National cooperative group trials of "high-risk" patients with lung cancer: are they truly "high-risk"?

Preoperative respiratory assessment predicts post-operative survival in stage IA non-small cell lung cancer

Background

Respiratory impairment can lead to pulmonary complications after surgery; therefore, it should be considered when determining the choice of surgical procedure. Several studies have examined the relationship between preoperative respiratory function and postoperative mortality and morbidity after lung resection; however, there are no indicators for limited surgical procedure selection. The aim of this study was to examine the association between preoperative respiratory function and postoperative early and late complications, recurrence-free survival (RFS), and overall survival (OS) in patients undergoing pulmonary resection for stage I lung cancer.

Methods

We performed a retrospective analysis of data from 192 patients undergoing pulmonary resection for primary pathological stage IA non-small cell lung cancer (NSCLC) at the Iwakuni Clinical Center in Japan between 2012 and 2015. We reviewed clinicopathological characteristics including preoperative pulmonary function and elucidated the relationship between them and postoperative survival.

Results

Obstructive ventilatory impairment was present in 55 patients (28.6%), and restrictive ventilatory impairment was present in 31 patients (16.1%). Seven patients (3.6%) had both ventilatory impairment. Obstructive ventilatory impairment did not affect the 5-year RFS (P=0.08) or OS (P=0.21). However, restrictive ventilatory impairment reduced the 5-year RFS (P=0.002) and OS (P=0.009). The rates of early and late complications were not significantly different based on the preoperative respiratory function.

Conclusions

In patients with preoperative restrictive ventilatory impairment in whom lobectomy or segmentectomy cannot be performed, careful consideration is needed for surgical indications.

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

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.

Chronic Obstructive Pulmonary Disease and Lung Cancer: A Review for Clinicians

Chronic obstructive pulmonary disease (COPD) and lung cancer are common global causes of morbidity and mortality. Because both diseases share several predisposing risks, the 2 diseases may occur concurrently in susceptible individuals. The diagnosis of COPD has important implications for the diagnostic approach and treatment options if lesions concerning for lung cancer are identified during screening. Importantly, the presence of COPD has significant implications on prognosis and management of patients with lung cancer. In this monograph, we review the mechanistic linkage between lung cancer and COPD, the impact of lung cancer screening on patients at risk, and the implications of the presence of COPD on the approach to the diagnosis and treatment of lung cancer. This manuscript succinctly reviews the epidemiology and common pathogenetic factors for the concurrence of COPD and lung cancer. Importantly for the clinician, it summarizes the indications, benefits, and complications of lung cancer screening in patients with COPD, and the assessment of risk factors for patients with COPD undergoing consideration of various treatment options for lung cancer.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

National Trends and Outcomes of Segmentectomy in the Society of Thoracic Surgeons Database

BACKGROUND

Segmentectomy is gaining popularity as a parenchyma-sparing alternative for anatomic lung resection. This study sought to investigate temporal changes in patient selection, case volume, and outcomes for segmentectomy using the Society of Thoracic Surgeons (STS) National Database.

METHODS

The STS General Thoracic Database was queried for patients who had undergone segmentectomy as the primary procedure between 2002 and 2018. The American College of Surgeons Oncology Group definition of high-risk patients on the basis of pulmonary function and major cardiovascular comorbidities was applied. Annual trends of case volume, patient risk profile, surgical indication, approach, and outcomes were analyzed.

RESULTS

A total of 10 629 patients were analyzed from 310 contributing centers. The annual segmentectomy volume more than doubled from <4 per center in 2009 to 8.6 per center by 2017. Lung cancer was the most common indication (70.1%), followed by benign disease (15.6%) and metastatic tumors (14.3%). Although the operative indication remained constant, the subset of high-risk patients (24.5%) decreased gradually over time (slope, -0.6% per year; P = .001). After 2012, segmentectomies were most commonly performed minimally invasively (video-assisted thoracoscopic surgery, 58.3%; robotic surgery, 19.4%), with a steadily declining use of thoracotomy (overall, 22.3%; slope, -2.4%/y; P = .001). Overall complication rates decreased over the study period from 41.7% to 26.1% (slope, -0.57%/y; P = .001). The overall major complication rate was 4.6% (range, 2.0%-7.1%), 30-day mortality was 1.0% (range, 0.7%-5.0%), and both have been trending downward since 2009 (P = .01).

