Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis.

BACKGROUND: Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. METHODS: A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. RESULTS: A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation. CONCLUSION: Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Impact of the COVID-19 pandemic on esophageal cancer resource allocation: a systematic review.

Background: The coronavirus disease 2019 (COVID-19) pandemic challenged global infrastructure. Healthcare systems were forced to reallocate resources toward the frontlines. In this systematic review, we analyze the impact of resource reallocation during the COVID-19 pandemic on the diagnosis, management, and outcomes of esophageal cancer (EC) patients. Methods: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on EC patients. Of the 1,722 manuscripts initially screened, 23 met the inclusion criteria. Results: Heterogeneity of data and outcomes reporting prohibited aggregate analysis. Reduced detection of EC and considerable variability in disease stage at presentation were noted during the COVID-19 pandemic. EC patients experienced delays in diagnostic and preoperative staging investigations but surgical resection was not associated with greater short-term morbidity or mortality. Modeling the impact of pandemic-related delays in EC care predicts significant reductions in survival with associated economic losses in the coming years. Conclusions: Amidst resource scarcity during the COVID-19 pandemic, the multidisciplinary management of patients with EC was affected at multiple stages in the care pathway. Although the complete ramifications of reductions in EC diagnosis and delays in care remain unclear, EC surgery was able to safely continue as a result of collaboration between centers, strict adherence to COVID-19 protective measures, and reallocation of healthcare resources towards the same. Ultimately, when healthcare systems are pushed to the brink, the downstream consequences of resource reallocation require judicious analysis to optimize overall patient outcomes.

Conflict of interest disclosure by US cardiothoracic surgeons.

BACKGROUND: Surgeon-industry collaboration is a key driver of advancement in surgical technology and practice. Disclosures of financial relationships between investigators and industries are important to ensure transparent and critical evaluation of literature. METHODS: All American cardiothoracic (CT) surgeons who published in three major CT surgery journals in 2019 were identified. Whether these surgeons disclosed any conflicts of interest was recorded and compared to actual payments received within 5 years of publication as reported by the Centers for Medicare and Medicaid Services data. RESULTS: In the study period, there were 1079 unique manuscripts involving 885 American CT surgeons as authors, which combined for 2719 author instances. Of these, 96.2% of authors (851 of 885) received payments from companies. The authors who received payments produced 2651 author instances (97.4%). Financial disclosure was reported in only 11.4% (301 of 2651) of these instances. In total, 851 surgeons received more than $187 million over 5 years, with the highest-paid surgeon receiving an average of over $5.9 million per year. The largest individual payments were from "Associated Research Funding," with over $115 million being paid to 277 surgeons over 5 years. The top paying company issued over $96.5 million to American CT surgeons over 5 years. CONCLUSIONS: Nearly all the reviewed publications in three top CT surgery journals were by surgeons who received payments from companies, but very few of these payments were recorded as potential conflicts of interest. A more consistent and robust policy of COI disclosure is needed to reduce perceptions of bias.

Health Care Utilization and Costs in Lung Cancer Screening Participants-A Propensity-Matched Economic Analysis.

Introduction: Lung cancer screening (LCS) for high-risk populations has been firmly established to reduce lung cancer mortality, but concerns exist regarding unintended downstream costs. Methods: Mean health care utilization and costs were compared in the Alberta Lung Cancer Screening Study in a cohort undergoing LCS versus a propensity-matched control group who did not. Results: A cohort of 651 LCS participants was matched to 336 unscreened controls. Over the study period (mean 3.6 y), a modest increase in the number of claims (22.4 versus 21.9 per person-year [PY]; Δ 0.50 [95% confidence interval: 0.15-0.86], p = 0.006) and outpatient visits (4.01 versus 3.50 per PY; Δ 0.51 [0.37-0.65], p <0.0001), but not in inpatient admissions, was noted in the screened cohort. Claims payments, inpatient costs, and cancer care costs were similar in the screening arm versus the unscreened. Outpatient encounter costs per participant were higher in the screened group ($2662.18 versus $2040.67 per PY; Δ -$621.51 [-1118.05 to -124.97], p = 0.014). Removing the additional computed tomography screening examinations rendered differences not significant. Mean total costs were not significantly different at $6461.10 per PY in the screening group and $6125.31 in the unscreened group (Δ -$335.79 [-2009.65 to 1338.07], p = 0.69). Conclusions: Modest increases in outpatient costs are noted in individuals undergoing LCS, in part attributable to the screening examinations, without differences in overall health care costs. Health care costs and utilization seem otherwise similar in individuals participating in LCS and those who do not.

