Changes in Quality of Life After Pulmonary Resection

Musculoskeletal Disorders Related to Upper Limb Disability after One-Year Lung Cancer Resection

Lung resection represents the main curative treatment in lung cancer; however, this surgical process leads to several disorders in tissues and organs. Previous studies have reported cardiovascular, pulmonary, and muscular disturbances that affect the functional capacity of these patients in the short, mid, and long term. However, upper limb impairment has been scarcely explored in the long term, despite the relevance in the independence of the patients. The aim of this study was to characterize the upper limb impairment in survivors of lung cancer one year after pulmonary resection. In this observational trial, patients who underwent lung cancer surgery were compared to control, healthy subjects matched by age and gender. Upper limb musculoskeletal disorders (shoulder range of motion, pain pressure threshold, nerve-related symptoms) and functional capacity (upper limb exercise capacity) were evaluated one-year post-surgery. A total of 76 survivors of lung cancer and 74 healthy subjects were included in the study. Significant differences between groups were found for active shoulder mobility (p < 0.05), widespread hypersensitivity to mechanical pain (p < 0.001), mechanosensitivity of the neural tissue (p < 0.001), and upper limb exercise capacity (p < 0.001). Patients who undergo lung cancer surgery show upper limb musculoskeletal disorders and upper limb functional impairment after a one-year lung resection. This clinical condition could limit the functionality and quality of life of patients with lung cancer.

Physiotherapy and Exercise Management of People Undergoing Surgery for Lung Cancer: A Survey of Current Practice across Australia and New Zealand

Background: Moderate- to high-certainty evidence supports the benefits of pre- and post-operative exercise for people undergoing surgical resection for lung cancer. Despite this, exercise programs are not commonly provided. Previous data regarding exercise practices are a decade old. Therefore, this study aimed to understand current exercise practices in surgical lung cancer care in Australia and New Zealand. Methods: An online cross-sectional survey of Australian and New Zealand allied health professionals specialising in exercise-based interventions was carried out. Survey development and reporting adhered to CHERRIES and CROSS checklists. Institutions with thoracic surgery departments were invited to participate via email, and additional responses were sought via snowballing. Results: The response rate was 81%, with a total of 70 health services responding. A total of 18 (26%) pre-operative services, 59 (84%) inpatient post-operative services, and 39 (55%) community/outpatient post-operative services were identified. Only eight (11%) services provided a pre-operative exercise program. Half of the respondents referred less than 25% of patients to community/outpatient exercise programs on hospital discharge. Respondents reported that their clinical management was predominantly influenced by established workplace practices and personal experience rather than evidence. Conclusions: The availability and uptake of pre- and post-operative exercise remain low, and work should continue to make pre/post-operative exercise training usual practice.

Quality of Life in Octogenarians After Lung Resection Compared to Younger Patients

INTRODUCTION

To evaluate postoperative outcome and quality of life (QOL), comparing patients <80 years old to patients ≥ 80.

PATIENTS AND METHODS

EORTC questionnaires, QLQ-C30 and QLQ-LC13 was used to assess QOL, in patients after surgery. Results were evaluated according to 3 age groups: <70, 70 to 79, and ≥80.

RESULTS

106 patients were enrolled with 33 (<70), 25 (70-79), and 48 (≥80) patients per group. The median age was 74 years. 79% of patients had minimally invasive procedures, including 91% of those ≥80. Fifteen patients underwent wedge resections. Complication rates (18%, 32%, and 29%, P = .4) and median length of stay (4, 6, and 5 days, P = .2) were similar in all age groups, with no hospital mortality. One hundred one patients completed the questionnaires. Global QOL was highest among octogenarians. Overall functional and role QOL was higher among octogenarians than 70- to 79-year-olds, with emotional QOL higher than those <70 (P < .05). Social QOL in octogenarians was marginally lower than younger patients. Lung-specific symptom scores were at least 1.5 times lower than those <80 (P = .052). Patients aged 70 to 79 had the worst symptomatic and emotional effect on QOL. Surgical access and preoperative performance status did not affect final QOL across all age groups (P = .9 and P = .065). Among anatomical lung resections, QOL was higher in octogenarians than those 70 to 79 in all domains, and similar or higher than those <70 in most domains.