CONCLUSIONS

Segmentectomies are increasingly performed nationally, with a steady decline in the subset of high-risk patients over time. Complication rates have decreased significantly, parallel to the increasing use of minimally invasive techniques by video-assisted thoracoscopic surgery and robotic surgery.

Prognostic Impact of Postoperative Complications in High-Risk Operable Non-small Cell Lung Cancer

Background

Patients with high-risk (HR) operable non-small cell lung cancer (NSCLC) may have unique prognostic factors. This study aimed to evaluate surgical outcomes in HR patients and to investigate prognostic factors in HR patients versus standard-risk (SR) patients.

Methods

In total, 471 consecutive patients who underwent curative lung resection for NSCLC between January 2012 and December 2017 were identified and reviewed retrospectively. Patients were classified into HR (n=77) and SR (n=394) groups according to the American College of Surgeons Oncology Group criteria (Z4099 trial). Postoperative complications were defined as those of grade 2 or higher by the Clavien-Dindo classification.

Results

The HR group comprised more men and older patients, had poorer lung function, and had more comorbidities than the SR group. The patients in the HR group also experienced more postoperative complications (p≤0.001). More HR patients died without disease recurrence. The postoperative complication rate was the only significant prognostic factor in multivariable Cox regression analysis for HR patients but not SR patients. HR patients without postoperative complications had a survival rate similar to that of SR patients.

Conclusion

The overall postoperative survival of HR patients with NSCLC was more strongly affected by postoperative complications than by any other prognostic factor. Care should be taken to minimize postoperative complications, especially in HR patients.

Definition and assessment of high risk in patients considered for lobectomy for stage I non-small cell lung cancer: The American Association for Thoracic Surgery expert panel consensus document

OBJECTIVE

Lobectomy is a standard treatment for stage I non-small cell lung cancer, but a significant proportion of patients are considered at high risk for complications, including mortality, after lobectomy and might not be candidates. Identifying who is at risk is important and in evolution. The objective of The American Association for Thoracic Surgery Clinical Practice Standards Committee expert panel was to review important considerations and factors in assessing who is at high risk among patients considered for lobectomy.

METHODS

The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an expert panel that developed an expert consensus document after systematic review of the literature. The expert panel generated a priori a list of important risk factors in the determination of high risk for lobectomy. A survey was administered, and the expert panel was asked to grade the relative importance of each risk factor. Recommendations were developed using discussion and a modified Delphi method.

RESULTS

The expert panel survey identified the most important factors in the determination of high risk, which included the need for supplemental oxygen because of severe underlying lung disease, low diffusion capacity, the presence of frailty, and the overall assessment of daily activity and functional status. The panel determined that factors, such as age (as a sole factor), were less important in risk assessment.

CONCLUSIONS

Defining who is at high risk for lobectomy for stage I non-small cell lung cancer is challenging, but remains critical. There was impressive strong consensus on identification of important factors and their hierarchical ranking of perceived risk. The panel identified several key factors that can be incorporated in risk assessment. The factors are evolving and as the population ages, factors such as neurocognitive function and frailty become more important. A minimally invasive approach becomes even more critical in this older population to mitigate risk. The determination of risk is a clinical decision and judgement, which should also take into consideration patient perspectives, values, preferences, and quality of life.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Stereotactic body radiation therapy for empirically treated hypermetabolic lung lesions: a single-institutional experience identifying the Charlson score as a key prognostic factor

Background

Though pathologic evidence for non-small cell lung cancer (NSCLC) is preferred, many patients do not receive a biopsy prior to treatment with stereotactic body radiation therapy (SBRT). This study seeks to analyze the overall survival (OS), local control, and toxicity rates for such patients.

Methods

This retrospective review included patients empirically treated with SBRT for presumed non-metastatic NSCLC at a single institution. Inclusion criteria included a hypermetabolic pulmonary lesion noted on positron emission tomography (PET) imaging but no pathological evidence of NSCLC. Patients with another known metastatic tumor were excluded. Statistical analysis was conducted with Cox proportional hazards analysis, univariate analysis, and the Kaplan-Meier method.