Resource allocation during the coronavirus disease 2019 pandemic and the impact on patients with lung cancer: a systematic review.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented tolls on both economies and human life. Healthcare resources needed to be reallocated away from the care of patients and towards supporting the pandemic response. In this systematic review, we explore the impact of resource allocation during the COVID-19 pandemic on the screening, diagnosis, management and outcomes of patients with lung cancer during the pandemic. METHODS: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on patients with lung cancer. Of the 1605 manuscripts originally screened, 47 studies met the inclusion criteria. RESULTS: Patients with lung cancer during the pandemic experienced reduced rates of screening, diagnostic testing and interventions but did not experience worse outcomes. Population-based modelling studies predict significant increases in mortality for patients with lung cancer in the years to come. CONCLUSIONS: Reduced access to resources during the pandemic resulted in reduced rates of screening, diagnosis and treatment for patients with lung cancer. While significant differences in outcomes were not identified in the short term, ultimately the effects of the pandemic and reductions in cancer screening will likely be better delineated in the coming years. Future consideration of the long-term implications of resource allocation away from patients with lung cancer with an attempt to provide equitable access to healthcare and limited interruptions of patient care may help to provide the best care for all patients during times of limited resources.

A prospective Canadian gastroesophageal cancer database: What have we learned?

BACKGROUND: Minimal literature exists on outcomes for Canadian patients with gastroesophageal adenocarcinoma (GEA). The objective of our study was to establish a prospective clinical database to evaluate demographic characteristics, presentation and outcomes of patients with GEA. METHODS: Patients diagnosed with GEA were recruited from Jan. 30, 2017, to Aug. 30, 2020. Data collected included demographic characteristics, presentation, treatment and survival. A multivariable model for overall survival in patients treated with curative intent was created using sex, lymph node status, resection margin status, age and tumour location as variables. RESULTS: A total of 122 patients with adenocarcinoma of the stomach or gastroesophageal junction were included. Median age was 65 years (interquartile range [IQR] 59-74), 70% of patients were male and 26% were born outside of Canada. Median follow-up time was 14.5 (IQR 8.0-31.0) months. Following staging computed tomography scanning, 88% of patients were deemed to have potentially resectable disease. Eighty-one (76%) received staging laparoscopy and 74 (61%) were treated with curativeintent surgery. Forty-six (62%) patients had nodal metastases. The median number of nodes harvested was 22 (IQR 18-30). The R0 resection margin rate was 82%. The 3-year overall survival for patients who received curative-intent treatment was 63% and 38% for all patients. On multivariable analysis, female sex (hazard ratio [HR] 3.88, p = 0.01), positive nodal status (HR 3.58, p = 0.02), positive margins (HR 3.11, p = 0.03) and tumour location (HR 3.00, p = 0.03) were associated with decreased overall survival. CONCLUSION: Many of the patients with GEA in this study presented with advanced disease, and only 61% were offered curative-intent surgery. A prospective multicentre national GEA database is now being established.

Changes in Sarcopenia Status Predict Survival Among Patients with Resectable Esophageal Cancer.