CONCLUSION

Quality of life among octogenarians after surgery remains similar to younger patients even after anatomical lung resection. Surgery in octogenarians is safe, with minimal impact on postoperative QOL.

Effect of operative approach on quality of life following anatomic lung cancer resection

Patient-reported outcomes (PRO) after lung cancer surgery are of increasing interest to patients and clinicians. A variety of studies have investigated the impact of the surgical approach on quality of life (QOL) after surgery for early non-small-cell lung cancer (NSCLC). Our aim is to review the current evidence on how minimally-invasive approaches, including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), versus open thoracotomy for lung cancer affect QOL. We conducted a systematic review of the literature of studies comparing QOL after VATS/RATS versus thoracotomy approach using studies published before 2019 on PubMed and Google Scholar. Studies were assessed for differences in QOL by domains. Fifteen studies met our inclusion criteria including 14 observational studies and one randomized trial. Survey instruments and timing of QOL assessments differed between all studies. A thoracoscopic (VATS or RATS) approach was associated with better general health (3/10 studies), physical functioning (9/14 studies), social functioning (1/12 studies), mental health (3/13 studies), emotional role functioning (4/12 studies), physical role functioning (7/12 studies), and bodily pain (7/12 studies) as compared to open surgery. The open thoracotomy approach was associated with better general health and mental health in one study each. Although QOL assessment in current studies is highly variable, the existing evidence suggests that a thoracoscopic approach is associated with improved QOL, particularly in the areas of physical functioning and pain as compared to open lung cancer surgery.

[Health-Related Quality of Life in Patients with Non-Small Cell Lung Cancer before and after Surgery - a Comparison between Thoracotomy and Video-Assisted Thoracoscopic Surgery]

BACKGROUND

Earlier studies have proven that in patients with non-small cell lung cancer video-assisted thoracoscopic surgery is functionally superior to thoracotomy in terms of perioperative and postoperative complications. The objective of this work was to determine whether there is a difference in health-related quality of life (HRQoL) of patients with non-small cell lung cancer - compared to the German normal population - before and after surgery. Moreover, HRQoL after thoracotomy was compared to HRQoL after video-assisted thoracoscopic surgery (VATS).

MATERIAL AND METHODS

Based on retrospective data generated during a 7-year period (2010 - 2017), 327 patients with non-small cell lung cancer who underwent therapy were examined. Patients either underwent thoracotomy or video-assisted thoracoscopic surgery. 456 of short form 12 questionnaires were analysed. Via norm-based scoring, and physical and mental component summaries (PCS and MCS) were calculated before and 6, 12, and 24 months after treatment. Using t tests, potential differences in physical and mental component summaries were evaluated between patients and the German normal population as well as between patients after thoractomy and after VATS.

RESULTS

Up to 24 months after surgery, the physical dimension of HRQoL is significantly reduced, while the mental component summary does not significantly differ from the German population. Moreover, thoracotomy and VATS gave equivalent values for health-related quality of life.

CONCLUSION

With respect to health-related quality of life, thoracotomy and video-assisted thorascopic surgery are equivalent in the long term. But there was a trend to improvement with both summary scores that might indicate superiority of video-assisted thoracoscopic surgery.

EORTC QLQ-C30 summary score reliably detects changes in QoL three months after anatomic lung resection for Non-Small Cell Lung Cancer (NSCLC)

INTRODUCTION

We tested the European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ-C30) summary score (SumSC) to detect changes in the HRQOL after Non-small-cell lung cancer (NSCLC) surgery and compared its performance to the traditional scales.

METHOD

EORTC QLQ-C30 data was obtained from 326 consecutive pre-operative patients submitted for anatomical lung resections for NSCLC.66 patients completed post-operative assessments 3 months after surgery. The data was analysed to evaluate the ability of the SumSC compared to the traditional scales to [1] preoperatively differentiate between clinical groups [2]; detect post-op changes and to [3] compare pre and post-op changes in clinically different groups.The importance of perioperative changes was measured by calculating the effect size (ES).

