Improving care in lung cancer surgery: a review of quality measures and evolving standards.

PURPOSE OF REVIEW: Lung cancer is the leading cause of cancer-related death in the United States. Pulmonary resection, in addition to perioperative systemic therapies, is a cornerstone of treatment for operable patients with early-stage and locoregional disease. In recent years, increased emphasis has been placed on surgical quality metrics: specific and evidence-based structural, process, and outcome measures that aim to decrease variation in lung cancer care and improve long term outcomes. These metrics can be divided into potential areas of intervention or improvement in the preoperative, intraoperative, and postoperative phases of care and form the basis of guidelines issued by organizations including the National Cancer Center Network (NCCN) and Society of Thoracic Surgeons (STS). This review focuses on established quality metrics associated with lung cancer surgery with an emphasis on the most recent research and guidelines. RECENT FINDINGS: Over the past 18 months, quality metrics across the peri-operative care period were explored, including optimal invasive mediastinal staging preoperatively, the extent of intraoperative lymphadenectomy, surgical approaches related to minimally invasive resection, and enhanced recovery pathways that facilitate early discharge following pulmonary resection. SUMMARY: Quality metrics in lung cancer surgery is an exciting and important area of research. Adherence to quality metrics has been shown to improve overall survival and guidelines supporting their use allows targeted quality improvement efforts at a local level to facilitate more consistent, less variable oncologic outcomes across centers.

Surgical treatment of lung cancer.

Surgical resection is a principal treatment modality in the early stages of non-small cell lung cancer. The risks of surgical procedures are decreasing due to advancements in surgical techniques. However, optimal treatment strategy in locally advanced stages is unclear. Neoadjuvant immunotherapy could be a future treatment alternative.

Impact of Trainee Involvement on Video-Assisted Thoracoscopic Lobectomy for Cancer.

BACKGROUND: Previous literature in other surgical disciplines regarding the impact of resident and fellow involvement on operative time and outcomes has yielded mixed results. The impact of trainee involvement on minimally invasive thoracic surgery is unknown. This study compared risk-adjusted differences in operative time and outcomes of video-assisted thoracoscopic lobectomy for cancer between cases performed with and without residents and fellows involved. METHODS: All patients undergoing elective video-assisted thoracoscopic lobectomy for cancer between 2008 and 2018 were identified in the Veterans Affairs Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: cases with residents and fellows involved, and cases performed only by attending surgeons. Primary outcomes included operative time, postoperative hospital length of stay, and composite 30-day morbidity and mortality. Secondary outcomes included factors associated with high and low trainee operative autonomy. RESULTS: A total of 3678 patients met study inclusion criteria. In all, 1780 cases were performed with residents and fellows involved (median postgraduate year, 5; interquartile range, 4-7). Multivariate analysis showed that operative time was significantly shorter in resident- and fellow-involved cases compared with attending-only cases (mean [SD], 3.6 [1.4] versus 3.8 [1.6] hours; P < .001). There were no significant differences in composite 30-day morbidity and mortality (16.0% versus 17.1%; adjusted odds ratio = 0.93; 95% confidence interval, 0.77-1.11; P = .40) or length of stay. Substratification of trainees by postgraduate year resulted in similar findings. Cases performed in July through October and those in the Northeastern United States were associated with low autonomy. CONCLUSIONS: Current training paradigms in thoracic surgery are safe, and the involvement of motivated and skilled trainees with appropriate supervision may benefit operative duration.

[Approaches to the pre-operative functional assessment of patients with lung cancer and preoperative rehabilitation]. / Bilan fonctionnel préopératoire du cancer bronchique et réhabilitation préopératoire.

Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.

The Society of Thoracic Surgeons Composite Score Rating for Pulmonary Resection for Lung Cancer.

BACKGROUND: The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) has developed composite quality measures for lobectomy and esophagectomy. This study sought to develop a composite measure including all resections for lung cancer. METHODS: The STS lung cancer composite score is based on 2 outcomes: risk-adjusted mortality and morbidity. GTSD data were included from January 2015 to December 2017. "Star ratings" were created for centers with 30 or more cases by using 95% Bayesian credible intervals. The Bayesian model was performed with and without inclusion of the minimally invasive approach to assess the impact of approach on the composite measure. RESULTS: The study population included 38,461 patients from 256 centers. Overall operative mortality was 1.3% (495 of 38,461). The major complication rate was 7.9% (3045 of 38,461). The median number of nodes examined was 10 (interquartile range, 5 to 16); the median number of nodal stations sampled was 4 (interquartile range, 3 to 5). Positive resection margins were identified in 3.7% (1420 of 38,461). A total of 214 centers with 30 or more cases were assigned star ratings. There were 7 1-star, 194 2-star, and 13 3-star programs; 70.6% of resections were performed through a minimally invasive approach. Inclusion of minimally invasive approach, which was adjusted for in previous models, altered the star ratings for 3% (6 of 214) of the programs. CONCLUSIONS: Participants in the STS GTSD perform lung cancer resection with low morbidity and mortality. Lymph node data suggest that participants are meeting contemporary staging standards. There is wide variability among participants in application of minimally invasive approaches. The study found that risk adjustment for approach altered ratings in 3% of participants.

