University School of Medicine, St. Louis, MO
- VA St. Louis Health Care System, St. Louis, MO
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14
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Heiden BT, Kozower BD. Value-based Care in Thoracic Surgery. Ann Thorac Surg 2023; 115:677-678. [PMID: 35598710 DOI: 10.1016/j.athoracsur.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/07/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Brendan T Heiden
- Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8234, St Louis, MO 63110.
| | - Benjamin D Kozower
- Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8234, St Louis, MO 63110
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15
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Heiden BT, Puri V. Response to "Which Factors Determinate the Lymphadenectomy Definition?". J Thorac Oncol 2023; 18:e8-e9. [PMID: 36682847 DOI: 10.1016/j.jtho.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 01/22/2023]
Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Veterans Affairs, St. Louis Health Care System, St. Louis, Missouri
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16
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Heiden BT, Keller M, Meyers BF, Puri V, Olsen MA, Kozower BD. Assessment of short readmissions following elective pulmonary lobectomy. Am J Surg 2023; 225:220-225. [PMID: 35970614 PMCID: PMC9900449 DOI: 10.1016/j.amjsurg.2022.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/31/2022] [Accepted: 07/31/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reducing readmissions is critical for improving patient care and lowering costs. Despite this, few studies have assessed length of readmission following pulmonary lobectomy. METHODS Using the Healthcare Cost and Utilization Project New York State Inpatient Database, we identified adult patients undergoing elective pulmonary lobectomy (2007-2015) and assessed readmission within 30 days of hospital discharge. We analyzed the relationship between length of readmission and post-operative morbidity and mortality as well as primary diagnoses at readmission. RESULTS Of 19947 included patients, 2173 (10.9%) were readmitted within 30 days. The median (IQR) length of readmission was 5 (2-8) days. Longer length of readmission was associated with significantly higher likelihood of major complication (for every 1-day increase, aOR = 1.14, 95% CI = 1.12-1.17, p < 0.001) and mortality (aOR = 1.03, 95% CI = 1.02-1.04, p < 0.001) within 90 days. Primary diagnosis codes at readmission differed significantly with length of readmission. CONCLUSIONS Interventions that target short readmissions may help to prevent a proportion of readmissions following elective lung resection.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States.
| | - Matthew Keller
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Margaret A Olsen
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
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17
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Heiden BT, Chen LS, Puri V. Response. Chest 2023; 163:e51. [PMID: 36628690 DOI: 10.1016/j.chest.2022.08.2218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023] Open
Affiliation(s)
- Brendan T Heiden
- Departments of Surgery, Divisions of Cardiothoracic Surgery, St. Louis, MO; Public Health Sciences, St. Louis, MO.
| | - Li-Shiun Chen
- Department of Psychiatry, St. Louis, MO; Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Departments of Surgery, Divisions of Cardiothoracic Surgery, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
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18
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Subramanian MP, Yang Z, Chang SH, Willis D, Zhang J, Semenkovich TR, Heiden BT, Kozower BD, Kreisel D, Meyers BF, Patterson GA, Nava RG, Puri V. Minimum Volume Standards for Surgical Care of Early-Stage Lung Cancer: A Cost-Effectiveness Analysis. Ann Thorac Surg 2022; 114:2001-2007. [PMID: 35780816 DOI: 10.1016/j.athoracsur.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 04/17/2022] [Accepted: 06/13/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Multiple stakeholders have advocated for minimum volume standards for complex surgical procedures. The Leapfrog Group recommends that patients with non-small cell lung cancer (NSCLC) receive surgical resection at hospitals that perform at least 40 lung resections annually. However, the cost-effectiveness of this paradigm is unknown. METHODS A cost-effectiveness analysis was performed on 90-day and 5-year horizons for patients with clinical stage I NSCLC undergoing surgical resection at hospitals stratified by Leapfrog standard. Model inputs were derived from either the literature or a propensity score-matched cohort using the National Cancer Database. For the 5-year horizon, we simulated using a Markov model with 1-year cycle. Incremental cost-effectiveness ratio (ICER) was calculated to evaluate cost-effectiveness. RESULTS For the 90-day horizon, resection at a Leapfrog hospital was more costly ($25 567 vs $25 530) but had greater utility (0.185 vs 0.181 quality-adjusted life-years), resulting in an ICER of 10 506. Similarly, for the 5-year horizon, resection at a Leapfrog hospital was more costly ($26 600 vs $26 495) but more effective (3.216 vs 3.122 quality-adjusted life-years), resulting in an ICER of 1108. When the costs for long-distance travel, lodging, and loss of productivity for caregivers were factored in, the ICER was 20 499 during the 5-year horizon for resection at Leapfrog hospitals. Using a willingness-to-pay threshold of $50 000, resection at a Leapfrog hospital remained cost-effective. CONCLUSIONS Receiving surgery for clinical stage I NSCLC at hospitals that meet Leapfrog volume standards is cost-effective. Payers and policymakers should consider supporting patient and caregiver travel to higher volume institutions for lung cancer surgery.
