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Onaitis MW, Furnary AP, Kosinski AS, Feng L, Boffa D, Tong BC, Cowper P, Jacobs JP, Wright CD, Habib R, Putnam JB, Fernandez FG. Equivalent Survival Between Lobectomy and Segmentectomy for Clinical Stage IA Lung Cancer. Ann Thorac Surg 2020; 110:1882-1891. [PMID: 32119855 DOI: 10.1016/j.athoracsur.2020.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [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: 03/08/2019] [Revised: 01/06/2020] [Accepted: 01/13/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND The oncologic efficacy of segmentectomy is controversial. We compared long-term survival in clinical stage IA (T1N0) Medicare patients undergoing lobectomy and segmentectomy in The Society of Thoracic Surgeons database. METHODS The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data in 14,286 lung cancer patients who underwent segmentectomy (n = 1654) or lobectomy (n = 12,632) for clinical stage IA disease from 2002 to 2015. Cox regression was used to create a long-term survival model. Patients were then propensity matched on demographic and clinical variables to derive matched pairs. RESULTS In Cox modeling segmentectomy was associated with survival similar to lobectomy in the entire cohort (hazard ratio, 1.04; 95% confidence interval, 0.89-1.20; P = .64) and in the matched subcohort. A subanalysis restricted to the 2009 to 2015 population (n = 11,811), when T1a tumors were specified and positron emission tomography results and mediastinal staging procedures were accurately recorded in the database, also showed that segmentectomy and lobectomy continue to have similar survival (hazard ratio, 1.00; 95% confidence interval, 0.87-1.16). Subanalysis of the pathologic N0 patients demonstrated the same results. CONCLUSIONS Lobectomy and segmentectomy for early-stage lung cancer are equally effective treatments with similar survival. Surgeons from The Society of Thoracic Surgeons database appear to be selecting patients appropriately for sublobar procedures.
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Affiliation(s)
- Mark W Onaitis
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, California.
| | | | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Liqi Feng
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Daniel Boffa
- Division of Cardiothoracic Surgery, Yale University, New Haven, Connecticut
| | - Betty C Tong
- Division of Cardiothoracic Surgery, Duke University, Durham, North Carolina
| | - Patricia Cowper
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute, St Petersburg, Florida
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Habib
- The Society of Thoracic Surgeons, Chicago, Illinois
| | - Joe B Putnam
- Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
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Tong BC, Kim S, Kosinski A, Onaitis MW, Boffa DJ, Habib RH, Putnam JB, Furnary AP, Cowper P, Wright CD, Jacobs JP, Fernandez FG. Penetration, Completeness, and Representativeness of The Society of Thoracic Surgeons General Thoracic Surgery Database for Lobectomy. Ann Thorac Surg 2019; 107:897-902. [DOI: 10.1016/j.athoracsur.2018.07.059] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/30/2018] [Accepted: 07/29/2018] [Indexed: 10/28/2022]
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Onaitis MW, Furnary AP, Kosinski AS, Kim S, Boffa D, Tong BC, Cowper P, Jacobs JP, Wright CD, Putnam JB, Fernandez FG. Prediction of Long-Term Survival After Lung Cancer Surgery for Elderly Patients in The Society of Thoracic Surgeons General Thoracic Surgery Database. Ann Thorac Surg 2017; 105:309-316. [PMID: 29174391 DOI: 10.1016/j.athoracsur.2017.06.071] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [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: 02/14/2017] [Revised: 06/23/2017] [Accepted: 06/28/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prior risk models using the STS General Thoracic Surgery database (STS-GTSD) have been limited to 30-day outcomes. We have now linked STS data to Medicare data and sought to create a risk prediction model for long-term mortality after lung cancer resection in patients older than 65 years. METHODS The STS-GTSD was linked to Medicare data for lung cancer resections from 2002 to 2013 as previously reported. Successful linkage was performed in 29,899 lung cancer resection patients. Cox proportional hazards modeling was used to create a long-term survival model. Variable selection was performed using statistically significant univariate factors and known clinical predictors of outcome. Calibration was assessed by dividing the cohort into deciles of predicted survival and discrimination assessed with a C-statistic corrected for optimism via 1,000 bootstrap replications. RESULTS Median age was 73 years (interquartile range, 68 to 78 years), and 48% of the patients were male. Of the 29,094 patients with nonmissing pathologic stage, 69% were stage I, 18% stage II, 11% stage III, and 2% stage IV. Procedure performed was lobectomy in 69%, bilobectomy in 3%, pneumonectomy in 3%, segmentectomy in 7%, sleeve lobectomy in 1%, and wedge resection in 17%. Thoracoscopic approach was performed in 47% of resections. The final Cox model reveals that stage and age are the strongest predictors of long-term survival. Even after controlling for stage, wedge resection, segmentectomy, bilobectomy, and pneumonectomy are all associated with increased hazard of death in comparison with lobectomy. Thoracoscopic approach is associated with improved long-term survival in comparison with thoracotomy. Other modifiable predictive factors include smoking and low body mass index. Calibration of the model demonstrates excellent performance across all survival deciles and a C-statistic of 0.694. CONCLUSIONS The STS-GTSD-Medicare long-term risk model includes several novel factors associated with mortality. Although medical factors predict long-term survival, age and stage are the strong predictors. Despite this, procedure choice and thoracoscopic/open approach are potentially modifiable predictors of long-term survival after lung cancer resection.