RESULTS

Of the 326 patients, those older than 70 years, with higher DLCO value and Performance Status (PS) ≤1 had a significantly better preoperative SumScore. Physical function (PF) showed a large and significant decline (ES 0.91). Role and social function also showed a significant and medium decline (ES 0.62 and 0.41). Postoperatively some symptoms scales showed significant increases in the values, implying worse symptoms with the largest increase in dyspnoea (ES -0.88). The change in General Health score (GH) was not significant after surgery (ES 0.26, p = 0.062). The SumSc, decreased significantly postoperatively. In particular, medium or large postoperative declines of SumSc were observed in both males and females, in patients with lower FEV1, lower performance score, and in those older than 70 years. Interestingly the decline of SumSc was observed irrespective of the preoperative DLCO level.

DISCUSSION

The Summary Score was more sensitive to changes in subjects' HRQOL, than the GH score. The SumSc can be used as a parsimonious and easy to interpreted patient-reported-outcome measure in multi-institutional database and future clinical trials.

Computer Aided Nodule Analysis and Risk Yield (CANARY) characterization of adenocarcinoma: radiologic biopsy, risk stratification and future directions

The majority of incidentally and screen-detected lung cancers are adenocarcinomas. Optimal management of these tumors is clinically challenging due to variability in tumor histopathology and behavior. Invasive adenocarcinoma (IA) is generally aggressive while adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) may be extremely indolent. Computer Aided Nodule Analysis and Risk Yield (CANARY) is a quantitative computed tomography (CT) analysis tool that allows non-invasive assessment of tumor characteristics. This analysis may obviate the need for tissue biopsy and facilitate the risk stratification of adenocarcinoma of the lung. CANARY was developed by unsupervised machine learning techniques using CT data of histopathologically-characterized adenocarcinomas of the lung. This technique identified 9 distinct exemplars that constitute the spectrum of CT features found in adenocarcinoma of the lung. The distributions of these features in a nodule correlate with histopathology. Further automated clustering of CANARY nodules defined three distinct groups that have distinctly different post-resection disease free survival (DFS). CANARY has been validated within the NLST cohort and multiple other cohorts. Using semi-automated segmentation as input to CANARY, there is excellent repeatability and interoperator correlation of results. Confirmation and longitudinal tracking of indolent adenocarcinoma with CANARY may ultimately add decision support in nuanced cases where surgery may not be in the best interest of the patient due to competing comorbidity. Currently under investigation is CANARY's role in detecting differing driver mutations and tumor response to targeted chemotherapeutics. Combining the results from CANARY analysis with clinical information and other quantitative techniques such as analysis of the tumor-free surrounding lung may aid in building more powerful predictive models. The next step in CANARY investigation will be its prospective application, both in selecting low-risk stage 1 adenocarcinoma for active surveillance and investigation in selecting high-risk early stage adenocarcinoma for adjuvant therapy.

Preparing Cancer Patients and Family Caregivers for Lung Surgery: Development of a Multimedia Self-Management Intervention

The surgical treatment of lung malignancies often results in persistent symptoms, psychosocial distress, and decrements in quality of life (QOL) for cancer patients and their family caregivers (FCGs). The potential benefits of providing patients and FCGs with preparatory education that begins in the preoperative setting have been explored in multiple medical conditions, with positive impact observed on postoperative recovery, psychological distress, and QOL. However, few studies have explored the benefits of preparatory educational interventions to promote self-management in cancer surgery, including lung surgery. This paper describes the systematic approach used in the development of a multimedia self-management intervention to prepare cancer patients and their FCGs for lung surgery. Intervention development was informed by (1) contemporary published evidence on the impact of lung surgery on patients and FCG, (2) our previous research that explored QOL, symptoms, and caregiver burden after lung surgery, (3) the use of the chronic care self-management model (CCM) to guide intervention design, and (4) written comments and feedback from patients and FCGs that informed intervention development and refinement. Pilot-testing of the intervention is in process, and a future randomized trial will determine the efficacy of the intervention to improve patient, FCG, and system outcomes.