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Affiliation(s)
- Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Zhizhou Yang
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Su-Hsin Chang
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Willis
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jianrong Zhang
- George Warren Brown School of Social Work, Washington University in St Louis, St Louis, Missouri
| | - Tara R Semenkovich
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Brendan T Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri.
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19
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Assessment of Updated Commission on Cancer Guidelines for Intraoperative Lymph Node Sampling in Early Stage NSCLC. J Thorac Oncol 2022; 17:1287-1296. [PMID: 36049657 DOI: 10.1016/j.jtho.2022.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The American College of Surgeons Commission on Cancer recently updated its sampling recommendations for early stage NSCLC from at least 10 lymph nodes to at least one N1 (hilar) and three N2 (mediastinal) lymph node stations. Nevertheless, intraoperative lymph node sampling minimums remain subject to debate. We sought to evaluate these guidelines in patients with early stage NSCLC. METHODS We performed a cohort study using a uniquely compiled data set from the Veterans Health Administration. We manually abstracted data from operative notes and pathology reports of patients with clinical stage I NSCLC receiving surgery (2006-2016). Adequacy of lymph node sampling was defined using count-based (≥10 lymph nodes) and station-based (≥three N2 and one N1 nodal stations) minimums. Our primary outcome was recurrence-free survival. Secondary outcomes were overall survival and pathologic upstaging. RESULTS The study included 9749 patients. Count-based and station-based sampling guidelines were achieved in 3302 (33.9%) and 2559 patients (26.3%), respectively, with adherence to either sampling guideline increasing over time from 35.6% (2006) to 49.1% (2016). Adherence to station-based sampling was associated with improved recurrence-free survival (multivariable-adjusted hazard ratio = 0.815, 95% confidence interval: 0.667-0.994, p = 0.04), whereas adherence to count-based sampling was not (adjusted hazard ratio = 0.904, 95% confidence interval: 0.757-1.078, p = 0.26). Adherence to either station-based or count-based guidelines was associated with improved overall survival and higher likelihood of pathologic upstaging. CONCLUSIONS Our study supports station-based sampling minimums (≥three N2 and one N1 nodal stations) for early stage NSCLC; however, the marginal benefit compared with count-based guidelines is minimal. Further efforts to promote widespread adherence to intraoperative lymph node sampling minimums are critical for improving patient outcomes after curative-intent lung cancer resection.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, Missouri; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, Missouri; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, Missouri; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; VA St. Louis Health Care System, St. Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; VA St. Louis Health Care System, St. Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; VA St. Louis Health Care System, St. Louis, Missouri
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20
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Heiden BT, Eaton DB, Chang SH, Yan Y, Baumann AA, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Racial Disparities in the Surgical Treatment of Clinical Stage I Non-Small Cell Lung Cancer Among Veterans. Chest 2022; 162:920-929. [PMID: 35405111 PMCID: PMC9562435 DOI: 10.1016/j.chest.2022.03.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prior studies in the civilian population have reported racial disparities in lung cancer outcomes following surgical treatment, including inferior quality of care and worse survival. It is unclear if racial disparities exist in the Veterans Health Administration (VHA), the largest integrated health care system in the United States. RESEARCH QUESTION Do racial disparities affect early-stage non-small cell lung cancer (NSCLC) outcomes following surgical treatment within the VHA? STUDY DESIGN AND METHODS This retrospective cohort study was conducted in veterans with clinical stage I NSCLC undergoing surgical treatment in the VHA system. Demographic characteristics, access to care, surgical quality measures, and short- and long-term oncologic outcomes between White and Black veterans were evaluated. RESULTS From 2006 to 2016, a total of 18,800 veterans with clinical stage I NSCLC were included. The rates of definitive surgical treatment were similar between Black (57.3%) and White (58.1%) veterans (P = .42). The final study cohort included 9,842 patients receiving surgical treatment, of whom 8,356 (84.9%) were White and 1,486 (15.1%) were Black. Black patients were younger and more likely to smoke, although comorbidities were similar between the two groups. Black patients were somewhat less likely to receive adequate lymph node sampling (30.6% vs 33.3%; P = .050); however, other access-to-care metrics and surgical quality measures, including rates of anatomic lobectomy (71.9% vs 69.4%; P = .189) and positive margins (3.2% vs 3.1%; P = .955), were similar between the two groups. Although Black veterans were less likely to experience major postoperative complications, there was no difference in 30-day readmission, 30-day mortality, or disease-free survival between the two groups. Black patients had significantly better risk-adjusted overall survival (hazard ratio, 0.802; 95% CI, 0.729-0.883; P < .001). INTERPRETATION Among veterans with NSCLC undergoing surgical treatment through the VHA, Black patients received comparable care with equivalent if not superior outcomes compared with White patients.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, MO; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
