Point: Should UItrasonographic Endoscopy Be the Preferred Modality for Staging of Lung Cancer? Yes

Safety and Costs of Endobronchial Ultrasound-Guided Nodal Aspiration and Mediastinoscopy

BACKGROUND

There remains debate over the best invasive diagnostic modality for mediastinal nodal evaluation. Prior studies have limited generalizability and insufficient power to detect differences in rare adverse events. We compared the risks and costs of endobronchial ultrasound (EBUS)-guided nodal aspiration and mediastinoscopy performed for any indication in a large national cohort.

METHODS

We conducted a retrospective study (2007-2015) with MarketScan, a claims database of individuals with employer-provided insurance in the United States. Patients who underwent multimodality mediastinal evaluation (n = 1,396) or same-day pulmonary resection (n = 2,130) were excluded. Regression models were used to evaluate associations between diagnostic modalities and risks and costs while adjusting for patient characteristics, year, concomitant bronchoscopic procedures, and lung cancer diagnosis.

RESULTS

Among 30,570 patients, 49% underwent EBUS. Severe adverse events-pneumothorax, hemothorax, airway/vascular injuries, or death-were rare and invariant between EBUS and mediastinoscopy (0.3% vs 0.4%; P = .189). The rate of vocal cord paralysis was lower for EBUS (1.4% vs 2.2%; P < .001). EBUS was associated with a lower adjusted risk of severe adverse events (OR, 0.42; 95% CI, 0.32-0.55) and vocal cord paralysis (OR, 0.57; 95% CI, 0.54-0.60). The mean cost of EBUS was $2,211 less than mediastinoscopy ($6,816 vs $9,023; P < .001). After adjustment this difference decreased to $1,650 (95% CI, $1,525-$1,776).

CONCLUSIONS

When performed as isolated procedures, EBUS is associated with lower risks and costs compared with mediastinoscopy. Future studies comparing the effectiveness of EBUS vs mediastinoscopy in the community at large will help determine which procedure is superior or if trade-offs exist.

What is quality, and can we define it in lung cancer?-the case for quality improvement

Decades worth of advances in diagnostics and therapeutics are associated with only marginal improvements in survival among lung cancer patients. An obvious explanation is late stage at presentation, but gaps in the quality of care may be another reason for stifled improvements in survival rates. A framework for quality put forth by Avedis Donabedian consists of measuring structures-of-care, processes, and outcomes. Using this approach to explore for potential quality gaps, there is evidence of inexplicable variability in outcomes across patients and hospitals; variation in outcomes across differing provider types (structures-of-care); and variation in approaches to staging (processes-of-care). However, this research has limitations and incontrovertible evidence of quality gaps is challenging to obtain. Other challenges to defining quality include scientific and clinical uncertainty among providers and the fact that quality is a multi-dimensional construct that cannot be measured by a single metric. Nonetheless, two facts compel us to pursue quality improvement: (I) both empirically and anecdotally, actual care falls short of expected care; and (II) evidence of potential quality gaps is not ignorable primarily on ethical grounds.