BACKGROUND: Sarcopenia is a predictor of survival in patients with esophageal cancer. The objective of this research was to obtain insight into how changes in sarcopenia influence survival in resectable esophageal cancer. PATIENTS AND METHODS: A retrospective cohort of patients with esophageal cancer undergoing tri-modality therapy was selected. Body composition parameters from the staging, post-neoadjuvant, and 1-year surveillance computed tomography (CT) scans were calculated. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method and log-rank test, as well as multivariable Cox-proportional hazards models. RESULTS: Of 141 patients, 118 had images at all three timepoints. The median DFS and OS were 33.2 [95% confidence interval (CI) 19.1-73.7] and 34.5 (95% CI 23.1-57.6) months, respectively. Sarcopenia classified by the staging CT was present in 20 (17.0%) patients. This changed to 45 (38.1%) patients by the post-neoadjuvant scan, and 44 (37.3%) by the surveillance scan. In multivariable analysis, sarcopenia at the post-neoadjuvant scan was significantly associated with OS [hazards ratio (HR) 2.65, 95% CI 1.59-4.40; p < 0.001] and DFS (HR 1.80, 95% CI 1.03-3.13; p = 0.038). The net change in skeletal muscle index was associated with OS (HR 0.93, 95% CI 0.90-0.97; p < 0.001) and DFS (HR 0.94, 95% CI 0.91-0.98; p = 0.001). CONCLUSIONS: Patients who develop sarcopenia as a consequence of skeletal muscle wasting during neoadjuvant therapy are at risk for worse DFS and OS. Patients who have a net loss of muscle over time may be at high risk for early disease recurrence.

Optimizing management for early-stage esophageal adenocarcinoma: longitudinal results from a multidisciplinary program.

BACKGROUND: The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. METHODS: Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan-Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. RESULTS: A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95% CI 1.09-6.00; p = 0.032), but equivalent OS (HR 1.03, 95% CI 0.46-2.32; p = 0.941), compared to patients undergoing esophagectomy. High-grade disease (OR 5.43, 95% CI 1.13-26.10; p = 0.035) and submucosal involvement (OR 7.75, 95% CI 1.90-31.40; p = 0.004) were identified as significant predictors of proceeding to esophagectomy. CONCLUSIONS: Through a multidisciplinary approach, patients with early-stage esophageal cancer achieve excellent RFS and OS. Submucosal involvement and high-grade disease place patients at increased risk for local disease recurrence; these patients may undergo endoscopic resection safely if treated with a multidisciplinary approach incorporating endoscopic surveillance and surgical consultation. Further risk-stratification models may enable better patient selection and optimization of long-term outcomes.

Oral care reduces incidence of pneumonia after esophagectomy: systematic review and meta-analysis.

PURPOSE: Post-operative pneumonia after esophagectomy is a major contributor to morbidity and mortality. Prior studies have demonstrated a link between the presence of pathologic oral flora and the development of aspiration pneumonia. The objective of this systematic review and meta-analysis was to evaluate the effect of pre-operative oral care on the incidence of post-operative pneumonia after esophagectomy. METHODS: A systematic search of the literature was performed on September 2, 2022. Screening of titles and abstracts, full-text articles, and evaluation of methodological quality was performed by two authors. Case reports, conference proceedings, and animal studies were excluded. A meta-analysis of peri-operative oral care on the odds of post-operative pneumonia after esophagectomy was performed using Revman 5.4.1 with a Mantel-Haenszel, random-effects model. RESULTS: A total of 736 records underwent title and abstract screening, leading to 28 full-text studies evaluated for eligibility. A total of nine studies met the inclusion criteria and underwent meta-analysis. Meta-analysis revealed a significant reduction in post-operative pneumonia among patients undergoing pre-operative oral care intervention compared to those without an oral care intervention (OR 0.57, 95% CI 0.43-0.74, p < 0.0001; I2 = 49%). CONCLUSION: Pre-operative oral care interventions have significant potential in the reduction of post-operative pneumonia after esophagectomy. North American prospective studies, as well as studies on the cost-benefit analysis, are required.

Sarcopenia in Lung Cancer: A Narrative Review.

It has been over 10 years since the relationship between sarcopenia and lung cancer was first explored. Since then, sarcopenia research has progressed substantially, and the prognostic value of this condition is becoming increasingly apparent. Prior systematic reviews and meta-analyses have established sarcopenia to be negatively associated with disease-free and overall-survival, as well as a major risk factor for post-operative complications. The bulk of the literature has explored sarcopenia in the resectable setting, with less emphasis placed on studies evaluating this condition in advanced disease. In this up-to-date review, an examination of the literature exploring the association between sarcopenia and long-term outcomes in advanced lung cancer is provided. We further explore the association between adverse events of medical therapy and the role of sarcopenia as a predictor of tumor response. Finally, the interventions on sarcopenia and cancer cachexia are reviewed, with an emphasis placed on prospective studies.