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21
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Heiden BT, Baker TB, Smock N, Pham G, Chen J, Bierut LJ, Chen LS. Assessment of formal tobacco treatment and smoking cessation in dual users of cigarettes and e-cigarettes. Thorax 2022; 78:thoraxjnl-2022-218680. [PMID: 35863765 PMCID: PMC9852353 DOI: 10.1136/thorax-2022-218680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The utility of electronic cigarettes ('e-cigarettes') as a smoking cessation adjunct remains unclear. Similarly, it is unclear if formal tobacco treatment (pharmacotherapy and/or behavioural support) augments smoking cessation in individuals who use both cigarettes and e-cigarettes. METHODS We performed a longitudinal cohort study of adult outpatients evaluated in our tertiary care medical centre (6/2018-6/2020). E-cigarette use, smoking status and formal tobacco treatment (deterrent pharmacotherapy and/or behavioural support) were assessed in 6-month blocks (eg, cohort 1 (C1)=6/2018-12/2018, C2=1/2019-6/2019 and so on) using our electronic health record. We assessed the relationship between e-cigarette use (either with or without formal tobacco treatment) and point prevalence of smoking cessation at 6 and 12 months. RESULTS 111 823 unique patients were included in the study. The prevalence of dual use of cigarettes and e-cigarettes increased significantly over the study period (C1=0.8%; C2=1.1%; C3=1.8%; C4=2.3%; p<0.001). The prevalence of smoking cessation at 12 months was higher among e-cigarette users (20.8%) compared with non-users (16.8%) (risk difference, 4.0% (95% CI 2.5% to 5.5%); adjusted relative risk (aRR) 1.354, 95% CI 1.252 to 1.464, p<0.0001). Further, among dual users of cigarettes and e-cigarettes, the prevalence of smoking cessation at 12 months was higher among individuals who received tobacco treatment (29.1%) compared with individuals who did not receive tobacco treatment (19.6%) (risk difference, 9.5% (95% CI, 4.6% to 14.4%); aRR 1.238, 95% CI 1.071 to 1.432, p=0.004). INTERPRETATION These results suggest that dual users of cigarettes and e-cigarettes benefit from formal tobacco treatment. Clinicians should consider offering formal tobacco treatment to such patients, though future trials are needed.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Timothy B Baker
- Center for Tobacco Research and Intervention, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Nina Smock
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Giang Pham
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Jingling Chen
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Laura J Bierut
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Li-Shiun Chen
- Division of Public Health Sciences, Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Department of Psychiatry, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Alvin J. Siteman Cancer Center, Washington Univeristy in St Louis, St Louis, Missouri, USA
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22
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Heiden BT, Engelhardt KE, Cao C, Meyers BF, Puri V, Cao Y, Kozower BD. Association between lung cancer screening and smoking cessation. Cancer Epidemiol 2022; 79:102194. [PMID: 35688050 DOI: 10.1016/j.canep.2022.102194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adults with high-risk smoking histories benefit from annual lung cancer screening. It is unclear if there is an association between lung cancer screening and smoking cessation among U.S. adults who receive screening. METHODS We performed this population-based cross-sectional study using data from the Behavioral Risk Factor Surveillance System (2017-2020). We defined individuals eligible for lung cancer screening as adults 55-80 years old with ≥ 30 pack-year smoking history who were currently smoking or quit within the last 15 years. We assessed the association between lung cancer screening and current smoking status. RESULTS Between 2017 and 2020, 12,382 participants met screening criteria. Current smoking was reported by 5685 (45.9 %) participants, of whom 40.4 % (2298) reported a cessation attempt in the prior year. Lung cancer screening was reported by only 2022 (16.3 %) eligible participants. Lung cancer screening was associated with lower likelihood of currently smoking (odds ratio [OR] 0.705, 95 % CI 0.626-0.793) compared to individuals who did not receive screening. Screening was also associated with higher likelihood of reporting a cessation attempt in the prior year (OR 1.562, 95 % CI 1.345-1.815) compared to individuals who did not receive screening. CONCLUSIONS Receipt of lung cancer screening was associated with lower smoking rates and more frequent cessation attempts among U.S. adults. Better implementation of lung cancer screening programs is critical and may profoundly increase smoking cessation in this population at risk of developing lung cancer.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States.
