Higher Use of Surgery Confers Superior Survival in Stage I Non-Small Cell Lung Cancer.

BACKGROUND: Lobar resection is the gold standard therapy for medically fit patients with stage I non-small cell lung cancer (NSCLC). However, considerable variability exists in the use of surgical therapy. This study tested the hypothesis that center-based variation in the use of surgical therapy affects survival in NSCLC. METHODS: We queried the National Cancer Database for patients with stage I NSCLC. Mixed-effects multivariable models were developed to establish the per-center adjusted rate of surgical therapy. Patients were stratified into quartiles based on the treating center's adjusted rate of surgical therapy. Survival was estimated and then tested by using Kaplan-Meier and the log-rank test. Multivariable Cox proportional hazard models were developed to estimate the effect of rate of surgical therapy on overall survival. RESULTS: A total of 139,802 patients met the criteria. There was wide variation in the per-center rate of surgical resection in the highest (80.8%) versus lowest (41.4%, p < 0.001) quartile. Across cohorts, patients were similar in age (mean 68.8 years in the highest quartile versus 69.7 in the lowest quartile) and Charlson-Deyo Score of 2 or greater (15.1% in the highest quartile versus 14.4% in the lowest quartile). Five-year survival was higher for patients treated at high-use centers (52.7% versus 36.7%, p < 0.001). After adjustment, an adjusted rate of surgical therapy in the lowest 25th percentile was associated with lower survival (adjusted hazard ratio 1.40, 95% confidence interval: 1.37 to 1.40, p < 0.001). CONCLUSIONS: Treatment at a center with a higher rate of surgical therapy confers a considerable survival advantage, even after adjustment for hospital volume, surgical approach, and other confounders. Targeted efforts to improve adherence to guidelines about provision of surgical therapy in early-stage NSCLC may represent a meaningful opportunity to improve outcomes.

Extracorporeal life support use in pediatric trauma: a review of the National Trauma Data Bank.

PURPOSE: As the role of extracorporeal life support (ECLS) continues to evolve in the adult and pediatric populations, smaller studies and case reports have described successful use of ECLS in specific groups of pediatric trauma patients. To further define the role of ECLS in pediatric trauma, we examined indications and outcomes for use of ECLS in injured children using a large national database. METHODS: All trauma patients ≤18years old were identified from the 2007 to 2011 National Trauma Data Bank. We collected patient demographics, mechanism of injury, injury severity, use of ECLS, and survival to discharge. Children undergoing ECLS were compared to those who did not undergo ECLS, using a 3:1 propensity matched analysis to compare outcomes between ECLS and non-ECLS patients with similar injury patterns. RESULTS: Of 589,895 pediatric trauma patients identified, 36 patients underwent ECLS. Within the ECLS cohort, 21/36 (58%) survived, and 10/36 (28%) were discharged directly home. Most ECLS patients were between 15 and 18years 20/36 (56%). Mechanisms of injury (MOI) resulting in ECLS use included: motor vehicle collision (MVC) 16/36 (44%), gunshot wound (GSW) 6/36 (17%), burns 6/36 (17%), and drowning/suffocation (D/S) 5/36 (14%). Among the ECLS cohort, survival varied by MOI from 75% in D/S to 56% in MVC and 33% in GSW and was 55% in patients with significant head injuries. Using propensity analysis for matched injury patterns, survival for ECLS and non-ECLS patients was similar (58% vs. 65%, p=0.61). CONCLUSIONS: In the largest study to date of ECLS support in pediatric trauma patients, we found encouraging survival rates to discharge, comparable to patients not undergoing ECLS with similar injuries. These results support further use and focused research of ECLS in pediatric trauma, including drowning, burn, and MVC victims and those with significant head injuries. LEVEL OF EVIDENCE: Level III; treatment study.