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Affiliation(s)
- Mark W Onaitis
- Department of Surgery, University of California-San Diego, La Jolla, California.
| | | | - Andrzej S Kosinski
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sunghee Kim
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Daniel Boffa
- Department of Surgery, Yale University, New Haven, Connecticut
| | - Betty C Tong
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Patricia Cowper
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jeffrey P Jacobs
- Department of Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida
| | - Cameron D Wright
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Joe B Putnam
- Department of Surgery, Baptist MD Anderson Cancer Center, Jacksonville, Florida
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Boffa D, Fernandez FG, Kim S, Kosinski A, Onaitis MW, Cowper P, Jacobs JP, Wright CD, Putnam JB, Furnary AP. Surgically Managed Clinical Stage IIIA-Clinical N2 Lung Cancer in The Society of Thoracic Surgeons Database. Ann Thorac Surg 2017; 104:395-403. [PMID: 28527969 DOI: 10.1016/j.athoracsur.2017.02.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 11/10/2016] [Revised: 01/18/2017] [Accepted: 02/07/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND The role of surgical resection in patients with clinical stage IIIA-N2 positive (cIIIA-N2) lung cancer is controversial, partly because of the variability in short- and long-term outcomes. The objective of this study was to characterize the management of cIIIA-N2 lung cancer in The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD). METHODS The STS-GTSD was queried for patients who underwent operations for cIIIA-N2 lung cancer between 2002 and 2012. A subset of patients aged older than 65 years was linked to Medicare data. RESULTS Identified were 3,319 surgically managed, cIIIA-N2 patients, including 1,784 (54%) treated with upfront resection (treatment naïve upfront surgery group, and 1,535 (46%) with induction therapy. A positron emission tomography scan was documented in 93% of patients, and 51% of patients were coded in STS-GTSD as having undergone invasive mediastinal staging. Nodal overstaging (cN2→pN0/N1) was observed in 43% of upfront surgery patients. Lobectomy was performed in 69% of patients and pneumonectomy in 11%. Operative mortality was similar between patients treated with upfront surgery (1.9%) and induction therapy (2.5%, p = .2583). The unadjusted Kaplan-Meier estimate of 5-year survival of cIII-N2 patients treated with induction therapy then resection was 35%. CONCLUSIONS STS surgeons achieve excellent short- and long-term results treating predominantly lobectomy-amenable cIIIA-N2 lung cancer. However, prevalent overstaging and abstention from induction therapy suggest "overcoding" of false positives on imaging or variable compliance with current guidelines for cIIIA-N2 lung cancer. Efforts are needed to improve clinical stage determination and guideline compliance in the GTSD for this cohort.
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Affiliation(s)
- Daniel Boffa
- Department of Thoracic Surgery, Yale New Haven Hospital, New Haven, Connecticut.
