National practice trends for the surgical management of lung cancer in the CMS population: an atlas of care

Comparison of a Risk Calculator With Frailty Indices in Patients Undergoing Lung Cancer Resection

INTRODUCTION

While frailty has gained attention for its utility in risk stratification, no studies have directly compared them to existing risk calculators. The objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other than home.

METHODS

Patients undergoing anatomic lung resection for primary, nonsmall cell lung cancer were identified within the ACS National Quality Improvement Program (ACS NSQIP) database. Tools were compared for discrimination in the primary outcomes.

RESULTS

9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (IQR 59-74) years. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% CI). This included perioperative mortality (AUC 0.74, 95% CI 0.71-0.78), compared to RAI-rev (AUC 0.66, 95% CI 0.62-0.69) and 5-mFI (AUC 0.61, 95% CI 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes.

CONCLUSION

ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

Comparison of a risk calculator with frailty indices in patients undergoing lung cancer resection

INTRODUCTION

Perioperative risk stratification is an essential component of preoperative planning for cancer surgery. While frailty has gained attention for its utility in risk stratification, no studies have directly compared it to existing risk calculators. Therefore, the objective of this study was to compare the risk stratification of the American College of Surgeons Surgical Risk Calculator (ACS-SRC), the Revised Risk Analysis Index (RAI-rev), and the Modified Frailty Index (5-mFI). The primary outcomes were 30-day postoperative morbidity, 30-day postoperative mortality, unplanned readmission, unplanned reoperation, and discharge disposition other-than-home.

METHODS

Patients undergoing anatomic lung resection for primary, non-small cell lung cancer were identified within the American College of Surgeons National Quality Improvement Program (ACS NSQIP) database. The ACS-SRC, RAI-rev, and 5-mFI tools were used to predict adverse postoperative events. Tools were compared for discrimination in the primary outcomes.

RESULTS

9663 patients undergoing anatomic lung resection for cancer between 2012 and 2014 were included. The cohort was 53.1% female. Median age at diagnosis was 67 (interquartile range = 59-74) years. Cardiothoracic surgeons performed 89% and general surgeons performed 11.0% of the operations. Perioperative morbidity and mortality rates were 10.9% (n = 1048) and 1.6% (n = 158). Rates of 30-day postoperative unplanned readmission and reoperation were 7.5% (n = 725) and 4.8% (n = 468). The ACS-SRC had the highest discrimination for all measured outcomes, as measured by the area under the receiver operating curve (AUC) and corresponding confidence interval (95% confidence interval [CI]). This included perioperative mortality (AUC = 0.74, 95% CI = 0.71-0.78), compared to RAI-rev (AUC = 0.66, 95% CI = 0.62-0.69) and 5-mFI (AUC = 0.61, 95% CI = 0.57-0.65; p < 0.001). The RAI-rev and 5-mFI had similar discrimination for all measured outcomes.

CONCLUSION

ACS-SRC was the perioperative risk stratification tool with the highest predictive discrimination for adverse, 30-day, postoperative events for patients with cancer treated with anatomic lung resection.

Comparative effectiveness of perioperative physical activity in older adults with lung cancer and their family caregivers: design of a multicenter pragmatic randomized trial

BACKGROUND

With a median age at diagnosis of 70, lung cancer remains a significant public health challenge for older Americans. Surgery is a key component in treating most patients with non-metastatic lung cancer. These patients experience postoperative pain, fatigue, loss of respiratory capacity, and decreased physical function. Data on quality of life (QOL) in older adults undergoing lung cancer surgery is limited, and few interventions are designed to target the needs of older adults and their family caregivers (FCGs). The primary aim of this comparative effectiveness trial is to determine whether telephone-based physical activity coaching before and after surgery will be more beneficial than physical activity self-monitoring alone for older adults and their FCGs.

METHODS

In this multicenter comparative effectiveness trial, 382 older adults (≥ 65 years) with lung cancer and their FCGs will be recruited before surgery and randomized to either telephone-based physical activity coaching or physical activity self-monitoring alone. Participants allocated to the telephone-based coaching comparator will receive five telephone sessions with coaches (1 pre and 4 post surgery), an intervention resource manual, and a wristband pedometer. Participants in the self-monitoring only arm will receive American Society of Clinical Oncology (ASCO) physical activity information and wristband pedometers. All participants will be assessed at before surgery (baseline), at discharge, and at days 30, 60, and 180 post-discharge. The primary endpoint is the 6-minute walk test (6MWT) at 30 days post-discharge. Geriatric assessment, lower extremity function, self-reported physical function, self-efficacy, and QOL will also be assessed.

DISCUSSION

The trial will determine whether this telephone-based physical activity coaching approach can enhance postoperative functional capacity and QOL outcomes for older adults with lung cancer and their FCGs. Trial results will provide critical findings to inform models of postoperative care for older adults with cancer and their FCGs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06196008.

The value of perioperative physical activity in older patients undergoing surgery for lung cancer

INTRODUCTION

With a median age at diagnosis of 70, lung cancer represents an enormous public health problem among older Americans. An estimated 19,000 people age 65 and older undergo lung cancer surgery annually in the US. Older adults undergoing lung cancer surgery are often frail with limited physiologic reserves, multi-morbidities, and functional impairments. Physical function, dyspnea, and quality of life return to baseline slower in older adults compared with younger adults after lung surgery.