| | - Kathryn E Engelhardt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Chao Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, United States
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23
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Heiden BT, Eaton DB, Chang SH, Yan Y, Schoen MW, Chen LS, Smock N, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. The Impact of Persistent Smoking After Surgery on Long-term Outcomes After Stage I Non-small Cell Lung Cancer Resection. Chest 2022; 161:1687-1696. [PMID: 34919892 PMCID: PMC9248074 DOI: 10.1016/j.chest.2021.12.634] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Smoking at the time of surgical treatment for lung cancer increases the risk for perioperative morbidity and mortality. The prevalence of persistent smoking in the postoperative period and its association with long-term oncologic outcomes are poorly described. RESEARCH QUESTION What is the relationship between persistent smoking and long-term outcomes in early-stage lung cancer after surgical treatment? STUDY DESIGN AND METHODS We performed a retrospective cohort study using a uniquely compiled Veterans Health Administration dataset of patients with clinical stage I non-small cell lung cancer (NSCLC) undergoing surgical treatment between 2006 and 2016. We defined persistent smoking as individuals who continued smoking 1 year after surgery and characterized the relationship between persistent smoking and disease-free survival and overall survival. RESULTS This study included 7,489 patients undergoing surgical treatment for clinical stage I NSCLC. Of 4,562 patients (60.9%) who were smoking at the time of surgery, 2,648 patients (58.0%) continued to smoke at 1 year after surgery. Among 2,927 patients (39.1%) who were not smoking at the time of surgical treatment, 573 (19.6%) relapsed and were smoking at 1 year after surgery. Persistent smoking at 1 year after surgery was associated with significantly shorter overall survival (adjusted hazard ration [aHR], 1.291; 95% CI, 1.197-1.392; P < .001). However, persistent smoking was not associated with inferior disease-free survival (aHR, 0.989; 95% CI, 0.884-1.106; P = .84). INTERPRETATION Persistent smoking after surgery for stage I NSCLC is common and is associated with inferior overall survival. Providers should continue to assess smoking habits in the postoperative period given its disproportionate impact on long-term outcomes after potentially curative treatment for early-stage lung cancer.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
| | - Daniel B Eaton
- Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO
| | - Su-Hsin Chang
- Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Martin W Schoen
- Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - Li-Shiun Chen
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO; Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO
| | - Nina Smock
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Mayank R Patel
- Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; Division of Research and Education, VA St. Louis Health Care System, St. Louis, MO
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Affiliation(s)
- Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO
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Heiden BT, Subramanian MP, Liu J, Keith A, Engelhardt KE, Meyers BF, Puri V, Kozower BD. Long-term patient-reported outcomes after non-small cell lung cancer resection. J Thorac Cardiovasc Surg 2022; 164:615-626.e3. [PMID: 35430080 DOI: 10.1016/j.jtcvs.2021.11.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 10/07/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Patient-reported outcomes (PROs) are critical tools for evaluating patients before and after lung cancer resection. In this study, we assessed patient-reported pain, dyspnea, and functional status up to 1 year postoperatively. METHODS This study included patients who underwent surgery for non-small cell lung cancer at a single institution (2017-2020). We collected PROs using the National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS). Data were prospectively collected and merged with our institutional Society of Thoracic Surgeons data. Using multivariable linear mixed effect models, we compared PROMIS scores for preoperative and several postoperative visits. RESULTS From 2017 until 2020, 334 patients underwent lung cancer resection with completed PROMIS assessments. Pain interference, physical function, and dyspnea severity scores were worse 1 month after surgery (P < .001). Pain interference and physical function scores returned to baseline by 6 months after surgery. However, dyspnea severity scores remained persistently worse up to 1 year after surgery (1-month difference, 8.8 ± 1.9; 6-month difference, 3.6 ± 2.2; 1-year difference, 4.9 ± 2.8; P < .001). Patients who received a thoracotomy had worse physical function and pain interference scores 1 month after surgery compared with patients who received a minimally invasive operation; however, there were no differences in PROs by 6 months after surgery. CONCLUSIONS PROs are important metrics for assessing patients before and after lung cancer resection. Patients may report persistent dyspnea up to 1 year after resection. Additionally, patients undergoing thoracotomy initially report worse pain and physical function but these impairments improve by 6 months after surgery.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Melanie P Subramanian
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Angela Keith
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Kathryn E Engelhardt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
