Characteristics associated with the use of nonanatomic resections among medicare patients undergoing resections of early-stage lung cancer.
ABSTRACT Racial disparities in access to surgical resection for treatment of early-stage non-small-cell lung cancer (NSCLC) are well documented. However it is unclear how race, clinical, and hospital characteristics affect the surgical approach among patients undergoing resection.
Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)/Medicare linked database, we identified patients 67 years of age or older diagnosed with stage I NSCLC who underwent surgical resection from 2000 to 2007. Surgical approach was categorized as lobectomy or segmentectomy (anatomic) versus wedge resection (nonanatomic). We used logistic regression to identify the association between demographic, clinical, and hospital factors and the use of nonanatomic resections.
There were 8,986 patients in the sample (mean age, 75 years; 53% women); 12.8% underwent nonanatomic resection. The use of nonanatomic resection increased significantly, from 11.0% in 2000 to 15.9% in 2007 (p=0.008). In multivariable analysis, race was not associated with the receipt of nonanatomic resection. Factors associated with the use of nonanatomic resections included age greater than 80 years (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.15-1.98), T1a primary tumor status, chronic obstructive pulmonary disease (COPD) (OR, 1.81; 95% CI, 1.55-2.12), and volume of hospital lung resections performed (highest versus lowest hospital volume, OR, 1.58; 95% CI, 1.23-2.04). More nonanatomic resections were performed in 2007 than in 2000 (OR, 1.73; 95% CI, 1.27-2.37). After stratifying by tumor size, the temporal trend in the use of nonanatomic resection remained significant only among patients with tumors greater than 3 cm.
Since 2000, the use of nonanatomic resections in stage I NSCLC has increased, most significantly among patients with larger tumors. After adjusting for clinical factors, there was no relation between race and type of surgical resection.
Article: Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition).[show abstract] [hide abstract]
ABSTRACT: This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer. Current guidelines and medical literature applicable to this issue were identified by computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee. The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV(1). If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV(1), the diffusing capacity of the lung for carbon monoxide (Dlco) should also be measured. In patients with either an FEV(1) or Dlco < 80% predicted, the likely postoperative pulmonary reserve should be estimated by either the perfusion scan method for pneumonectomy or the anatomic method, based on counting the number of segments to be removed, for lobectomy. An estimated postoperative FEV(1) or Dlco < 40% predicted indicates an increased risk for perioperative complications, including death, from a standard lung cancer resection (lobectomy or greater removal of lung tissue). Cardiopulmonary exercise testing (CPET) to measure maximal oxygen consumption (Vo(2)max) should be performed to further define the perioperative risk of surgery; a Vo(2)max of < 15 mL/kg/min indicates an increased risk of perioperative complications. Alternative types of exercise testing, such as stair climbing, the shuttle walk, and the 6-min walk, should be considered if CPET is not available. Although often not performed in a standardized manner, patients who cannot climb one flight of stairs are expected to have a Vo(2)max of < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will likely have a Vo(2)max of < 10 mL/kg/min. Desaturation during an exercise test has not clearly been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) improves survival in selected patients with severe emphysema. Accumulating experience suggests that patients with extremely poor lung function who are deemed inoperable by conventional criteria might tolerate combined LVRS and curative-intent resection of lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should be considered in patients with a cancer in an area of upper lobe emphysema, an FEV(1) of > 20% predicted, and a Dlco of > 20% predicted. A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer resection and to enable an informed decision by the patient about the appropriate therapeutic approach to treating their lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment for this disease.Chest 09/2007; 132(3 Suppl):161S-77S. · 5.25 Impact Factor
Article: Treatment of non-small cell lung cancer stage I and stage II: ACCP evidence-based clinical practice guidelines (2nd edition).[show abstract] [hide abstract]
ABSTRACT: The surgical treatment of stage I and II non-small cell lung cancer (NSCLC) continues to evolve in the areas of intraoperative lymph node staging (specifically the issue of lymph node dissection vs sampling), the role of sublobar resections instead of lobectomy for treatment of smaller tumors, and the use of video-assisted techniques to perform anatomic lobectomy. Adjuvant therapy (both chemotherapy and radiation therapy) and the use of larger fractions of radiotherapy delivered to a smaller area for nonoperative treatment of early stage NSCLC have shown promising results. The panel selected the following areas for review based on clinical relevance and the amount and quality of data available for analysis: surgical approaches to resecting early stage NSCLC, methods of lymph node staging at the time of surgical resection, adjuvant chemotherapy in the treatment of early stage NSCLC, and the use of radiation therapy for primary treatment of early stage NSCLC as well as in the adjuvant setting. Recommendations by the multidisciplinary writing committee were based on literature review using established methods. Surgical resection remains the treatment of choice for stage I and II NSCLC, although surgical methods continue to evolve. Adjuvant chemotherapy for patients with stage II, but not stage I, NSCLC is well established. Radiotherapy remains an important treatment for either cases of early stage NSCLC that are medically inoperable or patients who refuse surgery.Chest 10/2007; 132(3 Suppl):234S-242S. · 5.25 Impact Factor