A Pilot Study Using Machine Learning Algorithms and Wearable Technology for the Early Detection of Postoperative Complications After Cardiothoracic Surgery.

OBJECTIVE: To evaluate whether a machine learning algorithm (i.e. the "NightSignal" algorithm) can be used for the detection of postoperative complications prior to symptom onset after cardiothoracic surgery. SUMMARY BACKGROUND DATA: Methods that enable the early detection of postoperative complications after cardiothoracic surgery are needed. METHODS: This was a prospective observational cohort study conducted from July 2021 to February 2023 at a single academic tertiary care hospital. Patients aged 18 years or older scheduled to undergo cardiothoracic surgery were recruited. Study participants wore a Fitbit watch continuously for at least 1 week preoperatively and up to 90-days postoperatively. The ability of the NightSignal algorithm-which was previously developed for the early detection of Covid-19-to detect postoperative complications was evaluated. The primary outcomes were algorithm sensitivity and specificity for postoperative event detection. RESULTS: A total of 56 patients undergoing cardiothoracic surgery met inclusion criteria, of which 24 (42.9%) underwent thoracic operations and 32 (57.1%) underwent cardiac operations. The median age was 62 (IQR: 51-68) years and 30 (53.6%) patients were female. The NightSignal algorithm detected 17 of the 21 postoperative events a median of 2 (IQR: 1-3) days prior to symptom onset, representing a sensitivity of 81%. The specificity, negative predictive value, and positive predictive value of the algorithm for the detection of postoperative events were 75%, 97%, and 28%, respectively. CONCLUSIONS: Machine learning analysis of biometric data collected from wearable devices has the potential to detect postoperative complications-prior to symptom onset-after cardiothoracic surgery.

Surgery for M1A Non-Small-Cell Lung Cancer With Additional Pulmonary Nodules in a Contralateral Lobe.

INTRODUCTION: Limited consensus exists on the optimal treatment strategy for clinical M1a non-small-cell lung cancer (NSCLC) presenting as a primary tumor with additional intrapulmonary nodules in a contralateral lobe ("M1a-Contra"). This study sought to compare long-term survival of patients with M1a-Contra tumors receiving multimodal therapy with versus without thoracic surgery. METHODS: Overall survival of patients with cT1-4, N0-3, M1a NSCLC with contralateral intrapulmonary nodules who received surgery as part of multimodal therapy ("Thoracic Surgery") versus systemic therapy with or without radiation ("No Thoracic Surgery") in the National Cancer Database from 2010 to 2015 was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching. RESULTS: Of the 5042 patients who satisfied study inclusion criteria, 357 (7.1%) received multimodal therapy including surgery. In multivariable-adjusted analysis, the Thoracic Surgery cohort had better overall survival than the No Thoracic Surgery cohort (HR: 0.66, 95% CI: 0.56-0.79, P < 0.001). In a propensity score-matched analysis of 386 patients, well-balanced on 12 common prognostic covariates, the Thoracic Surgery group had better 5-year overall survival than the No Thoracic Surgery group (P = 0.020). In propensity score-matched analyses stratified by clinical N status, Thoracic Surgery was associated with better overall survival than No Thoracic Surgery for patients with cN0 disease and cN1-2 disease. CONCLUSIONS: In this national analysis, multimodal treatment including surgery was associated with better overall survival than systemic therapy with or without radiation without surgery for patients with M1a-Contra tumors. These preliminary findings highlight the importance of further evaluation of surgery in a multidisciplinary treatment setting for M1a-Contra tumors.

Efficacy and Safety of Supraclavicular Thoracic Outlet Decompression.

