Association of Food Desert Residence and 5-Year Mortality in Lung Cancer Patients Undergoing Resection.

INTRODUCTION: Food desert (FD) residence has emerged as a risk factor for poor outcomes in breast, colon and esophageal cancers. The purpose of this retrospective study was to examine FD residence as an associated risk factor in nonsmall cell lung cancer (NSCLC) patients treated with anatomic lung resection (ALR). METHODS: All consecutive ALRs for stage I-III NSCLC from January 2015 to December 2017 at a single institution were reviewed. The primary exposure of interest was FD residence as defined by the United States Department of Agriculture. The primary outcome was 5-y overall mortality. Secondary outcomes were 30-d complications and 1- and 3-y mortality. Cox proportional hazard analysis was used to model factors associated with each outcome, adjusted for covariates. RESULTS: A total of 348 ALRs were included, with 101 (29%) patients residing in an FD. In the unadjusted Cox model, those residing in FD had an associated lower 5-year mortality risk compared to those not residing in an FD (hazard ratio = 0.56, 95% confidence interval (0.33-0.97); P = 0.04). That association was not statistically significant once adjusted for covariates (hazard ratio = 0.59, 95% confidence interval (0.34-1.04); P = 0.07). CONCLUSIONS: In this study, FD residence was not associated with an increase in the risk of 5-y mortality. Selection bias of patients deemed healthy enough to undergo surgery may have mitigated the negative association of FD residence demonstrated in other cancers. Future work will evaluate all NSCLC patients undergoing treatments at our institution to further evaluate FDs as a risk factor for worse outcomes.

The Effect of Lung Resection for NSCLC on Circulating Immune Cells: A Pilot Study.

This pilot study sought to evaluate the circulating levels of immune cells, particularly regulatory T-cell (Treg) subsets, before and after lung resection for non-small cell lung cancer. Twenty-five patients consented and had specimens collected. Initially, peripheral blood of 21 patients was collected for circulating immune cell studies. Two of these patients were excluded due to technical issues, leaving 19 patients for the analyses of circulating immune cells. Standard gating and high-dimensional unsupervised clustering flow cytometry analyses were performed. The blood, tumors and lymph nodes were analyzed via single-cell RNA and TCR sequencing for Treg analyses in a total of five patients (including four additional patients from the initial 21 patients). Standard gating flow cytometry revealed a transient increase in neutrophils immediately following surgery, with a variable neutrophil-lymphocyte ratio and a stable CD4-CD8 ratio. Unexpectedly, the total Treg and Treg subsets did not change with surgery with standard gating in short- or long-term follow-up. Similarly, unsupervised clustering of Tregs revealed a dominant cluster that was stable perioperatively and long-term. Two small FoxP3hi clusters slightly increased following surgery. In the longer-term follow-up, these small FoxP3hi Treg clusters were not identified, indicating that they were likely a response to surgery. Single-cell sequencing demonstrated six CD4+FoxP3+ clusters among the blood, tumors and lymph nodes. These clusters had a variable expression of FoxP3, and several were mainly, or only, present in tumor and lymph node tissue. As such, serial monitoring of circulating Tregs may be informative, but not completely reflective of the Tregs present in the tumor microenvironment.

Food Deserts Increase Readmission After Esophagectomy for Cancer: A Multi-institutional Study.