Cost and effectiveness of lung lobectomy by video-assisted thoracic surgery for lung cancer

BACKGROUND

Video-assisted thoracic surgery (VATS) emerged as a minimally invasive surgery for diseases in the field of thoracic surgery. We herein reviewed our experience on thoracoscopic lobectomy for early lung cancer and evaluated Health System use.

METHODS

A cost-effectiveness study was performed comparing VATS vs. open thoracic surgery (OPEN) for lung cancer patients. Demographic data, tumor localization, dynamic pulmonary function tests [forced vital capacity (FVC), forced expiratory volume in one second (FEV1), diffusion capacity (DLCO) and maximal oxygen uptake (VO2max)], surgical approach, postoperative details, and complications were recorded and analyzed.

RESULTS

One hundred seventeen patients underwent lung resection by VATS (n=42, 36%; age: 63±9 years old, 57% males) or OPEN (n=75, 64%; age: 61±11 years old, 73% males). Pulmonary function tests decreased just after surgery with a parallel increasing tendency during first 12 months. VATS group tended to recover FEV1 and FVC quicker with significantly less clinical and post-surgical complications (31% vs. 53%, P=0.015). Costs including surgery and associated hospital stay, complications and costs in the 12 months after surgery were significantly lower for VATS (P<0.05).

CONCLUSIONS

The VATS approach surgery allowed earlier recovery at a lower cost than OPEN with a better cost-effectiveness profile.

The effects of respiratory physiotherapy after lung resection: Protocol for a systematic review

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To investigate the effects of respiratory physiotherapy after lung resection surgery on mortality rate within 30 days after surgery.

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Postoperative pulmonary complications within 30 days after surgery.

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Length of stay in hospital postoperatively.

Background

The main treatment of lung cancer (stage 1 and 2) is lung resection surgery. The risk of postoperative pulmonary complications is high and therefore standard postoperative care involves respiratory physiotherapy. The purpose of this systematic review is to create an overview of the evidence on respiratory physiotherapy after lung resection surgery on mortality rate (within 30 days) and postoperative pulmonary complications.

Methods and analysis

The review will include randomized or quasi-randomized controlled studies investigating the effect of all types of respiratory physiotherapy on mortality and postoperative pulmonary complications after lung resection surgery. Furthermore, the effect of respiratory physiotherapy is evaluated on secondary outcomes such as length of hospital stay, lung volumes and function, and adverse events. The method of the planned review is described in this paper. The literature search will include the databases PubMed, Cochrane (Central), Embase, Cinahl and PEDro. The literature search is being performed in 2017. If meta-analyses are not undertaken, a narrative synthesis of the available data will be provided. The protocol was registered in PROSPERO on the 10th of October 2016 (registration number CRD42016048956).

Ethics and dissemination

Conclusion of this systematic review is expected available in the second half of 2017.

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

A new era of thoracic oncology? Ex-vivo stereotactic ablative radiosurgery within Ex-vivo Lung Treatment System as a hybrid therapy for unresectable locally advanced pulmonary malignancies

The concept of oligometastases is the medical rationale for a local treatment of a limited number of metastatic tumor manifestations. Patients with pulmonary oligometastases are candidates for surgery or radiotherapy, however there are a number of technical issues that limit treatment. Technical issues relating to radiotherapy include organs at risk of irradiation, chest wall toxicity and decreased precision of tumor targeting because of breathing movements. Technical issues relating to surgery include loss of lung parenchyma and unresectability. We propose the hypothesis that ex-vivo radiosurgery as new hybrid technique in thoracic oncology has the capability to overcome these technical issues and will expand the medical spectrum in thoracic oncology. The proposed - highly complex - technique consists of surgical lung explantation, followed by stereotactic radiotherapy during ex-vivo perfusion followed by surgical re-implantation.