OBJECTIVES: We aimed to report efficacy, safety, and health-related quality of life (HRQoL) outcomes of a multidisciplinary treatment approach including supraclavicular thoracic outlet decompression among patients with thoracic outlet syndrome (TOS). BACKGROUND: TOS is a challenging condition where controversy remains in diagnosis and treatment, primarily given a lack of data exploring various treatment approaches and associated patient outcomes. METHODS: Patients who underwent unilateral, supraclavicular thoracic outlet decompression, or pectoralis minor tenotomy for neurogenic, venous, or arterial TOS were identified from a prospectively maintained database. Demography, use of preoperative botulinum toxin injection, and participation in multidisciplinary evaluation were measured. The primary endpoints were composite postoperative morbidity and symptomatic improvement compared with baseline. RESULTS: Among 2869 patients evaluated (2007-2021), 1032 underwent surgery, including 864 (83.7%) supraclavicular decompressions and 168 (16.3%) isolated pectoralis minor tenotomies. Predominant TOS subtypes among surgical patients were neurogenic (75.4%) and venous TOS (23.4%). Most patients (92.9%) with nTOS underwent preoperative botulinum toxin injection; 56.3% reported symptomatic improvement. Before surgical consultation, few patients reported participation in physical therapy (10.9%). The median time from first evaluation to surgery was 136 days (interquartile range: 55, 258). Among 864 patients who underwent supraclavicular thoracic outlet decompression, complications occurred in 19.8%; the most common complication was chyle leak (8.3%). Four patients (0.4%) required revisional thoracic outlet decompression. At a median follow-up of 420 days (interquartile range: 150, 937) 93.3% reported symptomatic improvement. CONCLUSION: Based on low composite morbidity, need for very few revisional operations, and high rates of symptomatic improvement, a multidisciplinary treatment approach including primarily supraclavicular thoracic outlet decompression is safe and effective for patients with TOS.

Small molecule RAF265 as an antiviral therapy acts against HSV-1 by regulating cytoskeleton rearrangement and cellular translation machinery.

Host-targeting antivirals (HTAs) have received increasing attention for their potential as broad-spectrum antivirals that pose relatively low risk of developing drug resistance. The repurposing of pharmaceutical drugs for use as antivirals is emerging as a cost- and time- efficient approach to developing HTAs for the treatment of a variety of viral infections. In this study, we used a virus titer method to screen 30 small molecules for antiviral activity against Herpes simplex virus-1 (HSV-1). We found that the small molecule RAF265, an anticancer drug that has been shown to be a potent inhibitor of B-RAF V600E, reduced viral loads of HSV-1 by 4 orders of magnitude in Vero cells and reduced virus proliferation in vivo. RAF265 mediated cytoskeleton rearrangement and targeted the host cell's translation machinery, which suggests that the antiviral activity of RAF265 may be attributed to a dual inhibition strategy. This study offers a starting point for further advances toward clinical development of antivirals against HSV-1.

Wedge Resection Versus Segmentectomy for Older Patients With Stage IA Non-Small-Cell Lung Cancer.

INTRODUCTION: Anatomic lung resection remains the standard of care for early-stage non-small-cell lung cancer (NSCLC), but wedge resection may offer similar survival in older adult patients. The objective of this study was to evaluate the survival of patients aged 80 y and older undergoing wedge resection versus segmentectomy for stage IA NSCLC using a large clinical registry. METHODS: Patients aged 80 y and older in the National Cancer Database who underwent wedge resection or segmentectomy for cT1a-b N0 M0 NSCLC between 2004 and 2018 were identified for an analysis. Survival was assessed using multivariable Cox proportional hazards analysis, propensity-score matching, and inverse probability weighting. A subgroup analysis of patients who underwent lymph node evaluation with their wedge resection or segmentectomy was also performed. RESULTS: Of the 2690 patients identified, 2272 (84%) underwent wedge resection and 418 (16%) underwent segmentectomy. Wedge resection was associated with worse 5-year overall survival relative to segmentectomy in multivariable-adjusted (adjusted Hazard Ratio: 1.26, [1.06-1.51], P = 0.01) and propensity score-matched analysis (49% [95% confidence interval {CI}: 42%-55%] versus 59% [95% CI: 52%-65%], P = 0.02). Among a subgroup of 1221 wedge resection and 347 segmentectomy patients who also received intraoperative lymph node evaluation, however, there were no significant differences in 5-year survival in multivariable-adjusted (adjusted Hazard Ratio: 1.12, [0.90-1.39], P = 0.31) or propensity score-matched analysis (55% [95% CI: 48%-62%] versus 61% [95% CI: 54%-68%], P = 0.10). CONCLUSIONS: In this national analysis, there were no significant differences in survival between older adult patients with stage IA NSCLC who underwent wedge resection versus segmentectomy when a lymph node evaluation was performed.