BACKGROUND: Food deserts are low-income census tracts with poor access to supermarkets and are associated with worse outcomes in breast, colon, and a small number of esophageal cancer patients. This study investigated residency in food deserts on readmission rates in a multi-institutional cohort of esophageal cancer patients undergoing trimodality therapy. METHODS: A retrospective review of patients who underwent trimodality therapy at 6 high-volume institutions from January 2015 to July 2019 was performed. Food desert status was defined by the United States Department of Agriculture by patient ZIP Code. The primary outcome was 30-day readmission after esophagectomy. Multilevel, multivariable logistic regression was used to model readmission on food desert status adjusted for diabetes, insurance type, length of stay, and any complication, treating the institution as a random factor. RESULTS: Of the 453 records evaluated, 425 were included in the analysis. Seventy-three patients (17.4%) resided in a food desert. Univariate analysis demonstrated food desert patients had significantly increased 30-day readmission. No differences were seen in length of stay, complications, or 30-day mortality. In the adjusted logistic regression model, residing in a food desert remained a significant risk factor for readmission (odds ratio, 2.11; 95% CI, 1.07-4.15). There were no differences in 30-day, 90-day, or 1-year mortality based on food desert status, although readmission was associated with worse 90-day and 1-year mortality. CONCLUSIONS: Food desert residence was associated with 30-day readmission after esophagectomy in patients undergoing trimodality treatment for esophageal cancer in this multi-institutional population. Identification of patients residing in a food desert may allow surgeons to focus preventative interventions during treatment and postoperatively to improve outcomes.

Reducing Unnecessary Type and Screens Prior to Thoracic Surgery: A Quality Improvement Initiative.

INTRODUCTION: Previous work identified that routine preoperative type and screen (T&S) testing before elective thoracic surgery is overutilized. We hypothesized that instituting a quality improvement (QI) initiative to change practice would significantly reduce this unnecessary testing, reduce costs, and improve healthcare efficiency. MATERIALS AND METHODS: A QI initiative was developed at a single, academic center to reduce empiric T&S ordering before elective anatomic lung resections. Two interventions were implemented: 1) education based on current institutional data and 2) an electronic medical record order set modification. Utilization of T&S testing, blood transfusion data, and perioperative outcomes were tracked and compared between a preintervention group (2015-2018) and a postintervention group (2020-2021). Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. RESULTS: Of the 553 patients included: 420 were in the preintervention group and 133 were in the postintervention group. The rate of routine T&Ss significantly dropped after implementing the QI initiative (97 versus 20%, P ≤ 0.001). Additionally, no difference in blood transfusion rate was observed (4.3 versus 2.3%, P = 0.29), and there were no differences noted in postoperative complications (P = 0.82), 30-day readmission (P = 0.29), or mortality (P = 0.96). Based on current volumes of ∼200 anatomic lung resections/year, estimated cost savings from reducing T&S testing from 97 to 20% would be at least $40,000 a year. CONCLUSIONS: Our QI initiative significantly reduced the use of routine T&S testing. This practice change was achieved while maintaining excellent outcomes demonstrating routine preoperative T&S testing can be safely reduced in most elective thoracic surgery.

Surgical results of the Lung Cancer Mutation Consortium 3 trial: A phase II multicenter single-arm study to investigate the efficacy and safety of atezolizumab as neoadjuvant therapy in patients with stages IB-select IIIB resectable non-small cell lung cancer.

OBJECTIVE: Multimodality treatment for resectable non-small cell lung cancer has long remained at a therapeutic plateau. Immune checkpoint inhibitors are highly effective in advanced non-small cell lung cancer and promising preoperatively in small clinical trials for resectable non-small cell lung cancer. This large multicenter trial tested the safety and efficacy of neoadjuvant atezolizumab and surgery. METHODS: Patients with stage IB to select IIIB resectable non-small cell lung cancer and Eastern Cooperative Oncology Group performance status 0/1 were eligible. Patients received atezolizumab 1200 mg intravenously every 3 weeks for 2 cycles or less followed by resection. The primary end point was major pathological response in patients without EGFR/ALK+ alterations. Pre- and post-treatment computed tomography, positron emission tomography, pulmonary function tests, and biospecimens were obtained. Adverse events were recorded by Common Terminology Criteria for Adverse Events v.4.0. RESULTS: From April 2017 to February 2020, 181 patients were entered in the study. Baseline characteristics were mean age, 65.1 years; female, 93 of 181 (51%); nonsquamous histology, 112 of 181 (62%); and clinical stages IIB to IIIB, 147 of 181 (81%). In patients without EGFR/ALK alterations who underwent surgery, the major pathological response rate was 20% (29/143; 95% confidence interval, 14-28) and the pathological complete response rate was 6% (8/143; 95% confidence interval, 2-11). There were no grade 4/5 treatment-related adverse events preoperatively. Of 159 patients (87.8%) undergoing surgery, 145 (91%) had pathologic complete resection. There were 5 (3%) intraoperative complications, no intraoperative deaths, and 2 postoperative deaths within 90 days, 1 treatment related. Median disease-free and overall survival have not been reached. CONCLUSIONS: Neoadjuvant atezolizumab in resectable stage IB to IIIB non-small cell lung cancer was well tolerated, yielded a 20% major pathological response rate, and allowed safe, complete surgical resection. These results strongly support the further development of immune checkpoint inhibitors as preoperative therapy in locally advanced non-small cell lung cancer.