Use of the lung cancer-specific Quality of Life Questionnaire EORTC QLQ-LC13 in clinical trials: A systematic review of the literature 20 years after its development

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer 13 (QLQ-LC13) covers 13 typical symptoms of lung cancer patients and was the first module developed in conjunction with the EORTC core quality-of-life (QL) questionnaire. This review investigates how the module has been used and reported in cancer clinical trials in the 20 years since its publication. Thirty-six databases were searched with a prespecified algorithm. This search plus an additional hand search generated 770 hits, 240 of which were clinical studies. Two raters extracted data using a coding scheme. Analyses focused on the randomized controlled trials (RCTs). Of the 240 clinical studies that were identified using the LC13, 109 (45%) were RCTs. More than half of the RCTs were phase 3 trials (n = 58). Twenty RCTs considered QL as the primary endpoint, and 68 considered it as a secondary endpoint. QL results were addressed in the results section of the article (n = 89) or in the abstract (n = 92); and, in half of the articles, QL results were presented in the form of tables (n = 53) or figures (n = 43). Furthermore, QL results had an impact on the evaluation of the therapy that could be clearly demonstrated in the 47 RCTs that yielded QL differences between treatment and control groups. The EORTC QLQ-LC13 fulfilled its mission to be used as a standard instrument in lung cancer clinical trials. An update of the LC13 is underway to keep up with new therapeutic trends and to ensure optimized and relevant QL assessment in future trials.

The Role of Surgical Resection in Stage IIIA Non-Small Cell Lung Cancer: A Decision and Cost-Effectiveness Analysis

BACKGROUND

This study evaluated the cost-effectiveness of combination chemotherapy, radiotherapy, and surgical intervention (CRS) vs definitive chemotherapy and radiotherapy (CR) in clinical stage IIIA non-small cell lung cancer (NSCLC) patients at academic and nonacademic centers.

METHODS

Patients with clinical stage IIIA NSCLC receiving CR or CRS from 1998 to 2010 were identified in the National Cancer Data Base. Propensity score matching on patient, tumor, and treatment characteristics was performed. Medicare allowable charges were used for treatment costs. The incremental cost-effectiveness ratio (ICER) was based on probabilistic 5-year survival and calculated as cost per life-year gained.

RESULTS

We identified 5,265 CR and CRS matched patient pairs. Surgical resection imparted an increased effectiveness of 0.83 life-years, with an ICER of $17,618. Among nonacademic centers, 1,634 matched CR and CRS patients demonstrated a benefit with surgical resection of 0.86 life-years gained, for an ICER of $17,124. At academic centers, 3,201 matched CR and CRS patients had increased survival of 0.81 life-years with surgical resection, for an ICER of $18,144. Finally, 3,713 CRS patients were matched between academic and nonacademic centers. Academic center surgical patients had an increased effectiveness of 1.5 months gained and dominated the model with lower surgical cost estimates associated with lower 30-day mortality rates.

CONCLUSIONS

In stage IIIA NSCLC, the selective addition of surgical resection to CR is cost-effective compared with definitive chemoradiation therapy at nonacademic and academic centers. These conclusions are valid over a range of clinically meaningful variations in cost and treatment outcomes.

Quality of life after lung resection for lung cancer

Radical and palliative treatments for non-small cell lung cancer (NSCLC) have been reported to have a significant impact on the patient quality of life (QoL). The increasing improvements in lung cancer diagnosis and cures in recent years have changed the perspectives of quantity and quality of the life after cancer in these patients. However, despite a growing interest about patient reported outcome measures (PROMs) in surgical oncology, we are quite distant from a routine collection of QoL data after pulmonary resection for NSCLC. The presence of this gap is due to several reasons: the lack of validated surgical-specific questionnaires, the inappropriate consideration of traditional objective parameters as surrogates of QoL outcomes and the difficulties in dealing with missing items in this type of research. However, a recent the European Society of Thoracic Surgeons (ESTS) survey exploring the use of QoL data in our field has revealed that almost half of the units responding to the questionnaire collect QoL informations from their patients. Increased consensus and collaboration between surgeons are needed to include routinely PROMs in randomized controlled trials. The objective of this paper is to review the best available evidence published in the literature and regarding QoL after lung resection for cancer, aiming at identifying topics deserving further investigations.