The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States.

OBJECTIVE: To assess the association between the timing of surgery relative to the development of Covid-19 and the risks of postoperative complications. SUMMARY BACKGROUND DATA: It is unknown whether patients who recovered from Covid-19 and then underwent a major elective operation have an increased risk of developing postoperative complications. METHODS: The risk of postoperative complications for patients with Covid-19 undergoing 18 major types of elective operations in the Covid-19 Research Database was evaluated using multivariable logistic regression. Patients were grouped by time of surgery relative to SARS-CoV-2 infection; that is, surgery performed: (1) before January 1, 2020 ("pre-Covid-19"), (2) 0 to 4 weeks after SARS-CoV-2 infection ("peri-Covid-19"), (3) 4 to 8 weeks after infection ("early post-Covid-19"), and (4) ≥8 weeks after infection ("late post-Covid-19"). RESULTS: Of the 5479 patients who met study criteria, patients with peri-Covid-19 had an elevated risk of developing postoperative pneumonia [adjusted odds ratio (aOR), 6.46; 95% confidence interval (CI): 4.06-10.27], respiratory failure (aOR, 3.36; 95% CI: 2.22-5.10), pulmonary embolism (aOR, 2.73; 95% CI: 1.35-5.53), and sepsis (aOR, 3.67; 95% CI: 2.18-6.16) when compared to pre-Covid-19 patients. Early post-Covid-19 patients had an increased risk of developing postoperative pneumonia when compared to pre-Covid-19 patients (aOR, 2.44; 95% CI: 1.20-4.96). Late post-Covid-19 patients did not have an increased risk of postoperative complications when compared to pre-Covid-19 patients. CONCLUSIONS: Major, elective surgery 0 to 4 weeks after SARS-CoV-2 infection is associated with an increased risk of postoperative complications. Surgery performed 4 to 8 weeks after SARS-CoV-2 infection is still associated with an increased risk of postoperative pneumonia, whereas surgery 8 weeks after Covid-19 diagnosis is not associated with increased complications.

Safety and Optimizing Ergonomics for Cardiothoracic Surgeons.

Cardiothoracic surgery, demanding in nature, often results in surgeons suffering from musculoskeletal injuries, causing chronic pain and leading to premature retirement. A significant majority report experiencing pain, exacerbated by minimally invasive techniques such as video-assisted thoracoscopic surgery. Despite this, many surgeons delay seeking medical assistance. To mitigate these risks, preventative strategies such as strength exercises, stretching during operations, and taking brief breaks are crucial. However, the surgical community faces a shortage of institutional support and comprehensive ergonomic education. Advancements in technology, including artificial intelligence and virtual reality, could offer future solutions.

Early Detection and Interception of Lung Cancer.

Recent advances in lung cancer treatment have led to dramatic improvements in 5-year survival rates. And yet, lung cancer remains the leading cause of cancer-related mortality, in large part, because it is often diagnosed at an advanced stage, when cure is no longer possible. Lung cancer screening (LCS) is essential for intercepting the disease at an earlier stage. Unfortunately, LCS has been poorly adopted in the United States, with less than 5% of eligible patients being screened nationally. This article will describe the data supporting LCS, the obstacles to LCS implementation, and the promising opportunities that lie ahead.

Long-Term Survival of American Joint Committee on Cancer 8th Edition Staging Descriptors for Clinical M1a Non-Small Cell Lung Cancer.