Residing in a food desert is associated with an increased risk of readmission following esophagectomy for cancer.

Background: Nutritional status is related to treatment outcomes for esophageal cancer. Residing in a food desert (FD) has been associated with worse outcomes in breast and colon cancer. We assessed the association of residing in a FD on 30-day outcomes of esophageal cancer patients who received tri-modality therapy. Methods: A retrospective review of patients who underwent esophagectomy (1/2015 to 7/2020, in New Hampshire, USA) was performed. Patients were excluded if they did not undergo neo-adjuvant treatment, required treatment outside of standard Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) protocol, or lacked both pre and post neo-adjuvant treatment computed tomography (CT) scans for review. Demographics, nutrition parameters, treatment characteristics, 30-day complications and 90-day mortality were reviewed. FD status was defined by the United States Department of Agriculture (USDA) Food Access Research Atlas and cross-referenced with patients' home zip code. Readmission was defined as readmission to any hospital for any reason within 30-day of discharge. Univariable analysis was conducted using Student's t-test or Wilcoxon rank-sum for continuous variables, and Fisher's exact test for categorical variables. Multivariable logistic regression was then used to model readmission status on FD status adjusted for measures statistically associated with readmission status at the P<0.10 in univariable analyses. Results: Seventy-eight patients were included in the analysis. Overall pre-treatment prevalence of sarcopenia was 11.5% (9/78) and did not vary by FD status. Univariable analysis, demonstrated few significant differences between those who were readmitted and those who were not. On unadjusted analysis, patients who lived in a FD were 5 times more likely to be readmitted [5.16; 95% confidence interval (CI): 1.70-15.67] compared to those who did not. Residing in a FD remained a significant risk factor for readmission after adjustment for operative time, discharge to a rehabilitation facility and development of a grade III/IV complication [adjusted odds ratio (OR): 6.38; 95% CI: 1.45-28.08]. Conclusions: Our data suggest that residing in a FD is a prognostic factor for readmission after tri-modality therapy for esophageal cancer. Clinicians need to be aware that previously established nutritional markers may not completely capture nutritional status and living in a FD may significantly increase the risk of readmission in these patients.

Potential effectiveness of a surgeon-delivered exercise prescription and an activity tracker on pre-operative exercise adherence and aerobic capacity of lung cancer patients.