Probability of lung cancer in a population excluded from screening due to low PLCOM2012 risk.

BACKGROUND: Several randomized trials demonstrated have reduced lung cancer mortality with screening using computed tomography. However, there remains debate about the optimal approach for determining screening eligibility, and no evidence yet exists reporting lung cancer rates in those excluded from screening due to too low of a personalized risk. METHODS: This study was based on the Alberta Lung Cancer Screening Study, which received 1737 applicants and enrolled 850 based on the NLST criteria or a PLCOM2012 risk ≥ 1.5%. We excluded 887 applicants who were interested in screening but deemed ineligible. We report lung cancer rates in the screened and unscreened cohorts. RESULTS: We observed 30 and 8 lung cancers in the screened and unscreened groups, respectively. Only 1 of 8 lung cancers were among those considered too low risk (0.14%), while the remaining 7 were among those excluded for other reasons, including symptoms requiring more immediate workup. No NLST eligible but PLCO risk < 1.5% screened individual had a lung cancer detected as part of the study, so that of all applicants contacting the program with risk estimates less than 1.5%, only 1/857 (0.12%) developed lung cancer. CONCLUSION: Our findings indicate that a risk-based approach for screening eligibility is unlikely to miss many lung cancers.

Clinical Validation of the Canada Lymph Node Score for Endobronchial Ultrasound.

BACKGROUND: The Canada Lymph Node Score (CLNS) uses 4 sonographic criteria to predict the risk of malignancy in lymph nodes during endobronchial ultrasound. The CLNS may play a role in identifying targets for biopsy or rebiopsy during invasive mediastinal staging for lung cancer. However the CLNS has not yet been prospectively validated in routine clinical practice. METHODS: CLNSs for each lymph node biopsied during endobronchial ultrasound were prospectively captured for 1 year (2019). The CLNS and the presence of malignancy in each node were compared. Univariate binary logistic regression was completed for each ultrasonographic feature and multivariate logistic regression model. RESULTS: CLNSs and diagnostic pathology results were available for 367 lymph nodes. Incidence of malignancy increased with higher scores. Scores ≥ 3 were significantly associated with malignancy (specificity, 84.4%; positive likelihood ratio, 4.0). Area under the curve was 0.76, indicating a good ability of the model to predict presence or absence of malignancy. Nodes scoring < 2 and negative on computed tomography and positron emission tomography were malignant in 10.1%. CONCLUSIONS: The CLNS correlates with the presence or absence of malignancy in thoracic lymph nodes and may serve as an adjunct to currently available methods of invasive and noninvasive mediastinal staging. The CLNS may be most helpful in selecting which nondiagnostic lymph nodes require rebiopsy. There is a significant risk of a false-negative result even with a score of 0, and using a combination of low CLNSs and negative conventional radiology to obviate the need for any initial biopsy remains to be studied in prospective trials.

Sarcopenia reduces overall survival in unresectable oesophageal cancer: a systematic review and meta-analysis.