Results

Ninety-one treatments in 90 unique patients met inclusion criteria. Patients were a median 77.9 years at the start of treatment and had a median Charlson score of 7. Pre-treatment standardized uptake value (SUV) was a median 4.5 and 1.5 after treatment. At a median follow-up of 12.9 months, 36-month local control of 91.3% was achieved. Twenty-four-month OS and progression-free survival were 65.4% and 44.8%, respectively. On univariate analysis, biologically effective dose (BED) ≥120 Gy was predictive of improved OS (P=0.001), with 36-month OS of 50.5% for patients with BED ≥120 Gy and only 31.6% for patients with BED <120 Gy. On Kaplan-Meier analysis, Charlson score ≥9 was predictive of decreased OS (P=0.04), and BED ≥120 Gy trended towards improved OS (P=0.08). Thirty-two cases of grade <3 toxicity were reported, and only two cases of grade 3 morbidity (fatigue) were noted.

Conclusions

Local control rates for empiric SBRT treatment for hypermetabolic, non-metastatic NSCLC are similar to those for biopsied NSCLC. OS is primarily dependent on a patient’s overall health status, which can be accurately assessed with the Charlson score. BED ≥120 Gy may also contribute to improved OS.

Salvage stereotactic body radiotherapy for post-operative oligo-recurrence of non-small cell lung cancer: A single-institution analysis of 59 patients

A standard treatment for patients with early-stage non-small cell lung cancer (NSCLC) who undergo surgery, and subsequently develop local failure or intrathoracic oligo-recurrence, has not yet been established. The present study aimed to assess the feasibility of stereotactic body radiotherapy (SBRT) for this subgroup of patients. Consequently, a retrospective analysis was conducted of patients with NSCLC recurrence who were treated with SBRT, and previously underwent curative surgical resection between October 2011 and October 2016. Post-SBRT survival [overall survival (OS); progression-free survival (PFS); and local control (LC)] and toxicity were analyzed. Prognostic factors for OS were identified using univariate and multivariate analysis. A total of 52 patients and 59 tumors were analyzed. The median follow-up time was 25 months (35 months for surviving patients), and median OS following salvage SBRT was 32 months. The 1- and 3-year OS rates were 84.4 and 67.8%, respectively. 1- and 3-year PFS rates were 80.8 and 58.7%, respectively. Only 4 patients (7.7%) developed local failure. Median LC was 71 months and 1- and 3-year LC rate were 97.9 and 94.9%, respectively. A total of 4 patients experienced grade 3 or higher adverse events (AEs) and two experienced grade 5 AEs (pneumonitis and hemoptysis). Central tumor location and the possibility of re-operation were independent prognostic factors for OS. The present study indicated that post-operative salvage SBRT is a promising therapeutic option for patients with NSCLC with locoregional or intrathoracic oligo-recurrence. We regard toxicity was also acceptable. However, further research is required on the appropriate selection of subjects, and stratification of the analysis by certain risk factors would increase the accuracy of the conclusions.

Surgeons' preference sublobar resection for stage I NSCLC less than 3 cm

Background

This study aimed to compare survival between standard lobectomy and surgeons' preference sublobar resection among patients with stage I non‐small cell lung cancer (NSCLC).

Methods

Medical records of patients undergoing pulmonary resection between 2006 and 2016 were reviewed retrospectively. Differences in disease‐free survival (DFS) and DFS‐associated factors between patients receiving lobectomy and surgeons' preference sublobar resection were analyzed after 1‐1 propensity score‐matching (n = 119 per group).

Results

In total, 1064 pathological stage I NSCLC patients were identified, including 816 (76.7%) who underwent lobectomy, 111 (10.4%) who underwent sublobar resection as a compromised procedure (medically unfit), and 137 (12.9%) who underwent surgeons' preference sublobar resection. Rates of five‐year DFS for patients undergoing lobectomy, medically unfit, and surgeons' preference sublobar resection were 88.7%, 71.0%, and 93.4%, respectively (P < 0.001). Multivariable Cox regression analysis demonstrated that radiological solid‐appearance (adjusted hazard [aHR] = 2.908, P = 0.003), PL2 invasion (aHR = 1.970, P = 0.024), and angiolymphatic invasion (aHR = 2.202, P = 0.005) were significantly associated with lower DFS after adjusting for surgeons' preference sublobar resection (aH = 1.031, P = 0.939). Subgroup analysis of all 403 solid‐dominant patients demonstrated equivalent five‐year DFS between surgeons' preference sublobar resection and lobectomy (87.7% and 84.1%, respectively, P = 0.721). Propensity‐matched analysis showed no differences in five‐year DFS in stage I NSCLC patients undergoing lobectomy or surgeons' preference sublobar resection (90.5% vs. 93.4% P = 0.510), and DFS for surgeons' preference sublobar resection remained an insignificant factor (aHR = 0.894, P = 0.834).