OBJECTIVES: Pre-operative exercise may improve functional outcomes for lung cancer patients, but barriers associated with cost, resources, and burden make it challenging to deliver pre-operative exercise programs. The goal of this proof-of-concept study was to determine level of moderate-vigorous physical activity (MVPA) and change in aerobic capacity after participation in a home-based pre-operative exercise intervention. MATERIALS AND METHODS: Eighteen patients scheduled for surgery for suspected stage I-III lung cancer received an exercise prescription from their surgeon and wore a commercially-available device that tracked their daily MVPA throughout the pre-operative period. Descriptive statistics were used to calculate adherence to the exercise prescription. A one-sample t-test was used to explore change in aerobic capacity from baseline to the day of surgery. RESULTS: Participants exhibited a mean of 20.4 (sd = 46.2) minutes of MVPA per day during the pre-operative period. On average, the sample met the goal of 30 min of MVPA on 16.4% of the days during the pre-operative period. The mean distance achieved at baseline for the 6-min walk test was 456.7 m (sd = 72.9), which increased to 471.1 m (sd = 88.4) on the day of surgery. This equates to a mean improvement of 13.8 m (sd = 37.0), but this difference was not statistically different from zero (p = 0.14). Eight of the 17 participants (47%) demonstrated a clinically significant improvement of 14 m or more. CONCLUSION: A surgeon-delivered exercise prescription plus an activity tracker may promote clinically significant improvement in aerobic capacity and MVPA engagement among patients with lung cancer during the pre-operative period, but may need to be augmented with more contact with and support from practitioners over time to maximize benefits. TRIAL REGISTRATION: The study protocol was registered with ClinicalTrials.gov prior to initiating participant recruitment (NCT03162718).

Lung Cancer Screening in a Surgical Lung Cancer Population: Analysis of a Rural, Quaternary, Academic Experience.

BACKGROUND: Rural populations face many health disadvantages including higher rates of tobacco use and lung cancer than more populated areas. Given this, we specifically sought to understand the current screening landscape in a cohort of patients with resected lung cancer to help direct improvements in the screening process. MATERIALS AND METHODS: We retrospectively reviewed our prospective database at a rural, quaternary, academic institution from January 2015 to June 2018. All patients who underwent resection for primary lung cancer were studied to assess the frequency of preoperative low-dose chest computed tomography per accepted guidelines. The intent was to evaluate participant demographics, clinical stage, frequency, and distribution of Lung-RADS reporting. RESULTS: About 446 patients underwent primary resection, of which 252 were deemed screening-eligible. About 57 (22.6%) underwent low-dose chest computed tomography screening and 195 (77.4%) did not. No significant demographic differences were identified between groups. However, 82.5% (47/57) of the screened patients presented with clinical stage IA disease, compared with 67.1% (131/195) of the nonscreened patients (P = 0.03). Among those screened, 36.8% (21/57) did not have a Lung-RADS score documented despite 52.3% (11/21) of those coming from accredited programs. CONCLUSIONS: Our screening completion rate was only 22.6% of eligible patients and 36.8% of those patients did not have a documented Lung-RADS score. These findings, in combination with the increased rate of diagnosis of stage IA disease, provide compelling reasons to further investigate factors designed to improve access and screening practices at rural institutions.

Rural barriers to early lung cancer detection: Exploring access to lung cancer screening programs in New Hampshire and Vermont.

BACKGROUND: Rural populations face many health disadvantages compared to urban areas. There is a critical need to better understand the current lung cancer screening landscape in these communities to identify targeted areas to improve the impact of this proven tool. METHODS: Data from the County Health Rankings of New Hampshire and Vermont was reviewed for population density, distribution of adult smokers, and level of education compared to the distribution of Lung Cancer Screening Facilities throughout these two states. RESULTS: Screening programs in southern counties of Vermont with lower levels of education have decreased access. In New Hampshire, there are no programs within 30 miles of the areas with the largest distribution of smokers, and decreased access in some areas with the lowest levels of education. CONCLUSIONS: Improving equitable access to high-quality screening services in rural regions and the creation of targeted interventions to address decreased access in areas of high tobacco use and low education is vital to decreasing the incidence of latestage presentations of lung cancer within these populations.

Reducing Unnecessary Chest X-Ray Films After Thoracic Surgery: A Quality Improvement Initiative.