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Heiden BT, Engelhardt KE, Cao C, Meyers BF, Puri V, Cao Y, Kozower BD. Prevalence of cigarette and e-cigarette use among U.S. adults eligible for lung cancer screening based on updated USPSTF guidelines. Cancer Epidemiol 2021; 76:102079. [PMID: 34894590 DOI: 10.1016/j.canep.2021.102079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The United States Preventative Services Taskforce recently updated lung cancer screening guidelines for U.S. adults with high-risk smoking histories. This has generated a previously undescribed patient population in which the prevalence of cigarette and e-cigarette use has not been described. METHODS We performed a cross-sectional study using population-based data from the Behavioral Risk Factor Surveillance System (2017-2018). We defined lung cancer screening eligibility as adults 50-80 years old with ≥ 20 pack-year smoking history who were currently smoking or quit within the last 15 years. We assessed several smoking-related outcomes including current cigarette use, ever e-cigarette use, and current e-cigarette use among respondents. RESULTS Among 7541 screening-eligible adults, current cigarette use was reported by 3604 (47.8%) participants. Ever and current e-cigarette use were reported by 3003 (39.8%) and 670 (8.9%) participants, respectively. Compared to individuals who were previously eligible for screening, individuals newly eligible for screening (i.e., between 50 and 55 years old with a 20-30 pack-year smoking history) were more likely to currently smoke (aOR 1.828, 95% CI 1.649-2.026, p < 0.001). While newly eligible respondents were more likely to report a history of ever using an e-cigarette (aOR 1.144, 95% CI 1.034-1.266, p = 0.009), current e-cigarette use was similar in this group compared to those individuals who were previously screening-eligible (aOR 1.014, 95% CI 0.844-1.219, p = 0.88). CONCLUSIONS Cigarette and e-cigarette exposure are common among U.S. adults who are eligible for lung cancer screening. Expanded USPSTF criteria will capture a patient population with greater exposure to both of these products.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.
| | - Kathryn E Engelhardt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Chao Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
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Heiden BT, Tetteh E, Robbins KJ, Tabak RG, Nava RG, Marklin GF, Kreisel D, Meyers BF, Kozower BD, McKay VR, Puri V. Dissemination and Implementation Science in Cardiothoracic Surgery: A Review and Case Study. Ann Thorac Surg 2021; 114:373-382. [PMID: 34499861 PMCID: PMC9112075 DOI: 10.1016/j.athoracsur.2021.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/06/2021] [Accepted: 08/02/2021] [Indexed: 11/25/2022]
Abstract
Dissemination and implementation (D&I) science is the practice of taking evidence-based interventions (EBI) and sustainably incorporating them in routine clinical practice. As a relatively young field, D&I techniques are underutilized in cardiothoracic surgery. This review offers an overview of D&I science from the context of the cardiothoracic surgeon. First, we provide a general introduction to D&I science and basic terminology that is used in the field. Second, to illustrate D&I techniques in a real-world example, we discuss a case study for implementing lung protective management (LPM) strategies for lung donor optimization nationally. Finally, we discuss challenges to successful implementation that are unique to cardiothoracic surgery and give several examples of EBIs that have been poorly implemented into surgical practice. We also provide examples of successful D&I interventions - including de-implementation strategies - from other surgical subspecialties. We hope that this review offers additional tools for cardiothoracic surgeons to explore when introducing EBIs into routine practice.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Emmanuel Tetteh
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO
| | - Keenan J Robbins
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rachel G Tabak
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO; Institute for Implementation Science, Washington University in St. Louis, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Gary F Marklin
- Institute for Implementation Science, Washington University in St. Louis, St. Louis, MO
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Virginia R McKay
- Brown School of Public Health, Washington University in St. Louis, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
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Heiden BT, Subramanian MP, Nava R, Patterson AG, Meyers BF, Puri V, Oncken C, Keith A, Guthrie TJ, Epstein DJ, Lenk MA, Kozower BD. Routine Collection of Patient Reported Outcomes in Thoracic Surgery: A Quality Improvement Study. Ann Thorac Surg 2021; 113:1845-1852. [PMID: 34224723 DOI: 10.1016/j.athoracsur.2021.05.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/03/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient reported outcomes (PROs) are critical for delivering high quality surgical care yet they are seldom collected in routine clinical practice. The objective of this quality improvement study was to improve routine PROs collection in a thoracic surgery clinic. METHODS Thoracic surgery patients at a single academic institution were prospectively followed from April 2019 to March 2020. The National Institutes of Health (NIH)-validated Patient-Reported Outcomes Measurement Information System (PROMIS) was employed. Using a Model for Improvement design and through multidisciplinary participant observation, multiple plan-do-study-act (PDSA) cycles (an iterative, four-stage model for rapidly testing interventions) were performed to improve routine collection reliability. RESULTS Over the study period, a total of 2,315 patient visits occurred. The baseline PROMIS assessment collection rate was 53%. After convening a multidisciplinary stakeholder team, the key drivers for PROMIS collection were having engaged staff, engaged patients, adequate technological capacity, and adequate time for survey completion (including when to complete the survey during the patient visits). Regular meetings between stakeholders were initiated to promote these key drivers. Several PDSA cycles were then employed to test different interventions, resulting in several positive system shifts as demonstrated on statistical process control (SPC) chart. Adherence to survey collection reached 91% of office visits by approximately 7 months, a 72% relative improvement, which was sustained. CONCLUSIONS Routine collection of PROs, such as PROMIS, are critical for improving thoracic surgical care. Our study shows that reliably collecting these data is possible in a clinical setting with minimal additional hospital resources.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Melanie P Subramanian
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Alexander G Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Christian Oncken
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Angela Keith
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tracey J Guthrie
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Deirdre J Epstein
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mary Anne Lenk
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO.