AREAS COVERED

In this review, we summarize available data about perioperative physical activity interventions that may improve outcomes for older adults undergoing lung cancer surgery. We also review the limitations of existing studies and discuss emerging data on the roles of telehealth and family caregiver inclusion in peri-operative physical activity interventions.

EXPERT OPINION

We propose that future perioperative physical activity interventions in older adults undergoing lung cancer surgery should include a comprehensive geriatric assessment to guide personalized interventions. Interventions should be conceptually based, with a focus on enhancing self-efficacy, motivation, and adherence through classic behavior change strategies that are proven to impact outcomes. Finally, interventions should be designed with attention to feasibility and scalability. Exercise programs delivered via telehealth (telephone or tele-video) may improve access and convenience for patients.

Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study

OBJECTIVE

The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries.

SUMMARY OF BACKGROUND DATA

Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood.

METHODS

Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes.

RESULTS

Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits.

CONCLUSIONS

Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Early Outcomes of Robotic Versus Video-Assisted Thoracoscopic Anatomical Resection for Lung Cancer

Background

We compared the safety and effectiveness of robotic anatomical resection and video-assisted thoracoscopic surgery (VATS).

Methods

A retrospective analysis was conducted of the records of 4,283 patients, in whom an attempt was made to perform minimally invasive anatomical resection for lung cancer at Seoul National University Hospital from January 2011 to July 2020. Of these patients, 138 underwent robotic surgery and 4,145 underwent VATS. Perioperative outcomes were compared after propensity score matching including age, sex, height, weight, pulmonary function, smoking status, performance status, comorbidities, type of resection, combined bronchoplasty/angioplasty, tumor size, clinical T/N category, histology, and neoadjuvant treatment.

Results

In total, 137 well-balanced pairs were obtained. There were no cases of 30-day mortality in the entire cohort. Conversion to thoracotomy was required more frequently in the VATS group (VATS 6.6% vs. robotic 0.7%, p=0.008). The complete resection rate (VATS 97.8% vs. robotic 98.5%, p=1.000) and postoperative complication rate (VATS 17.5% vs. robotic 19.0%, p=0.874) were not significantly different between the 2 groups. The robotic group showed a slightly shorter hospital stay (VATS 5.8±3.9 days vs. robotic 5.0±3.6 days, p=0.052). N2 nodal upstaging (cN0/pN2) was more common in the robotic group than the VATS group, but without statistical significance (VATS 4% vs. robotic 12%, p=0.077).

Conclusion

Robotic anatomical resection in lung cancer showed comparable early outcomes when compared to VATS. In particular, robotic resection presented a lower conversion-to-thoracotomy rate. Furthermore, a robotic approach might improve lymph node harvesting in the N2 station.

Trends in Oncology: an Updated Review of Minimally Invasive Surgery vs. Traditional Open Surgery

Objective: To review the recent trends in methodology for the most frequent oncological surgeries. More specifically, this paper will compare the minimally invasive methods to the conventional open method. It aims to find out whether minimally invasive surgeries are feasible treatments for certain types of cancers.

Methods: A review of retrospective studies searched in PubMed, Cochrane Library etc. was used to identify the studies published on this topic within a period of 6 years. Oncologic outcomes, postoperative complications/outcomes, and intraoperative outcomes were the main variables in the comparison to the surgical methods under review.

Conclusion: Despite the recent controversy with minimally invasive surgery being contraindicated for cervical cancer, it is still an acceptable method for other types of common cancers. However, there are limitations to the approach, and the surgeon should make a prudent selection between minimally invasive and open surgery depending on the type of tumor and patient characteristics. Further studies, especially with randomized control trials, must be conducted.

Sublobar resection compared with stereotactic body radiation therapy and ablation for early stage non-small cell lung cancer: A National Cancer Database study

OBJECTIVES

To compare the overall survival (OS) outcomes of sublobar resection (SLR) with stereotactic body radiation therapy (SBRT) or ablation for patients with early stage non-small cell lung cancer (NSCLC).

METHODS

Patients with clinical stage I (T1-T2aN0M0) NSCLC from 2004 to 2014 who were treated with SLR, SBRT, or ablation as the sole treatment were identified from the National Cancer Database. OS was estimated using the Kaplan-Meier method and evaluated by log-rank test, univariate and multivariate Cox proportional hazard regression, and propensity score-matched analysis. Relative survival analyses compared with age- and sex-matched US population were performed.

RESULTS

A total of 53,973 patients were identified. The 1-, 2-, 3-, and 5-year relative survival rates were 96%, 90%, 84%, and 71% for SLR (n = 30,451); 93%, 78%, 65%, and 46% for SBRT (n = 22,134); and 90%, 73%, 58%, and 37% for ablation (n = 1388). Propensity score matching resulted in 9967 patients in the SBRT group versus 9967 in the SLR group and 1062 patients in the ablation group versus 1984 in the SLR group. After matching, both SBRT (hazard ratio, 1.559; 95% confidence interval, 1.497-1.623; P < .001) and ablation (hazard ratio, 1.906; 95% confidence interval, 1.730-2.101; P < .001) were associated with shorter OS when compared with SLR. These results persisted in patients with tumor size ≤2 cm.

CONCLUSIONS

Preliminary results suggest SLR may be associated with longer OS in patients with early-stage NSCLC compared with SBRT or ablation. Future prospective, randomized, controlled clinical trials comparing these treatments are needed to confirm these results.