Conclusions

Carefully selected patients who have undergone surgeons' preference sublobar resection have comparable outcomes to those receiving lobectomy for stage I NSCLC <3 cm.

Key points

Significant findings of the study Intended sublobar resection has a good outcome. What this study adds Sublobar resection is applicable for stage I NSCLC <3 cm.

Retrospective Observational Study into the Early Causes of Death Following Surgery for NSCLC

INTRODUCTION

Respiratory failure has historically been the major cause of mortality after elective lung resections. With improved intubation using fiber-optic scopes, better preoperative respiratory risk assessment, more advanced anesthetic single lung ventilation, and minimally invasive surgical technique, this may have changed. Our objective was to assess the main causes of mortality over the past 10 years in patients undergoing elective lung surgery in a major UK center.

MATERIALS AND METHODS

A retrospective unit data search was made for all deaths during the 10-year period between January 2007 and December 2016 inclusive. All inpatient deaths within 30 days of an elective anatomical lung resection for lung malignancies were included.

RESULTS

Three-thousand three-hundred sixteen lung resections for malignancy were performed in the 10-year period. There were 44 (1.3%) deaths during this period, 27 (61.4%) after open lobectomies, 8 (18.2%) after video-assisted thoracoscopic surgery lobectomies, 5 (11.4%) after sleeve lobectomies, and 4 (9%) after pneumonectomies. Causes of death included 24 (54.5%) respiratory failure, 10 (22.7%) ischemic bowel, 4 (9%) coronary events, 2 (4.5%) strokes, 2 (4.5%) on table hemorrhage, 1 (2.3%) massive pulmonary embolus, and 1 (2.3%) postoperative hemorrhage.

CONCLUSION

Although respiratory failure is still a major cause of mortality in the postoperative patient, bowel ischemia has been found to be the second greatest cause of death. This study highlights the need to identify those at risk of this fatal complication during preoperative assessment and their postoperative management.

Surgical Resection Versus Stereotactic Body Radiation Therapy for Stage I NSCLC: Can Randomized Trials Provide the Solution?

Surgical resection has traditionally been considered the standard of care for patients with stage I non-small cell lung cancer (NSCLC). With the introduction of stereotactic radiation body therapy (SBRT), there is now a viable option for medically inoperable patients with stage I NSCLC. The effectiveness of SBRT in patients with stage I disease but at elevated surgical risk is unknown. Multiple randomized controlled trials (RCTs) have been attempted to compare surgical resection and SBRT in this population, but have been aborted due to poor patient enrollment. Despite these failures, there still remains a push for more RCTs. In this commentary, we review the challenges that RCTs face in their ability to appropriately compare these two therapies.

Long-Term Results for Clinical Stage IA Lung Cancer: Comparing Lobectomy and Sublobar Resection

BACKGROUND

Lobectomy has been compared with sublobar resection for the treatment of stage IA non-small cell lung cancer (NSCLC). Accurate long-term data are lacking on the risk of recurrence in routine clinical practice. This study used a unique and representative dataset to compare recurrence, overall survival (OS), and lymph node staging between lobectomy and sublobar resection.

METHODS

The American College of Surgeons performed a Special Study of the National Cancer Data Base, by reabstracting records to augment NSCLC data with enhanced information on preoperative comorbidity and cancer recurrence from 2007 to 2012. For patients treated with lobectomy or sublobar resection (wedge resection or segmentectomy) for clinical stage IA NSCLC, propensity matching and competing risks models compared 5-year OS and risk of cancer recurrence. Secondary measures included lymph nodes collected, pathologic upstaging, and surgical margin status.

RESULTS

A total of 1,687 patients with stage IA NSCLC were identified (1,354 who underwent lobectomy, and 333 who had sublobar resections). Propensity matching yielded 325 pairs. Lobectomy and sublobar resection groups had similar 5-year OS (61.8% vs 55.6%, p = 0.561). The sublobar group had a 39% increased risk of NSCLC recurrence (hazard ratio, 1.39; 95% confidence interval, 1.04 to 1.87). Median lymph node counts were higher for lobectomy-treated patients (7 [3, 10] vs 1 [0, 4], p < 0.001)].