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Heiden BT, Eaton DB, Engelhardt KE, Chang SH, Yan Y, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Analysis of Delayed Surgical Treatment and Oncologic Outcomes in Clinical Stage I Non-Small Cell Lung Cancer. JAMA Netw Open 2021; 4:e2111613. [PMID: 34042991 PMCID: PMC8160592 DOI: 10.1001/jamanetworkopen.2021.11613] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE The association between delayed surgical treatment and oncologic outcomes in patients with non-small cell lung cancer (NSCLC) is poorly understood given that prior studies have used imprecise definitions for the date of cancer diagnosis. OBJECTIVE To use a uniform method to quantify surgical treatment delay and to examine its association with several oncologic outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted using a novel data set from the Veterans Health Administration (VHA) system. Included patients had clinical stage I NSCLC and were undergoing resection from 2006 to 2016 within the VHA system. Time to surgical treatment (TTS) was defined as the time between preoperative diagnostic computed tomography imaging and surgical treatment. We evaluated the association between TTS and several delay-associated outcomes using restricted cubic spline functions. Data analyses were performed in November 2021. EXPOSURE Wait time between cancer diagnosis and surgical treatment (ie, TTS). MAIN OUTCOMES AND MEASURES Several delay-associated oncologic outcomes, including pathologic upstaging, resection with positive margins, and recurrence, were assessed. We also assessed overall survival. RESULTS Among 9904 patients who underwent surgical treatment for clinical stage I NSCLC, 9539 (96.3%) were men, 4972 individuals (50.5%) were currently smoking, and the mean (SD) age was 67.7 (7.9) years. The mean (SD) TTS was 70.1 (38.6) days. TTS was not associated with increased risk of pathologic upstaging or positive margins. Recurrence was detected in 4158 patients (42.0%) with median (interquartile range) follow-up of 6.15 (2.51-11.51) years. Factors associated with increased risk of recurrence included younger age (hazard ratio [HR] for every 1-year increase in age, 0.992; 95% CI, 0.987-0.997; P = .003), higher Charlson Comorbidity Index score (HR for every 1-unit increase in composite score, 1.055; 95% CI, 1.037-1.073; P < .001), segmentectomy (HR vs lobectomy, 1.352; 95% CI, 1.179-1.551; P < .001) or wedge resection (HR vs lobectomy, 1.282; 95% CI, 1.179-1.394; P < .001), larger tumor size (eg, 31-40 mm vs <10 mm; HR, 1.209; 95% CI, 1.051-1.390; P = .008), higher tumor grade (eg, II vs I; HR, 1.210; 95% CI, 1.085-1.349; P < .001), lower number of lymph nodes examined (eg, ≥10 vs <10; HR, 0.866; 95% CI, 0.803-0.933; P < .001), higher pathologic stage (III vs I; HR, 1.571; 95% CI, 1.351-1.837; P < .001), and longer TTS, with increasing risk after 12 weeks. For each week of surgical delay beyond 12 weeks, the hazard for recurrence increased by 0.4% (HR, 1.004; 95% CI, 1.001-1.006; P = .002). Factors associated with delayed surgical treatment included African American race (odds ratio [OR] vs White race, 1.267; 95% CI, 1.112-1.444; P < .001), higher area deprivation index [ADI] score (OR for every 1 unit increase in ADI score, 1.005; 95% CI, 1.002-1.007; P = .002), lower hospital case load (OR for every 1-unit increase in case load, 0.998; 95% CI, 0.998-0.999; P = .001), and year of diagnosis, with less recent procedures more likely to have delay (OR for each additional year, 0.900; 95% CI, 0.884-0.915; P < .001). Patients with surgical treatment within 12 weeks of diagnosis had significantly better overall survival than those with procedures delayed more than 12 weeks (HR, 1.132; 95% CI, 1.064-1.204; P < .001). CONCLUSIONS AND RELEVANCE Using a more precise definition for TTS, this study found that surgical procedures delayed more than 12 weeks were associated with increased risk of recurrence and worse survival. These findings suggest that patients with clinical stage I NSCLC should undergo expeditious treatment within that time frame.
