Lung cancer, composite image

Research published today in JAMA Surgery from the Washington University School of Medicine has found that the quality of lung cancer surgery in the United States varies widely with patients whose surgery failed to meet established guidelines experiencing significantly worse outcomes.

“It is crucial to have a solid understanding of what constitutes a high-quality lung cancer surgery,” said Varun Puri, MD, a Washington University thoracic surgeon and professor of surgery, who is the lead author of the study. “Improving adherence to surgical quality measures is critical to optimize long-term outcomes among patients with early-stage lung cancer seeking treatment intended to cure their cancer.”

While treatment for lung cancer is rapidly evolving based on new targeted treatments and more precise diagnostics, it remains the leading cause of cancer deaths and is the second most common cancer in the U.S., according the American Cancer Society. The intent of the Washington University study is to bring to light gaps in quality surgical care and to demonstrate adherence to five quality metrics that serve as care guidelines from the National Comprehensive Cancer Network (NCCN) contributed to improved lung cancer survival rates.

The five quality metrics recommend by NCCN are: performing surgery in a timely manner, shortly after diagnosis; determining the appropriate amount of lung tissue to be surgically removed; sampling multiple lymph nodes to confirm the cancer is staged correctly and has not spread to the lymph nodes; using minimally invasive surgery to reduce postsurgical pain and accelerate the recovery process; and ensuring that no cancer is left within the body, also known as a positive margin.

“Ideally, these quality metrics should be met as frequently as possible in any lung cancer surgery,” Puri said. “However, as our data show, adherence to these metrics can be highly variable across the U.S.”

To conduct their analysis, the investigators at Washington University tapped de-identified medical records of 9,628 patients from the U.S. Veterans Health Administration. The patients all underwent surgery for early-stage non-small cell lung cancer (NSCLC) over the course of ten years from 2006 to 2016. In order to determine the relative quality of surgical care received by the patients, the WashU team developing a quality scoring system to show the association between the five NCCN recommended surgery metrics and overall patient survival.

Average patient age was 67.8 years, and while the patient population for the study was predominantly white, the researchers employed statistical modeling methods to control for differences in age, gender, and race. In addition to the veterans studied the group also examined adherence to the five quality metrics using data from more than 107,000 patients listed in the National Cancer Database from 2010 to 2016.

Among both populations, the research team found poor adherence to several quality measures, noting that nearly two out of every three patients didn’t receive adequate lymph node sampling and only 40% of patients received the recommended minimally invasive surgery.

“Many patient- and tumor-specific factors can influence the apparent quality of surgical care for lung cancer. Nevertheless, it is important to try to standardize and optimize adherence to quality measures whenever possible,” said Brendan Heiden, MD, a surgical resident and research fellow at Washington University and first author of the study. Early-stage lung cancer treatments are rapidly evolving with the introduction of exciting new therapies. Central to these advances, however, is the foundational principle of performing high-quality, evidence-based surgery. As our study demonstrates, adherence to surgical quality metrics can have a disproportionate impact on patients with lung cancer receiving surgical treatment aimed at curing the cancer.”

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