BACKGROUND: Previous work has identified that inpatient post-thoracic surgery chest x-ray films (CXR) are overutilized. METHODS: A three-phase rapid cycle quality improvement initiative was performed to reduce empiric post-thoracic surgery CXR use by 25% over 1 year. We adapted evidence-based guidelines and implemented "plan-do-study-act" (PDSA) cycle methodology. The PDSA cycles included (1) education with literature and preintervention statistics; (2) electronic medical record order-set modification; and (3) audit and feedback with monthly status reports. Each cycle lasted 3 months. Use of CXR was tracked in the post-anesthesia care unit and as a daily rate of non-post-anesthesia care unit CXRs. Cost data were estimated from Centers for Medicare & Medicaid Services fees. RESULTS: During the initiative, 292 thoracic surgery inpatients were monitored. Before intervention, 99% of patients (69 of 70) received a post-anesthesia care unit CXR, and the daily rate of other CXRs was 1.6. Overall, there was a significant reduction in CXR utilization (P < .001). Post-anesthesia care unit CXRs decreased by 42%, lowering to 89% (68 of 76) to 68% (50 of 74) to 57% (41 of 72) in PDSA cycles 1 through 3, respectively. The daily rate of other CXRs decreased by 38%, lowering to 1.4 to 1.3 to 1.0. Patient perioperative characteristics and health care quality measures were not different between cycles. After quality improvement implementation, cost savings were estimated to be at least $73,292 per year. CONCLUSIONS: Implementation of our quality improvement initiative safely and systematically reduced empiric CXR use after inpatient thoracic surgery. Results will be used in future quality improvement initiatives to reduce unnecessary postoperative testing.

Postoperative atrial fibrillation prophylaxis using a novel amiodarone order set.

BACKGROUND: Studies have demonstrated that chemoprophylaxis following anatomic lung resection can reduce post-operative atrial fibrillation (POAF). However, it is unclear if non-anatomic wedge resection warrants prophylaxis, as previously published rates vary widely. The primary goal of this study was to assess an institutional rate of POAF following anatomic resections with implementation of a novel amiodarone administration regimen compared to wedge resections without prophylaxis. METHODS: We performed a retrospective cohort study of a prospectively maintained database and compared anatomic and wedge lung resection patients from 1/2015 to 4/2018. During the study period, a previously unpublished amiodarone order set consisting of a 300 mg IV bolus followed by 400 mg tablets TID ×3 days was administered to anatomic resection patients ≥65 who met criteria. Wedge resection patients were not intended to receive amiodarone prophylaxis. The primary outcome was POAF incidence. Risk factors for developing POAF were assessed. RESULTS: A total of 537 patients met inclusion where 56% underwent anatomic resection and 44% wedge resection. Overall, 5.4% of patients experienced POAF. There was a significant reduction in post-anatomic resection POAF as compared to historic rates without prophylaxis (9.3% vs. 20.3%, P<0.001). A single wedge resection patient (0.4%) developed POAF. On multivariable analysis, the only independent POAF risk factor was age ≥65 (OR: 5.41, 95% CI: 1.47-19.85). CONCLUSIONS: Administration of our novel amiodarone order set reduces POAF after anatomic resection; however, POAF following wedge resection is too rare to warrant chemoprophylaxis.

Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy.

BACKGROUND: Preoperative type and screen (TS) is routinely performed before elective thoracic surgery. We sought to evaluate the utility of this practice by examining our institutional data related to intraoperative and postoperative transfusions for two common, complex procedures. MATERIALS AND METHODS: A single-center, retrospective review of a prospective thoracic surgery database was performed. Patients who underwent consecutive elective anatomic lung resection (ALR) and esophagectomy from January 2015 to April 2018 were included. Perioperative characteristics between patients who received transfusion of packed red blood cells and those who did not were compared. The rates of emergent and nonemergent transfusions were evaluated. Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. RESULTS: Of 370 patients, 16 (4.3%) received a transfusion and four (1.1%) were deemed emergent by the surgeons and 0 (0%) by blood bank criteria. For ALR (n = 321), 13 (4.0%) received a transfusion, and four (1.2%) were emergent. For esophagectomies (n = 49), three (6.1%) received a transfusion, and none were emergent. Patients who underwent ALR requiring a transfusion had a lower preoperative hemoglobin (11.7 versus 13.4 gm/dL, P = 0.001), higher estimated blood loss (1325 versus 196 mL, P < 0.001), and longer operative time (291 versus 217 min, P = 0.003) than nontransfused patients. Based on current volumes, eliminating TS in these patients would save at least an estimated $60,100 per year. CONCLUSIONS: Emergent transfusion in ALR and esophagectomy is rare. Routine preoperative TS is most likely unnecessary for these cases. These results will be used in a quality improvement initiative to change practice at our institution.