BACKGROUND: The American Joint Committee on Cancer (AJCC) 8th edition TNM staging manual for non-small cell lung cancer (NSCLC) M1a descriptors includes tumors presenting with malignant pleural or pericardial effusion (ie, M1a-Effusion), pleural or pericardial nodule(s) (ie, M1a-Pleural), or separate tumor nodule(s) in a contralateral lobe (ie, M1a-Contralateral). RESEARCH QUESTION: Is M1a NSCLC presenting with malignant pleural or pericardial effusion associated with worse survival compared with other types of M1a NSCLC? STUDY DESIGN AND METHODS: Patients with cT1-4, N0-3, M1a NSCLC (satisfying a single M1a descriptor of M1a-Effusion, M1a-Pleural, or M1a-Contralateral), according to AJCC eighth edition staging criteria, in the National Cancer Database from 2010 to 2015 were included. Overall survival was evaluated by using Kaplan-Meier analysis, multivariable-adjusted Cox proportional hazards modeling, and propensity score matching. RESULTS: Of the 25,716 patients who met study eligibility criteria, 12,756 (49.6%) presented with M1a-Effusion tumors, 3,589 (14.0%) with M1a-Pleural tumors, and 9,371 (36.4%) with M1a-Contralateral tumors. In multivariable-adjusted analysis, compared to M1a-Effusion tumors, both M1a-Pleural tumors (hazard ratio, 0.68; 95% CI, 0.64-0.71; P < .001) and M1a-Contralateral tumors (hazard ratio, 0.66; 95% CI, 0.64-0.69; P < .001) were associated with better overall survival. No significant differences were found in overall survival between patients with M1a-Pleural tumors vs M1a-Contralateral tumors. In a propensity score-matched analysis of 5,581 patients with M1a-Effusion tumors and 5,581 patients with other M1a tumors (ie, M1a-Contralateral or M1a-Effusion), those with M1a-Effusion tumors had worse 5-year overall survival than patients with other M1a tumors (M1a-Effusion 6.4% [95% CI, 5.7-7.1] vs M1a-Other 10.6% [95% CI, 9.7-11.5]; P < .001). INTERPRETATION: In this national analysis of AJCC 8th edition cT1-4, N0-3, M1a NSCLC, tumors with malignant pleural or pericardial effusion were associated with worse overall survival than tumors with either pleural or contralateral pulmonary nodules. These findings may be taken into consideration for the upcoming ninth edition of the AJCC lung cancer staging guidelines.

Surgical management of non-small cell lung cancer with limited metastatic disease involving only the brain.

OBJECTIVE: The optimal primary site treatment modality for non-small cell lung cancer with brain oligometastases is not well established. This study sought to evaluate the long-term survival of patients with non-small cell lung cancer with isolated brain metastases undergoing multimodal therapy with or without thoracic surgery. METHODS: Patients with cT1-3, N0-1, M1b-c non-small cell lung cancer with synchronous limited metastatic disease involving only the brain treated with brain stereotactic radiosurgery or neurosurgical resection in the National Cancer Database (2010-2017) were included. Long-term overall survival of patients who underwent multimodal therapy including thoracic surgery ("Thoracic Surgery") versus systemic therapy with or without radiation to the lung ("No Thoracic Surgery") was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching. RESULTS: Of the 1240 patients with non-small cell lung cancer with brain-only metastases who received brain stereotactic radiosurgery or neurosurgery and met study inclusion criteria, 270 (21.8%) received primary site resection. The Thoracic Surgery group had improved overall survival compared with the No Thoracic Surgery group in Kaplan-Meier analysis (P < .001) and after multivariable-adjusted Cox proportional hazards modeling (P < .001). In a propensity score-matched analysis of 175 patients each in the Thoracic Surgery and No Thoracic Surgery groups, matching on 13 common prognostic variables, thoracic surgery was associated with better survival (P = .012). CONCLUSIONS: In this national analysis, patients with cT1-3, N0-1, M1b-c non-small cell lung cancer with isolated limited brain metastases had better overall survival after multimodal therapy including thoracic surgery compared with systemic therapy without surgery. Multimodal thoracic treatment including surgery can be considered for carefully selected patients with non-small cell lung cancer and limited brain metastases.