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Affiliation(s)
- Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | | | - Kathryn E. Engelhardt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Su-Hsin Chang
- VA St Louis Health Care System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Yan Yan
- VA St Louis Health Care System, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
- VA St Louis Health Care System, St Louis, Missouri
| | - Ruben G. Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
- VA St Louis Health Care System, St Louis, Missouri
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, Missouri
- VA St Louis Health Care System, St Louis, Missouri
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Heiden BT, Semenkovich TR, Kozower BD. Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery. Ann Surg Oncol 2021; 28:6939-6942. [PMID: 33774770 DOI: 10.1245/s10434-021-09882-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/07/2021] [Indexed: 12/30/2022]
Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Tara R Semenkovich
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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Heiden BT, Patel N, Nancarrow DJ, Hermann M, Brown RKJ, Orringer MB, Lin J, Chang AC, Carrott PW, Lynch WR, Zhao L, Beer DG, Reddy RM. Positron Emission Tomography 18F-Fluorodeoxyglucose Uptake Correlates with KRAS and EMT Gene Signatures in Operable Esophageal Adenocarcinoma. J Surg Res 2018; 232:621-628. [PMID: 30463782 DOI: 10.1016/j.jss.2018.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/08/2018] [Accepted: 06/18/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND 18F-fluorodeoxyglucose positron emission tomography is an imaging modality critical to the diagnosis and staging of esophageal cancer. Despite this, the genetic abnormalities associated with increased 18F-fluorodeoxyglucose (FDG)-maximum standardized uptake value (SUVmax) have not been previously explored in esophageal adenocarcinoma. MATERIALS AND METHODS Treatment-naïve patients, for whom frozen tissue and 18F-fluorodeoxyglucose positron emission tomography data were available, undergoing esophagectomy from 2003 to 2012, were identified. Primary tumor FDG-uptake (SUVmax) was quantified as low (<5), moderate, or high (>10). Genome-wide expression analyses (e.g., microarray) were used to examine gene expression differences associated with FDG-uptake. RESULTS Eighteen patients with stored positron emission tomography data and tissue were reviewed. Overall survival was similar between patients with high (n = 9) and low (n = 6) FDG-uptake tumors (P = 0.71). Differences in gene expression between tumors with high and low FDG-uptake included enriched expression of various matrix metalloproteinases, extracellular-matrix components, oncogenic signaling members, and PD-L1 (fold-change>2.0, P < 0.05) among the high-FDG tumors. Glycolytic gene expression and pathway involvement were similar between the high- and low-FDG tumor subsets (P = 0.126). Gene ontology analysis of the most differentially expressed genes demonstrated significant upregulation of gene sets associated with extracellular matrix organization and vascular development (P < 0.005). Gene set enrichment analysis further demonstrated associations between FDG-uptake intensity and canonical oncogenic processes, including hypoxia, angiogenesis, KRAS signaling, and epithelial-to-mesenchymal transition (P < 0.001). Interestingly, KRAS expression did not predict worse survival in a larger cohort (n = 104) of esophageal adenocarcinomas (P = 0.64). CONCLUSIONS These results suggest that elevated FDG-uptake is associated with a variety of oncogenic alterations in operable esophageal adenocarcinoma. These pathways present potential therapeutic targets among tumors exhibiting high FDG-uptake.
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Affiliation(s)
- Brendan T Heiden
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Nathan Patel
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Derek J Nancarrow
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Matthew Hermann
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Richard K J Brown
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Mark B Orringer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew C Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Philip W Carrott
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - William R Lynch
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lili Zhao
- Biostatistics Unit, University of Michigan Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - David G Beer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Rishindra M Reddy
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan.