A feasibility study of an unsupervised, pre-operative exercise program for adults with lung cancer.

OBJECTIVE: The purpose of this study was to explore the feasibility, acceptability and perceived utility of the provision of a wearable fitness device and an exercise prescription from a surgeon, prior to surgery for lung cancer. METHODS: A single-arm, pre-post feasibility study was conducted with 30 participants scheduled for surgery to treat stage I, II or III lung cancer. Participants were given a Garmin Vivoactive HR device and a prescription for 150 min of moderately to vigorous exercise per week. Participants completed assessments on four occasions and completed a semi-structured interview on two occasions. Descriptive statistics were used to assess the feasibility and acceptability of study procedures, including synchronising the Garmin device and engaging in study assessments. RESULTS: Seventy-nine per cent of enrolled participants completed the pre-operative study activities. Seventy-one per cent of enrolled participants successfully synchronised their device during the pre-operative period. Data were transmitted from the device to the study team for an average of 70% of the pre-operative days. CONCLUSION: This pilot study demonstrated the feasibility and acceptability of a pre-operative exercise program for patients scheduled to undergo surgery for lung cancer. TRIAL REGISTRATION: The study protocol was registered with ClinicalTrials.gov prior to the initiation of participant recruitment (NCT03162718).

Long-Term Outcomes of a Preoperative Lung Resection Smoking Cessation Program.

BACKGROUND: Smoking cessation programs for patients with cancer suggest 6-mo quit rates between 22% and 40%, and 1-y rates of 33%. We sought to investigate the long-term outcomes of an intensive, preoperative smoking cessation program in patients undergoing lung resection. MATERIAL AND METHODS: A retrospective analysis of an IRB-approved, prospective database was performed. Elective lung resections between January 1, 2015 and June 30, 2017 were identified. Demographics, smoking status, pack years, occurrence of smoking cessation counseling, complications, and quit date were obtained. Smoking cessation included face-to-face motivational interviewing, choice of nicotine replacement therapy, discussion that surgery may be canceled or delayed without cessation, and follow-up as needed. RESULTS: A total of 340 patients underwent lung resection. Of these, 82 patients were classified as current smokers. All were advised to quit and encouraged to meet with a certified tobacco treatment specialist. Sixty-three patients met with a tobacco treatment specialist and 19 did not. Overall, 60 patients (73%) were able to quit before surgery. At 2 y postoperatively, 15 (18%) were lost to follow-up and 9 (11%) had died. Excluding deaths and censoring those lost to follow-up, cessation rates at 6, 12, and 24 mo postoperatively were 55.3%, 55.6%, and 51.7%, respectively. CONCLUSIONS: Implementation of an intensive smoking cessation program in the preoperative period demonstrated high initial, mid-term, and long-term success rates. The preoperative period, particularly one centered around lung cancer, is an effective time for smoking cessation intervention and can lead to a high rate of cessation up to 2 y after surgery.

Routine Chest X-Rays After Thoracic Surgery Are Unnecessary.