Long-term Survival After Lung Cancer Resection in the National Lung Screening Trial.

BACKGROUND: This study sought to evaluate the long-term survival and causes of death after surgery among patients with pathologic stage IA non-small cell lung cancer (NSCLC) in the National Lung Screening Trial (NLST). METHODS: Patients who underwent surgery and who had a diagnosis of pathologic stage IA NSCLC in the NLST were identified for analysis. The 5- and 10-year overall survival and lung cancer-specific survival, stratified by operation type, were evaluated. Among patients who underwent lobectomy, the causes of death and the cumulative incidence of lung cancer death were assessed. RESULTS: A total of 380 patients (n = 329, 86.6% lobectomy; n = 20, 5.3% segmentectomy; n = 31, 8.1% wedge resection) met inclusion criteria. Median follow-up time from the date of surgery was 7.8 years (interquartile range, 4.8-10.7 years). The 10-year overall survival rate was 58.3% (95% CI, 52.4%-63.8%) for lobectomy, 59.9% (95% CI, 33.2%-78.8%) for segmentectomy, and 45.2% (95% CI, 20.8%-66.9%) for wedge resection. The 10-year lung cancer-specific survival rate was 74.3% (95% CI, 68.6%-79.1%) for lobectomy, 81.3% (95% CI, 51.3%-93.8%) for segmentectomy, and 84.8% (95% CI, 64.0%-94.1%) for wedge resection. Lung cancer was the leading cause of death, accounting for 55.8% of deaths after lobectomy. The 10-year cumulative incidence of lung cancer death after lobectomy was 22.5% (95% CI, 18.3%-27.1%). CONCLUSIONS: The 10-year overall survival rate after lobectomy among patients with pathologic stage IA NSCLC in the NLST was 58%. Lung cancer was the leading cause of death, accounting for more than 55% of deaths.

Shortage of thoracic surgeons in the United States: Implications for treatment and survival for stage I lung cancer patients.

OBJECTIVES: To evaluate whether there is a shortage of thoracic surgeons in the United States and whether any potential shortage is impacting lung cancer treatment and outcomes. DESIGN: Using the US Area Health Resources File and Surveillance Epidemiology End Results database, we assessed the number of cardiothoracic surgeons per 100,000 people and the number of stage I non-small cell lung cancer (NSCLC) diagnoses in the US in 2010 versus 2018. Changes in the percentage of patients diagnosed with stage I NSCLC who underwent surgery and stereotactic body radiotherapy and changes in overall survival of patients with stage I NSCLC from 2010 to 2018 in the National Cancer Database were evaluated using multivariable logistic regression and Cox proportional hazards modeling. RESULTS: From 2010 to 2018, the number of cardiothoracic surgeons per 100,000 people in the US decreased by 12% (P < .001), while the number of patients diagnosed with stage I NSCLC increased by 40% (P < .001). Over the same period, the percentage of patients who underwent surgery for stage I NSCLC decreased from 81.0% to 72.3% (adjusted odds ratio, 0.59; 95% confidence interval, 0.55-0.63); this decrease was similarly seen in a subgroup of young and otherwise healthy patients. Greater decreases in the percentage of patients who underwent surgery in nonmetropolitan and underserved regions corresponded with worse improvements in survival among patients in these regions from 2010 to 2018. CONCLUSIONS: Recent declines in the US cardiothoracic surgery workforce may have led to significantly fewer patients undergoing surgery for stage I NSCLC and worsening disparities in survival between different patient populations.

Pack-Year Smoking History: An Inadequate and Biased Measure to Determine Lung Cancer Screening Eligibility.