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Heiden BT, Chen G, Hermann M, Brown RKJ, Orringer MB, Lin J, Chang AC, Carrott PW, Lynch WR, Zhao L, Beer DG, Reddy RM. 18F-FDG PET intensity correlates with a hypoxic gene signature and other oncogenic abnormalities in operable non-small cell lung cancer. PLoS One 2018; 13:e0199970. [PMID: 29966011 PMCID: PMC6028077 DOI: 10.1371/journal.pone.0199970] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 05/03/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is critical for staging non-small-cell lung cancer (NSCLC). While PET intensity carries prognostic significance, the genetic abnormalities associated with increased intensity remain unspecified. METHODS NSCLC samples (N = 34) from 1999 to 2011 for which PET data were available were identified from a prospectively collected tumor bank. PET intensity was classified as mild, moderate, or intense based on SUVmax measurement or radiology report. Associations between genome-wide expression (RNAseq) and PET intensity were determined. Associations with overall survival were then validated in two external NSCLC cohorts. RESULTS Overall survival was significantly worse in patients with PET-intense (N = 11) versus mild (N = 10) tumors (p = 0.039). Glycolytic gene expression patterns were markedly similar between intense and mild tumors. Gene ontology analysis demonstrated significant enhancement of cell-cycle and proliferative processes in FDG-intense tumors (p<0.001). Gene set enrichment analysis (GSEA) suggested associations between PET-intensity and canonical oncogenic signaling pathways including MYC, NF-κB, and HIF-1. Using an external cohort of 25 tumors with PET and genomic profiling data, common genes and gene sets were validated for additional study (P<0.05). Of these common gene sets, 20% were associated with hypoxia or HIF-1 signaling. While HIF-1 expression did not correlate with poor survival in the NSCLC validation cohort (N = 442), established targets of hypoxia signaling (PLAUR, ADM, CA9) were significantly associated with poor overall survival. CONCLUSIONS PET-intensity is associated with a variety of oncogenic alterations in operable NSCLC. Adjuvant targeting of these pathways may improve survival among patients with PET-intense tumors.
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Affiliation(s)
- Brendan T. Heiden
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Guoan Chen
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Matthew Hermann
- Department of Radiology, Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Richard K. J. Brown
- Department of Radiology, Division of Nuclear Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Mark B. Orringer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Andrew C. Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Philip W. Carrott
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - William R. Lynch
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Lili Zhao
- Biostatistics Unit, University of Michigan Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, United States of America
| | - David G. Beer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
| | - Rishindra M. Reddy
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
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Reddy RM, Weir WB, Barnett S, Heiden BT, Orringer MB, Lin J, Chang AC, Carrott PW, Lynch WR, Beer DG, Fenno JC, Kapila Y. Increased Variance in Oral and Gastric Microbiome Correlates With Esophagectomy Anastomotic Leak. Ann Thorac Surg 2018; 105:865-870. [PMID: 29307454 DOI: 10.1016/j.athoracsur.2017.08.061] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 08/17/2017] [Accepted: 08/18/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leak after esophagectomy remains a significant source of morbidity and mortality. The gastrointestinal (GI) microbiome has been found to play a significant role in tumor oncogenesis and postoperative bowel anastomotic leak. We hypothesized that the GI microbiome could differentiate between esophageal cancer histologies and predict postoperative anastomotic leak. METHODS A prospective study of esophagectomy patients was performed from May 2013 to August 2014, with the collection of oral saliva, intraoperative esophageal and gastric mucosa, and samples of postoperative infections (neck swab or sputum). The presence and level for each bacterial probe as end points were used to analyze correlations with tumor histology, tumor stage, and presence of postoperative complications by unequal variances t tests for multiple comparisons and principal coordinate analysis. RESULTS Esophagectomy was successful in 55 of 66 patients who were enrolled. Among those, the diagnosis was adenocarcinoma in 44 (80%) squamous cell carcinoma in (13%), and benign disease in 4 (7%). The 30-day mortality was 1.8% (1 of 55). Complications included anastomotic leak requiring local drainage in 18% (10 of 55) and postoperative pneumonia in 2% (1 of 55). No correlation was noted between GI microbiome flora and tumor histology or tumor stage. A significant difference (p = 0.015) was found when the variance in bacterial composition between the preoperative oral flora was compared with intraoperative gastric flora in patients who had a leak but not in patients with pneumonia. CONCLUSIONS Patients with anastomotic leaks had increased variance in their preoperative oral and gastric flora. Microbiome analysis could help identify patients at higher risk for leak after esophagectomy.
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Affiliation(s)
- Rishindra M Reddy
- University of Michigan Medical School, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan.
| | - William B Weir
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shari Barnett
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brendan T Heiden
- University of Michigan Medical School, Ann Arbor, Michigan; Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mark B Orringer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew C Chang
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Philip W Carrott
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - William R Lynch
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - David G Beer
- Department of Surgery, Section of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Yvonne Kapila
- Division of Periodontology, Department of Orofacial Sciences, University of California, San Francisco, San Francisco, California
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