Sarcopenia measured through body composition analysis is emerging as an important prognosticator among various malignancies, including oesophageal cancer. Skeletal muscle index (SMI) as determined by the third lumbar vertebrae on cross-sectional CT images has been demonstrated as a predictor of overall survival in oesophageal cancer, using pre-defined cut off values for sarcopenia. However, this is largely within the setting of resectable disease. The primary objective of this systematic review and meta-analysis was to determine the effect of sarcopenia defined by SMI on overall-survival in patients with unresectable oesophageal cancer. On 30 January 2021, a systematic search of the literature was conducted to identify the role of SMI among patients with unresectable oesophageal cancer, with overall survival as the primary outcome. Databases included MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library. Inclusion criteria included age >18, diagnosis of oesophageal cancer, and non-operative management. A meta-analysis was conducted using RevMan 5.4.1 using an inverse variance, random effects model. After the removal of duplicates, 2755 unique search results were obtained. Manual screening of titles and abstracts resulted in 287 full text articles that were reviewed. Of these, five studies met the inclusion criteria with data evaluating the effect of sarcopenia defined by SMI on overall survival. A total of 783 patients, the majority of which were male (n = 638, 81%), with a mean age of 68 ± 2.3 years were included. 641 (82%) patients were diagnosed with squamous cell carcinoma. Sarcopenia, as determined by SMI using pre-defined cut-off values, was reported in 517 patients (66%). Meta-analysis demonstrated decreased overall survival in the sarcopenia group compared with the non-sarcopenia group (HR = 1.51; 95% CI 1.21-1.89; P = 0.0003; I2  = 0%; Figure 1). No significant publication bias was noted on assessment of funnel plot and Egger's test (P = 0.295). Sarcopenia as defined by SMI is predictive of overall survival among patients with nonoperative oesophageal cancer. Further analysis on the effect of sarcopenia on treatment related adverse effects and complications, particularly related to chemotherapy, radiotherapy, and oesophageal stenting, is needed to identify the degree of prognostication offered by body composition analysis. Studies on the modifiability of sarcopenia will help determine the utility of nutritional interventions.

Sarcopenia Determined by Skeletal Muscle Index Predicts Overall Survival, Disease-free Survival, and Postoperative Complications in Resectable Esophageal Cancer: A Systematic Review and Meta-analysis.

BACKGROUND: Sarcopenia has been identified as a prognostic factor among certain types of cancer. In esophageal cancer, patients are at increased risk of malnutrition and sarcopenia, ultimately contributing to poor outcomes. A systematic review was conducted to determine whether sarcopenia, defined by the skeletal muscle index, is predictive of overall survival, disease-free survival, and postoperative complications in resectable esophageal cancer. MATERIALS AND METHODS: A systematic search of MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines up until January 2021. The primary outcome was overall survival; secondary outcomes included disease-free survival, pulmonary complications, and anastomotic leak. RESULTS: Twenty-one studies (4 prospective; 17 retrospective; 3966 patients) were included. Sarcopenia was present in 1940 (48.1%) patients and was associated with lower overall survival [hazard ratio (HR): 1.56; 95% confidence interval (CI): 1.25-1.95; P <0.00001; I2 =71%] and disease-free survival (HR: 1.73; 95% CI: 1.04-2.87; P =0.03; I2 =51%). A decrease in skeletal muscle index, independent of sarcopenia status, was associated with lower overall survival (HR: 1.81; 95% CI: 1.20-2.73; P =0.005; I2 =92%). Sarcopenia was associated with increased odds of pulmonary complications (odds ratio: 1.86; 95% CI: 1.29-2.66; P =0.0008; I2 =41%) and increased odds of anastomotic leak (odds ratio: 1.46; 95% CI: 1.11-1.93; P =0.008; I2 =0%). CONCLUSIONS: Sarcopenia is a predictor of overall survival, disease-free survival, and postoperative complications in patients with resectable esophageal cancer. Studies on the modifiability of sarcopenia in the preoperative period will help determine the utility of nutritional interventions.

Stigma in Early-Stage Lung Cancer.

BACKGROUND: The phenomenon of lung cancer stigma has been firmly established in the literature. However, studies have predominantly focused on patients with advanced disease, whose experiences may differ from patients with earlier stage, surgically resectable lung cancer and an improved prognosis. PURPOSE: The objective of the study was to examine the stigma experienced in a Canadian population with early-stage, resectable lung cancer. METHODS: Patients with newly diagnosed lung cancer were enrolled at a tertiary thoracic surgery clinic. The 25-item Lung Cancer Stigma Inventory (LCSI) was self-administered by patients to quantitatively measure experiences of lung cancer stigma. LCSI results informed the development of a semi-structured focus group and individual interviews. RESULTS: Of the 53 participants completing the survey, 38 (72%) met established LCSI score threshold, indicating a clinically meaningful level of stigma. No significant relationship was found between total LCSI scores and any demographic variable. Analysis of qualitative data revealed multiple themes related to experiences of lung cancer stigma. The major themes were classified into four categories: impact of the association between lung cancer and smoking, societal attitudes and assumptions, personal choices in relation to diagnosis, and experiences related to care. CONCLUSIONS: A surgical population of patients with predominantly early-stage lung cancer experienced lung cancer stigma at a high incidence and a level similar to previously studied populations with more advanced disease. The qualitative results support the quantitative findings that respondents experienced more internal stigma than either perceived stigma from others or constrained disclosure related to their diagnosis.