PURPOSE: Pack-year smoking history is an imperfect and biased measure of cumulative tobacco exposure. The use of pack-year smoking history to determine lung cancer screening eligibility in the current US Preventive Services Task Force (USPSTF) guideline may unintentionally exclude many high-risk individuals, especially those from racial and ethnic minority groups. It is unclear whether using a smoking duration cutoff instead of a smoking pack-year cutoff would improve the selection of individuals for screening. METHODS: We analyzed 49,703 individuals with a smoking history from the Southern Community Cohort Study (SCCS) and 22,126 individuals with a smoking history from the Black Women's Health Study (BWHS) to assess eligibility for screening under the USPSTF guideline versus a proposed guideline that replaces the ≥20-pack-year criterion with a ≥20-year smoking duration criterion. RESULTS: Under the USPSTF guideline, only 57.6% of Black patients with lung cancer in the SCCS would have qualified for screening, whereas a significantly higher percentage of White patients with lung cancer (74.0%) would have qualified (P < .001). Under the proposed guideline, the percentage of Black and White patients with lung cancer who would have qualified for screening increased to 85.3% and 82.0%, respectively, eradicating the disparity in screening eligibility between the groups. In the BWHS, using a 20-year smoking duration cutoff instead of a 20-pack-year cutoff increased the percentage of Black women with lung cancer who would have qualified for screening from 42.5% to 63.8%. CONCLUSION: Use of a 20-year smoking duration cutoff instead of a 20-pack-year cutoff greatly increases the proportion of patients with lung cancer who would qualify for screening and eliminates the racial disparity in screening eligibility between Black versus White individuals; smoking duration has the added benefit of being easier to calculate and being a more precise assessment of smoking exposure compared with pack-year smoking history.

Wedge Resection versus Stereotactic Body Radiation Therapy for Non-Small Cell Lung Cancer Tumors ≤8 mm.

The objective of this study was to evaluate the overall survival of patients with ≤8 mm non-small cell lung cancer (NSCLC) who undergo wedge resection versus stereotactic body radiation therapy (SBRT). Kaplan-Meier analysis, multivariable Cox proportional hazards modeling, and propensity score-matched analysis were performed to evaluate the overall survival of patients with ≤8 mm NSCLC in the National Cancer Database (NCDB) from 2004 to 2017 who underwent wedge resection versus patients who underwent SBRT. The above-mentioned matched analyses were repeated for patients with no comorbidities. Patients who were coded in the NCDB as having undergone radiation because surgery was contraindicated due to patient risk factors (e.g., comorbid conditions, advance age, etc.) and those with a history of prior malignancy were excluded from analysis. Of the 1505 patients who had NSCLC ≤8 mm during the study period, 1339 (89%) patients underwent wedge resection, and 166 (11%) patients underwent SBRT. In the unadjusted analysis, multivariable Cox modeling and propensity score-matched analysis, wedge resection was associated with improved survival when compared to SBRT. These results were consistent in a sensitivity analysis limited to patients with no comorbidities.

Segmentectomy versus lobectomy in the United States: Outcomes after resection for first primary lung cancer and treatment patterns for second primary lung cancers.

OBJECTIVE: The study objective was to identify whether the results of JCOG0802 could be generalized to US clinical settings. METHODS: Patients diagnosed with clinical stage IA (≤2 cm) non-small cell lung cancer who underwent segmentectomy versus lobectomy (2004-2017) in the National Cancer Database were identified. Overall survival of patients in the National Cancer Database was assessed using propensity score-matched analysis. A separate analysis of the Surveillance Epidemiology End Results database was conducted to evaluate treatment patterns of second primary lung cancers among patients who underwent segmentectomy versus lobectomy for a first primary lung cancer. RESULTS: Of the 23,286 patients in the National Cancer Database meeting inclusion criteria, 1397 (6.0%) underwent segmentectomy and 21,889 (94.0%) underwent lobectomy. In a propensity score-matched analysis of all patients in the study cohort, there were no significant differences in overall survival between patients undergoing segmentectomy versus lobectomy (5-year overall survival: 79.9% [95% CI, 76.7%-82.0%] vs 81.8% [95% CI, 78.7%-84.4%], log-rank: P = .72). In subgroup analyses by tumor grade and histologic subtype, segmentectomy was associated with similar overall survival compared with lobectomy in all subgroups evaluated. In a propensity score-matched analysis of patients in the Surveillance Epidemiology End Results database, there were no significant differences in treatment patterns of second primary lung cancers between patients who underwent segmentectomy and patients who underwent lobectomy for their first primary lung cancer. CONCLUSIONS: In this national analysis of US patients diagnosed with stage IA (≤2 cm) non-small cell lung cancer, there were no significant differences in overall survival between segmentectomy and lobectomy in the overall cohort or in subgroup analyses by tumor grade or histologic subtype.