| | | | - Sunghee Kim
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Mark W Onaitis
- Department of Thoracic Surgery, University of California-San Diego, San Diego, California
| | | | - Jeffrey P Jacobs
- Department of Cardiothoracic Surgery, Johns Hopkins All Children's Heart Institute, Saint Petersburg, Florida
| | - Cameron D Wright
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Joe B Putnam
- Department of Thoracic Surgery, Baptist MD Anderson Cancer Center, Jacksonville, Florida
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Lehman EP, Cowper P, Randolph T, Kosinski A, Lopes RD, Douglas P. UNIVERSAL USE OF CONTRAST TO DETECT LEFT VENTRICULAR THROMBUS IN PATIENTS WITH REDUCED EJECTION FRACTION IS NOT ASSOCIATED WITH IMPROVED CLINICAL OR COST-EFFECTIVENESS OUTCOMES. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35028-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kochar A, Chen A, Sharma P, Pagidipati N, Cowper P, Fonarow G, Peterson E, Wang T. TEN-YEAR MORTALITY OF ACUTE MYOCARDIAL INFARCTION PATIENTS TREATED IN U.S. COMMUNITY PRACTICE. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)33394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaul P, Ohman EM, Knight JD, Anstrom KJ, Roe MT, Boden WE, Hochman JS, Gašparović V, Armstrong PW, McCollam P, Fakhouri W, Cowper P, Davidson-Ray L, Clapp-Channing N, White HD, Fox KA, Prabhakaran D, Mark DB. Health-related quality of life outcomes with prasugrel among medically managed non-ST-segment elevation acute coronary syndrome patients: Insights from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial. Am Heart J 2016; 178:55-64. [PMID: 27502852 DOI: 10.1016/j.ahj.2016.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 03/26/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Few studies have assessed treatment effects on health-related quality of life (HRQoL) in patients with acute coronary syndrome (ACS) treated without revascularization. The TRILOGY ACS trial randomized patients with ACS to either prasugrel or clopidogrel therapy plus aspirin. Outcomes showed a complex pattern suggestive of late benefits with respect to repeat clinical events and benefits confined to patients who underwent angiography. Here, we examine the HRQoL correlates of these patterns. METHODS HRQoL was measured at baseline and 3, 12, and 24 months or end of study (EOS) in 7243 patients aged <75 years using the EuroQol 3-level, group 5-dimension index (EQ-5D). Linear mixed effects models for repeated measures were used to examine treatment differences in HRQoL overall, stratified by angiography status, and among patients who did and did not have non-fatal events. RESULTS No baseline differences in HRQoL were seen between patients randomized to prasugrel (n=3620) or clopidogrel (n=3623). At 24 months, remaining patients assigned to prasugrel (n=1450) vs. clopidogrel (n=1443) had higher EQ-5D index scores (86.4 vs. 84.9, P=.01). Mixed effects models found no difference in EQ-5D scores among prasugrel and clopidogrel patients overall across subgroups stratified by angiography status. However, among patients with non-fatal clinical events, patients on clopidogrel reported a larger decrement in HRQoL than patients on prasugrel (79.5±18.1 vs. 80.6±18.0; P=.02). CONCLUSIONS Overall, there was no difference in HRQoL outcomes among patients receiving prasugrel vs. clopidogrel. However, the differential effects of the treatments among patients with non-fatal events require further investigation.
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Fernandez FG, Furnary AP, Kosinski AS, Onaitis MW, Kim S, Boffa D, Cowper P, Jacobs JP, Wright CD, Putnam JB. Longitudinal Follow-up of Lung Cancer Resection From the Society of Thoracic Surgeons General Thoracic Surgery Database in Patients 65 Years and Older. Ann Thorac Surg 2016; 101:2067-76. [DOI: 10.1016/j.athoracsur.2016.03.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 11/28/2022]
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Kaul P, Davidson-Ray L, Cowper P, Liao L, Mark D. Economic burden of nonischemic congestive heart failure: Evidence from PRAISE-2. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)82865-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Oddone EZ, Cowper P, Hamilton JD, Matchar DB, Hartigan P, Samsa G, Simberkoff M, Feussner JR. Cost effectiveness analysis of early zidovudine treatment of HIV infected patients. BMJ 1993; 307:1322-5. [PMID: 8257887 PMCID: PMC1679458 DOI: 10.1136/bmj.307.6915.1322] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE--To compare cost effectiveness of early and later treatment with zidovudine for patients infected with HIV. DESIGN--Markov chain analysis of cost effectiveness based on results of use of health care and efficacy from a trial of zidovudine treatment. SETTING--Seven Veterans Affairs medical centres in the United States. SUBJECTS--338 patients with symptomatic HIV infection and a lymphocyte count of 200 x 10(6) to 500 x 10(6) CD4 cells/l. INTERVENTIONS--Zidovudine 1500 mg/day started either at recruitment to the trial or when CD4 cell count fell below 200 x 10(6)/l. MAIN OUTCOME MEASURES--Health care costs and rates of disease progression between six clinical states of HIV infection. RESULTS--Patients given early treatment with zidovudine remained without AIDS for an extra two months at a cost of $10,750 for each extra month without AIDS (at 1991 costs). Cost effectiveness ratio was most sensitive to the cost of zidovudine and to the quality of life of patients receiving early treatment. At treatment of 500 mg/day the cost effectiveness ratio for early treatment was $5432 for each extra month without AIDS. Patients given early treatment experienced more side effects, and if their quality of life was devalued by 8% compared with patients treated later the two treatments were equivalent in terms of quality adjusted months of life without AIDS. CONCLUSIONS--Early treatment with zidovudine is expensive and is very sensitive to the cost of zidovudine and to potential reductions in quality of life of patients who experience side effects. Doctors should reconsider early treatment with zidovudine for patients who experience side effects that substantially compromise their quality of life.
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Affiliation(s)
- E Z Oddone
- Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC 27705
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