ABSTRACT: We sought to evaluate the use of video-assisted thoracoscopy among patients with lung cancer and its safety and effectiveness relative to conventional resection.
A cohort study (1994-2002) was conducted by using the Surveillance, Epidemiology, and End-Results Medicare database. Video-assisted thoracoscopy and conventional resection were hypothesized to be equivalent in terms of risks of death. Equivalency was defined by a confidence interval of 0.72 to 1.28 for the odds of 30-day death and 0.89 to 1.11 for the hazard of death, corresponding to a difference of no more than 1% for 30-day mortality and 5% for 5-year survival, respectively.
Among 12,958 patients who underwent segmentectomy or lobectomy (mean age, 74 +/- 5 years), 6% underwent video-assisted thoracoscopy. The use of video-assisted thoracoscopy increased from 1% to 9% between 1994 and 2002. Compared with those who underwent conventional resection, patients who underwent video-assisted thoracoscopy more frequently had smaller tumors (P < .001) and stage I disease (P = .03), underwent lymphadenectomy (P < .001), and were cared for by higher-volume surgeons (P < .001) and at higher-volume hospitals (P < .001). After adjusting for differences in patient, cancer, management, and provider characteristics, the odds of early death were not significantly different between patients undergoing video-assisted thoracoscopy and those undergoing conventional resection, although equivalency was not demonstrated (adjusted odds ratio, 0.93; 95% confidence interval, 0.57-1.50). The hazard of death was equivalent for video-assisted thoracoscopy and conventional resection (adjusted hazard ratio, 0.99; 95% confidence interval, 0.90-1.08).
Video-assisted thoracoscopy was uncommonly used to manage lung cancer, although its use has increased over time. Video-assisted thoracoscopy and conventional resection were equivalent in terms of long-term survival.
The Journal of thoracic and cardiovascular surgery 06/2009; 137(6):1415-21. · 3.41 Impact Factor
ABSTRACT: Health care system and provider biases and differences in patient characteristics are thought to be prevailing factors underlying racial disparities. The influence of these factors on the receipt of care would likely be mitigated among patients who are recommended optimal therapy. We hypothesized that there would be no significant evidence of racial disparities among patients with early-stage lung cancer who are recommended surgical therapy.
Retrospective cohort study of patients in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stage I or II lung cancer between January 1, 1992, and December 31, 2002 (follow-up through December 31, 2005).
Receipt of lung resection and overall survival.
Among 17,739 patients who were recommended surgical therapy (mean [SD] age, 75  years; 89% white, 6% black), black patients less frequently underwent resection compared with white patients (69% vs 83%, respectively; P < .001). After adjustment, black race was associated with lower odds of receiving surgical therapy (odds ratio = 0.43; 99% confidence interval, 0.36-0.52). Unadjusted 5-year survival rates were lower for black patients compared with white patients (36% vs 42%, respectively; P < .001). After adjustment, there was no significant association between race and death (hazard ratio = 1.03; 99% confidence interval, 0.92-1.14) despite a 14% difference in receipt of optimal therapy.
Even among patients who were recommended surgical therapy, black patients underwent lung resection less often than white patients. Unexpectedly, racial differences in the receipt of optimal therapy did not appear to affect outcomes. These findings suggest that distrust, beliefs and perceptions about lung cancer and its treatment, and limited access to care (despite insurance) might have a more dominant role in perpetuating racial disparities than previously recognized.
Archives of surgery (Chicago, Ill.: 1960) 01/2009; 144(1):14-8. · 4.32 Impact Factor
ABSTRACT: Standardized, evidence-based guidelines recommend lung resection for patients with stage I or II nonsmall-cell lung cancer (NSCLC), and select patients with stage IIIA disease. We hypothesized that the proportion of patients operated on would increase over time coincident with increasing adherence to practice guidelines and improved patient/provider education over time.
This investigation was a cohort study of tumor-registry data linked to Medicare claims.
Between 1992 and 2002, 24,030 patients--mean age 75 +/- 6 years, 55% men--were diagnosed with NSCLC. In each stage, the proportion of patients undergoing resection was lower in 2002 compared with 1992: stage I (68% versus 80%, p < 0.001), II (59% versus 74%, p < 0.001), and IIIA (23% versus 35%, p < 0.001). The mean age and comorbidity index of the cohort was higher in 2002 compared with 1992 (76 versus 74 years, p < 0.001; and 0.47 and 0.82, p < 0.001, respectively). The unadjusted odds of resection decreased by 6% per year (odds ratio 0.94, 99% confidence interval: 0.93 to 0.95), and adjustment for age, comorbidity index, race, and stage resulted in a slightly smaller (4% per year) but significantly decreasing trend in operative management over time (odds ratio 0.96, 99% confidence interval: 0.95 to 0.97).
Unexpectedly, the use of resection for lung cancer has decreased dramatically over time, and this decline is not fully accounted for by an older cohort with more comorbid conditions. Future investigations should determine whether increasing unmeasured contraindications to resection, barriers to accessing specialty care, an inadequate supply of thoracic surgeons, or bias against operative therapy are responsible.
The Annals of thoracic surgery 06/2008; 85(6):1850-5; discussion 1856. · 3.74 Impact Factor
ABSTRACT: Management options for pleural space infections have changed over the last 2 decades. This study evaluated trends over time in the incidence of disease and use of different management strategies and their associated outcomes.
A retrospective study was performed by using a statewide administrative database of all hospitalizations for pleural space infections between 1987 and 2004.
Four thousand four hundred twenty-four patients (age, 57.1 +/- 18.6 years; 67% male; comorbidity index, 1.1 +/- 1.9) were hospitalized with pleural space infections. The incidence rate increased 2.8% per year (95% confidence interval, 2.2%-3.4%; P < .001). Overall, 51.6% of patients underwent an operation, and the proportion increased from 42.4% in 1987 to 58.4% in 2004 (P < .001). The risk of death within 30 days was less for patients undergoing operations compared with that for patients not undergoing operations (5.4% vs 16.6%, P < .001); however, patients undergoing operations were younger (52.9 +/- 17.6 years vs 61.5 +/- 18.6 years, P < .001) and had a lower comorbidity index (0.8 +/- 1.6 vs 1.4 +/- 2.1, P < .001). After adjusting for age, sex, comorbidity index, and insurance status, patients undergoing operative therapy had a 58% lower risk of death (odds ratio, 0.42; 95% confidence interval, 0.32-0.56; P < .001) than those undergoing nonoperative management.
The incidence of pleural space infections and the proportion of patients undergoing operative management have increased over time. Patients undergoing operations were younger and had less comorbid illness than those not undergoing operations but had a much lower risk of early death, even after adjusting for these factors.
The Journal of thoracic and cardiovascular surgery 02/2007; 133(2):346-51. · 3.41 Impact Factor