Update on Lung Cancer Screening Guideline.

Lung cancer screening has been shown to reduce lung cancer mortality and is recommended for individuals meeting age and smoking history criteria. Despite the expansion of lung cancer screening guidelines in 2021, racial/ethnic and sex disparities persist. High-risk racial minorities and women are more likely to be diagnosed with lung cancer at younger ages and have lower smoking histories when compared with White and male counterparts, resulting in higher rates of ineligibility for screening. Risk prediction models, biomarkers, and deep learning may help refine the selection of individuals who would benefit from screening.

Racial and ethnic disparities in end-of-life care for patients with oesophageal cancer: death trends over time.

Background: Given significant morbidity and mortality associated with oesophageal cancer, supportive, high-quality end-of-life care is critical. Most patients with advanced cancer prefer to die at home, but incongruence between preferred and actual place of death is common. Here, we examined trends and disparities in location of death among patients with oesophageal cancer. Methods: Using the Centers for Disease Control and Prevention Wide-Range Online Data for Epidemiologic Research database, we utilized multinomial logistic regression to assess associations between sociodemographic characteristics and location of death for patients with oesophageal cancer (n = 237,063). Additionally, we utilized linear regression models to evaluate the significance of changes in location of death trends over time and disparities in the relative change in location of death trends across sociodemographic groups. Findings: From 2003 to 2019, there was a decrease of deaths in hospitals, nursing homes, and outpatient medical facilities/emergency departments and an increase of deaths at home and in hospice. Relative to White decedents, Black and Asian decedents were less likely to die at home (relative risk ratio (RRR): 0.58 [95% confidence interval (CI): 0.56-0.60], RRR: 0.57 [95% CI: 0.53-0.61]) and in hospice (RRR: 0.67 [95% CI: 0.64-0.71], RRR: 0.49 [95% CI: 0.43-0.55]) when compared to the hospital. Similar disparities were noted for American Indian and Alaska Native (AIAN) decedents. These disparities persisted even upon stratifying by the number of listed causes of death, a proxy for severity of illness. Time trend analysis indicated that increases in deaths in hospice over time occurred at a slower rate for AIAN and Asian decedents relative to White decedents. Interpretation: 2 in 5 patients with oesophageal cancer die at home, with an increasing proportion dying at home and in hospice-in line with general patient preferences. However, location of death disparities have largely persisted over time among racial and ethnic minority groups. Our findings suggest the importance of improving access to advance care planning and delivering tailored, person-centred interventions. Funding: None.

Primary clear cell adenocarcinoma of the lung: a national analysis.