CONCLUSIONS

In an enhanced national dataset representative of outcomes for stage IA NSCLC, sublobar resection was associated with a 39% increased risk of cancer recurrence. The majority of patients treated with sublobar resection had an inadequate lymph node assessment. These real-world results must be considered when existing clinical trial results comparing these treatments are extrapolated for clinical use.

Predictive value of pulmonary function measures for short-term outcomes following lung resection: analysis of a single high-volume institution

Despite the importance of preoperative risk-stratification, there is a lack of consensus on how to identify high-risk patients for pulmonary resection. Enrollment criteria for national trials propose one definition based on preoperative pulmonary function tests. We sought to examine the value of preoperative forced expiratory volume in 1 second (FEV1) and diffusion capacity for carbon monoxide (DLCO) to predict short-term outcomes following pulmonary resection. Using our institutional Society of Thoracic Surgeons (STS) database we identified 419 consecutive lung cancer patients who presented to our institution for pulmonary resection between 2012 and 2016. We identified patients as "high risk" based on the national trial criteria of FEV1 or DLCO ≤50%. Our primary outcome was any postoperative complication within 30 days of surgery. Secondary outcomes included cardiac and pulmonary complications, 30-day readmission, and discharge disposition. DLCO ≤50% was associated with any postoperative complication (P=0.03), but not predictive of cardiac events, pulmonary complications, or 30-day readmission. There were no significant differences in any of these short-term outcomes for patients with FEV1 ≤50%. On multivariable analysis, neither FEV1 nor DLCO ≤50% were significantly associated with occurrence of postoperative complication (OR =1.67, 95% CI: 0.60-4.63; OR =1.66, 95% CI: 0.96-2.86, respectively). Notably, DLCO ≤50%-but not FEV1-was associated with discharge to a skilled facility on univariate (P=0.01) and multivariable analysis (OR =2.54; 95% CI: 1.08-5.99; P=0.03). This association between DLCO and discharge to a skilled facility persisted when DLCO was used as a continuous variable. For all-comers presenting to our institution for lung cancer resection, classification based on FEV1 or DLCO ≤50% may not reliably identify those at highest risk for short-term postoperative complications. While our findings suggest caution when using pulmonary parameters in isolation, the potential value of DLCO as a proxy for underlying comorbidity warrants further investigation.

Coronary artery disease is associated with an increased mortality rate following video-assisted thoracoscopic lobectomy

OBJECTIVE

To compare the incidence of major adverse cardiac events (MACE) and mortality following video-assisted thoracoscopic surgery (VATS) lobectomy in patients with and without coronary artery disease (CAD).

METHODS

Multicentre retrospective analysis of 1699 patients undergoing VATS lobectomy (January 2012-March 2015). CAD definition: previous acute myocardial infarct (AMI), angina, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). MACE definition: postoperative acute myocardial ischemia, cardiac arrest or any cardiac death. Propensity score analysis was performed to match patients with and without CAD. Outcomes of the 2 matched groups were compared.

RESULTS

The incidence of MACE and mortality for the entire population was 0.4% (7 patients) and 1.7% (29 patients); 218 patients (13%) had a history of CAD: 106 previous AMI, 55 angina, 32 CABG, and 81 PCI. The propensity score yielded 2 well-balanced groups of 218 pairs with and without CAD. MACE (CAD 2 [0.9%] vs no-CAD 1 [0.5%]; P = 1), cardiovascular and pulmonary complications (CAD 61 [28%] vs no-CAD 51 [23%]; P = .3) and postoperative stay (CAD 7.3 days vs no-CAD 6.2 days; P = .3) were not different between the groups. The incidence of atrial fibrillation (CAD 31 [14%] vs no-CAD 18 [8.2%]; P = .07), 30-day mortality (CAD: 11 [5%] vs no-CAD 2 [0.9%]; P = .02) and death among complicated patients (CAD 18% vs no-CAD 3.9%; P = .009) were higher in the CAD group.

CONCLUSIONS

The incidence of MACE following VATS lobectomy in patients with CAD is low and similar to patients without CAD. However, their risk of postoperative mortality is fivefold higher compared with non-CAD patients, warranting refined preoperative functional evaluation and more intense postoperative monitoring.

Treatment Outcomes in Stage I Lung Cancer: A Comparison of Surgery and Stereotactic Body Radiation Therapy

INTRODUCTION

The relative roles of surgery and stereotactic body radiation therapy in stage I non-small-cell lung cancer (NSCLC) are evolving particularly for marginally operable patients. Because there is limited prospective comparative data for these treatment modalities, we evaluated their relative use and outcomes at the population level using a national database.