Esophageal Adenocarcinoma Metastasizing to a Solitary Fibrous Tumor: An Unprecedented Case of Tumor-to-tumor Metastasis.

BACKGROUND: Tumor-to-tumor (TMT) metastasis is a rare phenomenon in which a primary malignancy undergoes metastasis to an additional synchronous or metachronous primary tumor. CASE REPORT: This is a case report of a tumor-to-tumor metastasis from a poorly differentiated adenocarcinoma of the esophagus to a solitary fibrous tumor (SFT) of the right posterior neck, in a 70-year-old-male with a solitary right vertebral artery. After appropriate work-up and involvement of the necessary specialties, the patient underwent a complex surgical resection with negative margins. CONCLUSION: We present the unique case of a patient with TMT from esophageal adenocarcinoma to an SFT in the posterior neck, not previously reported in the literature. This rare condition with unique oncologic implications highlights the need for a multidisciplinary approach, in this case involving thoracic surgery, head-and-neck surgery, medical oncology, radiation oncology, pathology, and neurosurgical sub-specialty services.

Two-Year Follow-Up of a Randomized Controlled Study of Integrated Smoking Cessation in a Lung Cancer Screening Program.

INTRODUCTION: Smoking cessation activities incorporated into lung cancer screening programs have been broadly recommended, but studies to date have not exhibited increased quit rates associated with cessation programs in this setting. We aimed to determine the long-term effectiveness of smoking cessation counseling in smokers presenting for lung cancer screening. METHODS: This was a randomized control trial of an intensive, telephone-based smoking cessation counseling intervention incorporating lung cancer screening results versus usual care (information pamphlet). This analysis reports on the long-term impact (24-mo) of the intervention on abstinence from smoking. RESULTS: A total of 337 active smokers who participated in the screening study were randomized to active smoking cessation counseling (n = 171) or control arm (n = 174) and completed a 24-month assessment. The 30-day smoking abstinence rates at 24 months postrandomization was 18.3% and 21.4% in the control and intervention arms, respectively-a 3.1% difference (95% confidence interval: -5.4 to 11.6, p = 0.48). No statistically significant differences in the 7-day abstinence, the use of pharmacologic cessation aids, nicotine replacement therapies, nor intent to quit in the following 30 days were noted (p > 0.05). The abstinence rates at 24-months were higher overall than at 12-months (19.9% versus 13.3%, p < 0.001), and smoking intensity was lower than at baseline for ongoing smokers. CONCLUSIONS: A telephone-based smoking cessation counseling intervention incorporating lung cancer screening results did not result in increased long-term cessation rates versus written information alone in unselected smokers undergoing lung cancer screening. Overall, quit rates were high and continued to improve throughout participation in the screening program. (ClinicalTrials.govNCT02431962).

A Novel Composite Biomarker Panel For Detection Of Early Stage Non-small Cell Lung Cancer.