Background: Primary clear cell adenocarcinoma of the lung (CCAL) is a rare form of lung cancer with poorly understood clinical features. We sought to investigate the clinicopathological characteristics and independent prognostic factors of primary CCAL. Methods: Overall survival (OS) of patients with CCAL in the National Cancer Database (NCDB) from 2004 to 2017 was compared to lung adenocarcinoma using Kaplan-Meier analysis, multivariable Cox proportional hazards modeling, and propensity score matching. Independent prognostic indicators for patients with CCAL were determined using multivariable Cox proportional hazards analysis. Results: A total of 1,396 CCAL and 462,360 lung adenocarcinoma patients were included in our analysis. When compared to patients diagnosed with lung adenocarcinoma, those diagnosed with CCAL were more likely to be younger, white, reside farther from a hospital, have higher Charlson/Deyo comorbidity condition (CDCC) scores, have private insurance, have T1, N0, M0 status. In unadjusted analysis, patients with CCAL had better survival than those with lung adenocarcinoma, although no significant differences in survival were found between the two groups with multivariable Cox proportional hazards and propensity score-matched analyses. Conclusions: In this national analysis, we found that the clinicopathological characteristics of CCAL are distinct from those of lung adenocarcinoma, but CCAL is not itself an independent predictor of survival after multivariable adjustment or propensity score-matched analysis.

Open, Video- and Robot-Assisted Thoracoscopic Lobectomy for Stage II-IIIA Non-Small Cell Lung Cancer.

BACKGROUND: This study compares the short- and long-term outcomes of open vs robotic vs video-assisted thoracoscopic surgery (VATS) lobectomy for stage II-IIIA non-small-cell lung cancer (NSCLC). METHODS: Outcomes of patients with stage II-IIIA NSCLC (excluding T4 tumors) who received open and minimally invasive surgery (MIS) lobectomy in the National Cancer Database from 2010 to 2017 were assessed using propensity score-matched analysis. RESULTS: A propensity score-matched analysis of 4652 open and 4652 MIS patients demonstrated a decreased median length of stay associated with MIS compared with open lobectomy (5 vs 6 days; P < .001). There were no significant differences in 30-day mortality, 30-day readmission, or overall survival between the open and MIS groups. A propensity score-matched analysis of 1186 VATS and 1186 robotic patients showed that compared with VATS, the robotic approach was associated with no significant differences in 30-day mortality, 30-day readmission, and overall survival. However, the robotic group had a decreased median length of stay compared with VATS (4 vs 5 days; P < .001). The conversion rate was also significantly lower for robotic compared with VATS lobectomy (8.9% vs 15.9%, P < .001). CONCLUSIONS: No significant differences were found in long-term survival between open and MIS lobectomy and between VATS and robotic lobectomy for stage II-IIIA NSCLC. However, the MIS approach was associated with a decreased length of stay compared with the open approach. The robotic approach was associated with decreased length of stay and decreased conversion rate compared with the VATS approach.

Postoperative radiotherapy with modern techniques does not improve survival for operable stage IIIA-N2 non-small cell lung cancer.

OBJECTIVES: This study aims to evaluate whether postoperative radiotherapy using newer techniques (intensity-modulated radiotherapy [IMRT]) is associated with improved survival for patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) who underwent complete resection. METHODS: The overall survival of patients with stage IIIA-N2 NSCLC who received postoperative IMRT versus no postoperative IMRT following induction chemotherapy and lobectomy in the National Cancer Database from 2010-2018 was assessed via Kaplan-Meier analysis, Cox proportional hazards analysis and propensity score-matched analysis. Additional survival analyses were also conducted in patients with completely resected stage IIIA-pN2 NSCLC who had upfront lobectomy (without induction therapy) followed by adjuvant chemotherapy alone or adjuvant chemotherapy with postoperative IMRT. Only patients receiving IMRT, which is a newer, more conformal radiotherapy technique, were included. Patients with positive surgical margins were excluded. RESULTS: A total of 3203 patients with stage IIA-N2 NSCLC who underwent lobectomy were included. Five hundred eighty-eight (18.4%) patients underwent induction chemotherapy followed by lobectomy, and 2615 (82%) underwent lobectomy followed by chemotherapy. In unadjusted, multivariable-adjusted, and propensity score--matched analyses, there were no significant differences in overall survival between the patients who also received postoperative IMRT versus those who did not. CONCLUSIONS: In this national analysis, the use of postoperative IMRT was not associated with improved survival in patients with completely resected stage IIIA-N2 NSCLC with or without induction chemotherapy.