METHODS

Patient variables and treatment-related outcomes were abstracted for patients with clinical stage I NSCLC from the National Cancer Database. Patients receiving surgery were compared with those undergoing stereotactic body radiation therapy (SBRT) in exploratory unmatched and subsequent propensity matched analyses.

RESULTS

Between 1998 and 2010, 117,618 patients underwent surgery or SBRT for clinical stage I NSCLC. Of these, 111,731 (95%) received surgery, whereas 5887 (5%) underwent SBRT. Patients in the surgery group were younger, more likely to be males, and had higher Charlson comorbidity scores. SBRT patients were more likely to have T1 (versus T2) tumors and receive treatment at academic centers. Thirty-day surgical mortality was 2596 of 109,485 (2.4%). Median overall survival favored the surgery group in both unmatched (68.4 versus 33.3 months, p < 0.001) and matched analysis based on patient characteristics (62.3 versus 33.1 months, p < 0.001). Disease-specific survival was unavailable from the data set.

CONCLUSION

In a propensity matched comparison, patients selected for surgery have improved survival compared with SBRT. In the absence of information on cause of death and with limited variables to characterize comorbidity, it is not possible to assess the relative contribution of patient selection or better cancer control toward the improved survival. Rigorous prospective studies are needed to optimize patient selection for SBRT in the high-risk surgical population.

Patient Preferences in Treatment Choices for Early-Stage Lung Cancer

BACKGROUND

Decision-making for lung cancer treatment can be complex because it involves both provider recommendations based on the patient's clinical condition and patient preferences. This study describes the relative importance of several considerations in lung cancer treatment from the patient's perspective.

METHODS

A conjoint preference experiment began by asking respondents to imagine that they had just been diagnosed with lung cancer. Respondents then chose among procedures that differed regarding treatment modalities, the potential for treatment-related complications, the likelihood of recurrence, provider case volume, and distance needed to travel for treatment. Conjoint analysis derived relative weights for these attributes.

RESULTS

A total of 225 responses were analyzed. Respondents were most willing to accept minimally invasive operations for treatment of their hypothetical lung cancer, followed by stereotactic body radiation therapy (SBRT); they were least willing to accept thoracotomy. Treatment type and risk of recurrence were the most important attributes from the conjoint experiment (each with a relative weight of 0.23), followed by provider volume (relative weight of 0.21), risk of major complications (relative weight of 0.18), and distance needed to travel for treatment (relative weight of 0.15). Procedural and treatment preferences did not vary with demographics, self-reported health status, or familiarity with the procedures.

CONCLUSIONS

Survey respondents preferred minimally invasive operations over SBRT or thoracotomy for treatment of early-stage non-small cell lung cancer. Treatment modality and risk of cancer recurrence were the most important factors associated with treatment preferences. Provider experience outweighed the potential need to travel for lung cancer treatment.

Outcomes After Surgery in High-Risk Patients With Early Stage Lung Cancer

BACKGROUND

Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery.

METHODS

A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV1) 50% or less or diffusing capacity of lung for carbon monoxide (Dlco) 50% or less; and minor: (two of the following), age 75 years or more, FEV1 51% to 60%, or Dlco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ(2) test/Fisher's exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn.

RESULTS

In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV1 (57% versus 85%, p < 0.0001), and Dlco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients (p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients (p < 0.0001).

CONCLUSIONS

Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy.

High-risk patients and postoperative complications following video-assisted thoracic surgery lobectomy: a case-matched comparison with lower-risk counterparts†

OBJECTIVES

To assess the postoperative incidence of major complications in high-risk patients following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer compared with their lower risk counterparts.

METHODS

A retrospective analysis on prospectively collected data of 348 consecutive patients subjected to VATS lobectomy (August 2012-September 2014) was performed. Patients were defined as high risk if one or more of the following characteristics were present: age >75 years, forced expiratory volume in 1 s (FEV1) <50%, carbon monoxide lung diffusion capacity (DLCO) <50%, history of coronary artery disease (CAD). Severity of complications was graded using the Thoracic Morbidity and Mortality (TM&M) score; major complications were defined if the TM&M score was greater than 2. The propensity score was used to match high-risk patients with their lower risk counterparts in order to minimize the influence of other confounders on outcome. The following variables were used to construct the propensity score: gender, side of operation, body mass index, American Society of Anaesthesiologists score, Eastern Cooperative Oncology Group score, Charlson's Comorbidity Index, number of functioning segments resected.