BACKGROUND: Routine chest x-rays (CXRs) ordered on thoracic surgery inpatients are common, costly, and of unclear clinical utility. We sought to investigate CXR ordering practices and their impact on clinical care. MATERIALS AND METHODS: A single-center, retrospective cohort study of adult patients admitted after undergoing thoracic surgery with an intraoperative chest tube (CT) placed was performed over a 1-y period. Our primary outcome was a CXR-driven change in care. We evaluated routine CXR orders immediately after surgery in the postanesthesia care unit (PACU) and after final CT removal. "Routine" was defined as not ordered during a workup for a clinical concern. Patients were excluded if they underwent pleurodesis, were discharged with a CT, or had an immediate post-CT removal clinical change prompting intervention. RESULTS: A total of 241 patients met inclusion. All patients received a routine PACU CXR, and 48% (117) had abnormal radiographic findings (e.g., pneumothorax, consolidation, effusion, etc). Secondary to this CXR, one patient (0.4%) experienced a change in care: a repeat CXR only. All patients received a routine final CT removal CXR, and 58% (140) had abnormal radiographic findings. After this CXR, 33 patients (14%) experienced a change in care: 32 underwent repeat CXR and one was clinically observed. Overall, no patients experienced a procedural intervention. CONCLUSIONS: Routine post-thoracic surgery CXRs in the PACU and after CT removal have limited clinical impact. Quality initiatives should be pursued to decrease empiric CXR use and reserve ordering for specific clinical concerns.

Outcomes of an Intensive, Preoperative Smoking Cessation Program.

The outcomes of an intensive, preoperative smoking cessation program in patients undergoing lung resection were evaluated. Of 340 patients undergoing resection, 82 were currently smoking. Sixty-one were involved in our smoking cessation program, and 45 patients (73.7%) in the program were able to quit by surgery. At the 6-month and 1-year follow-up, 29 (64.4%) and 22 patients (48.9%) abstained from smoking. An intensive smoking cessation program in the perioperative period demonstrated a high success rate, with good results up to 1 year postoperatively for those able to quit before surgery.

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

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been established as a safe and effective alternative to an open approach for the treatment of early-stage lung cancer. Despite this, differences in utilization across the nation are present. The aims of this study were to: (I) characterize trends in the use of open surgery and VATS for the management of lung cancer across the United States, and (II) describe if particular regions of the country utilize minimally invasive surgery more frequently. METHODS: We studied all Medicare beneficiaries from the ages of 65 to 99 years with full Part A and B coverage and no HMO coverage for the years of 2006 and 2014 (the most recent year available at the time of this analysis). Beneficiaries with a diagnosis of lung cancer (ICD-9 codes: 162.0 162.2 162.3 162.4 162.5 162.8 162.9) were selected. Rates of thoracoscopic surgery (CPT codes: 32663, 32666, 32667, 32668, 32669, 32670, 32671) and open lung resections (32505, 32506, 32507, 32608, 32440, 32442, 32445, 32480, 32482, 32484, 32486, 32488) were calculated by year and region. Rates in 2006 and 2014 with descriptive statistics and a univariate analysis were performed using Student's t-test and chi-square, as appropriate. A two-sided P value <0.05 was considered statistically significant. RESULTS: A total of 24,368,333 and 23,921,059 beneficiaries for the years of 2006 and 2014 were analyzed. A diagnosis of lung cancer was detected in claims of 167,418 patients (0.7%) in 2006 and 167,506 patients in 2014 (0.7%), which was not significantly different (P=0.7). Among these lung cancer patients, a surgical intervention was performed in 17,249 patients (10.3%) during 2006 and 18,603 patients (11.1%) in 2014 (P=0.01). Among those undergoing surgery, a VATS approach was performed in 2,512 patients (15%) during 2006 and 9,578 patients (54%) during 2014 (P=0.001). In 2006, California, New York, and New Jersey performed the most VATS procedures, in comparison to 2014, when New York, Florida, and California performed the highest number of VATS procedures. CONCLUSIONS: While the prevalence of lung cancer in the United States was unchanged between 2006 and 2014, the use of VATS techniques increased five-fold. Further studies to better understand the adoption or availability of new surgical techniques in lung cancer populations across geographic regions and patient populations are necessary.