PURPOSE: To investigate a novel composite methodology of using targeted serum microRNAs (micro ribonucleic acid; miRNA) and urine metabolites for the accurate detection of early stage non-small cell lung cancer (NSCLC). METHODS: Consecutively consenting NSCLC patients and matched control subjects were recruited to provide samples of serum for miRNA and/or urine for metabolite analyses. Serum miRNA levels were measured using quantitative real-time reverse-transcription with exogenous control, and the comparative delta cycle threshold (CT) method was used to calculate relative miRNA expression of two targeted miRNAs (miR-21 and miR-223). The concentrations of six targeted urinary metabolites in patients and healthy controls were measured using proton nuclear magnetic resonance (1H NMR) spectroscopy. A composite methodology of using the 35 accruals with both serum and urine biomarkers was then established with binary logistic regression, receiver operating characteristic (ROC) models with or without artificial intelligence (AI). RESULTS: The ROC analysis of miRNA expression yielded a sensitivity of 96.4% and a specificity of 88.2% for the detection of early stage NSCLC, with area under the curve (AUC) = 0.91 (CI 95%: 0.80-1.0). Relative urinary concentrations of 4-methoxyphenylacetic acid (4MPLA) were significantly different between NSCLC and healthy control (p=0.008). The ROC analysis of 4MPLA yielded a sensitivity of 82.1% and a specificity of 88.2%, with AUC = 0.85. The composite process combining miRNA and metabolite expression demonstrated a sensitivity and specificity of nearly 100% and AUC=1. CONCLUSIONS: A highly specific, sensitive and non-invasive detection method for NSCLC was developed. Pending validation, this can potentially improve the early detection and, hence, the treatment and survival outcomes of patients.

Automatic Referral for Potential Thoracic Malignant Diseases Detected on Computed Tomographic Scan.

BACKGROUND: Delays in care negatively affect patients with potentially resectable thoracic malignant diseases. The Alberta Thoracic Oncology Program established an automatic referral process for patients with chest computed tomographic (CT) scans suggestive of malignant disease. The objective of this study was to determine whether automatic referral was associated with decreased time to referral or differences in the quality of referral information received. METHODS: A single-center retrospective review of patients referred to a Canadian tertiary thoracic surgical center was performed. The time between the CT scan and the date of referral was calculated, and the type of information provided with the referral was tabulated. Automatic and traditional referral groups were compared using the Student t test, the Mann-Whitney U test, and multivariable analysis. RESULTS: A total of 689 patients met inclusion criteria, and 405 of these patients were automatic referrals. Average time to referral was shorter in the automatic referral group (4.7 days vs 23.6 days; P < .001). Only 2 automatic referrals took longer than 30 days, compared with more than 25% of traditional referrals. Automatic referrals were always associated with a shorter time for referral on subgroup analysis of lung nodules, different referring physician types, and patient location. There was no difference between referral types in the number of referral data provided to the center. CONCLUSIONS: Automatic referrals for patients with potential thoracic malignant disease have a significant beneficial impact on delays in care, and this could result in improved outcomes, such as decreased upstaging and improved survival. This was not associated with a decrease in the amount of information provided with the referral. Thus, automatic referrals may streamline patient care without compromising quality.

Development and Pilot Testing of an Assessment Tool for Performance of Anatomic Lung Resection.

BACKGROUND: To meet the need for competency assessment in thoracic surgery education, we developed and tested an instrument to assess trainees' ability to perform anatomic lung resection for cancer. METHODS: The Thoracic Competency Assessment Tool-Anatomic Resection for Lung Cancer (TCAT-ARC) was developed through a multistep process involving logical analysis, expert review, and simulation-based and clinical pilot testing. Validity evidence was gathered during a 6-month clinical study of trainees performing anatomic lung resections and assessments of practicing surgeons. Feedback was gathered via post-encounter questionnaires. RESULTS: A 35-item instrument was developed and was tested in the clinical validation study. Seven trainees in 4 North American institutions participated and completed 64 anatomic lung resections. Reliability was high (α = 0.93). Interobserver reliability (k = 0.73) and correlation with an existing global competency scale (k = 0.68) were moderately high. Item analysis revealed the most difficult and discriminatory items, which matched well with a conceptual understanding of lung resection. Both trainees and assessors viewed the instrument as highly educationally effective and user-friendly. Practicing surgeons outperformed trainees. CONCLUSIONS: The TCAT-ARC demonstrated early evidence of validity and reliability in assessing performance of anatomic lung resection. The instrument may be most useful early in training and as a means for providing fine-grained formative feedback about which steps have been mastered and which still require improvement. The TCAT-ARC may be used in training programs to aid in the development of trainees' competency and as a part of an aggregate assessment of trainees' overall mastery of the procedure and readiness for independent practice.