RESULTS

The high-risk group consisted of 141 patients (age >75 years: 84 patients; FEV1 <50: 14 patients; DLCO <50: 25 patients; history of CAD: 37 patients). The propensity score yielded two groups of 135 patients (high-risk vs low-risk) well matched for several baseline characteristics except for a lower performance status in the higher-risk group. Compared with their low-risk counterparts, high-risk patients had a higher incidence of cardiopulmonary complications (28 cases, 21% vs 14 cases, 10%; P < 0.0001) and major cardiopulmonary complications (12 cases, 9% vs 3 cases, 2%; P < 0.0001). Postoperative stay was 3 days longer in high-risk patients (8.6 vs 5.5 days, P = 0.0031). The 30-day or in-hospital mortality rates were not different between the two groups (2 cases, 1.5% vs 3 cases, 2.2%, P = 0.93).

CONCLUSIONS

The incidence of major complications after VATS lobectomy in high-risk patients is low, but not negligible. This information can be used when discussing surgical risk with the patient during preoperative counselling.

[Use of minimally invasive approaches for stage I non-small cell lung cancer: A surgeon's point of view]

Lobectomy with lymphadenectomy is the standard of care of patients with early stage non-small cell lung cancer, and the use of minimally invasive approaches is associated with reduced morbidity when compared with thoracotomy. Segmentectomy with lymphadenectomy seems to provide a curative effect equivalent to that of lobectomy for stage IA tumours of 2 cm or smaller, and for pure or predominant ground glass opacities. The combination of lung-sparing resections with minimally invasive approaches results in preserved pulmonary function, improved quality of life and very low morbidity. This benefit persists in so-called high-risk patients. Among patients with clinical stage IA managed with sublobar resections, more than 25% are proved to have a more advanced pathologic stage at surgery, suggesting that alternative ablative therapies would result in an incomplete resection in a similar proportion. Moreover, resection samples tumour tissue that is adequate in quantity and quality, and provides material for "research biopsies" to consolidate tissue availability for clinical trials, translational research, and in biobanks.

The National Surgical Quality Improvement Program risk calculator does not adequately stratify risk for patients with clinical stage I non-small cell lung cancer

OBJECTIVE

The study objective was to validate the National Surgical Quality Improvement Program (NSQIP) Risk Calculator in stratifying risk estimates for patients who received surgery or stereotactic body radiation therapy for clinical stage I non-small cell lung cancer.

METHODS

A retrospective analysis of patients with clinical stage I non-small cell lung cancer undergoing surgery (N = 279) or stereotactic body radiation therapy (N = 206) from 2009 to 2012 was performed. NSQIP complication risk estimates were calculated for both surgical and stereotactic body radiation therapy cases using the NSQIP Surgical Risk Calculator. NSQIP complication risk estimates were compared as continuous variables and by quartile ranges.

RESULTS

Compared with patients undergoing video-assisted thoracoscopic surgery wedge resection, patients receiving stereotactic body radiation therapy were older, had larger tumors, had lower forced expiratory volume (FEV1) in 1 second and diffusing capacity of the lungs (DLCO) for carbon monoxide values, had higher American Society of Anesthesiologists scores, had higher rates of dyspnea, and had higher NSQIP serious complication risk estimates (all P < .05). Compared with patients undergoing video-assisted thoracoscopic surgery lobectomy, patients receiving stereotactic body radiation therapy had similar disparities, along with higher Adult Comorbidity Evaluation-27 (ACE) scores comorbidity scores, higher rates of cardiac comorbidities, and worse functional status (all P < .05). Variables associated with receiving stereotactic body radiation therapy treatment, rather than wedge resection, included increasing age, higher Adult Comorbidity Evaluation (ACE)-27 comorbidity score, dyspnea status, and decreasing FEV1 in 1 second and DLCO for carbon monoxide, but NSQIP serious complication risk score. In addition, surgical patients' actual serious complication rate (16.6% vs 8.8%) and pneumonia rate (6.0% vs 3.2%) were significantly higher than the NSQIP risk calculator predicted (all P < .05).

CONCLUSIONS

The National Surgical Quality Improvement Program risk calculator does not effectively classify or stratify risk in patients with stage I non-small cell lung cancer. Continued efforts are needed to assess risk in this population and develop more tailored treatment decision aids.