Evaluation of adherence to the Commission on Cancer lung cancer quality measures.

OBJECTIVE: In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer. METHODS: The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics. RESULTS: Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy. CONCLUSIONS: Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.

Challenging 30-day mortality as a site-specific quality metric in non-small cell lung cancer.

OBJECTIVE: The objective of this project was to assess the best measure for postoperative outcomes by comparing 30-day and 90-day mortality rates after surgery for non-small cell lung cancer using the National Cancer Database. Secondarily, hospital performance was examined at multiple postoperative intervals to assess changes in ranking based on mortality up to 1 year after surgery. METHODS: Patients who had undergone surgery for non-small cell lung cancer between 2004 and 2013 were identified in the National Cancer Database. Mortality rates at 30 days and 90 days were compared after adjusting for several patient characteristics, tumor variables, and hospital procedural volume using generalized logistic mixed models. Subsequently, mixed model logistic regression models were employed to evaluate hospital performance based on calculated mortality at prespecified time points. RESULTS: A total of 303,579 patients with non-small cell lung cancer were included for analysis. The 90-day mortality was almost double the 30-day mortality (3.0% vs 5.7%). Several patient characteristics, tumor features, and hospital volume were significantly associated with mortality at both 30 days and 90 days. Hospital rankings fluctuate appreciably between early mortality time points, which is additional evidence that quality metrics need to be based on later mortality time points. CONCLUSIONS: Thirty-day mortality is the commonly accepted quality measure for thoracic surgeons; however, hospital rankings may be inaccurate if based on this variable alone. Mortality after 90 days appears to be a threshold after which there is less variability in hospital ranking and should be considered as an alternative quality metric in lung cancer surgery.

Defining Proficiency for The Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy.

BACKGROUND: Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. METHODS: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. RESULTS: Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p = 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p = 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. CONCLUSIONS: VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.

Exploring Shared Mental Models of Surgical Teams in Video-Assisted Thoracoscopic Surgery Lobectomy.

BACKGROUND: Nontechnical skills are important for safe and efficient surgery. Teams performing video-assisted thoracoscopic surgery (VATS) lobectomy express that it is of utmost importance to have a shared mental model (SMM) of the patient, current situation, and team resources. However, these SMMs have never been explored in a clinical setting. The aim of this observational study was to measure the similarity of SMMs within teams performing VATS lobectomy. METHODS: In this national, multicenter study, SMMs of teams performing VATS lobectomy (n = 64) were measured by preoperative and postoperative questionnaires that were completed by all team members (n = 172). Participants' responses were compared within each team to explore SMMs of risk assessment, familiarity, technical skills, nontechnical skills, and problems. RESULTS: Analysis showed poor agreement between team members with respect to risk assessment, but higher levels of agreement were found for assessments of familiarity, technical skills, and nontechnical skills within the team (Cronbach's alpha = 0.90), most notably for surgical subteams (ie, surgeon plus assistant surgeon plus surgical nurses). During the surgical procedure, the most frequent problems were related to anesthesia, and these were most often recognized by the surgeons. The operating room nurses were the least aware of each other's and the surgeons' problems. CONCLUSIONS: Significant variation exists in the SMMs among VATS team members, with poor agreement regarding the patient and current situation, but better agreement with respect to team resources. Focus on preoperative and perioperative team reflexivity, in addition to explicit communication within unfamiliar teams, may provide opportunities to enhance SMMs, with possible downstream effects on team performance.

NCCN Guidelines Insights: Small Cell Lung Cancer, Version 2.2018.

The NCCN Guidelines for Small Cell Lung Cancer (SCLC) address all aspects of disease management. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for SCLC regarding immunotherapy, systemic therapy, and radiation therapy. For the 2018 update, new sections were added on "Signs and Symptoms of SCLC" and "Principles of Pathologic Review."

Surgical treatment of pulmonary metastasis in colorectal cancer patients: Current practice and results.

Colorectal cancer (CRC) is a frequently occurring disease, yet diagnosed at a local stage in only 40% of cases. Lung metastases (LM) appear in 5-15% of patients and, left untreated, carry a very poor prognosis. Some CRC patients may benefit from a potentially curative LM resection, but success and benefit are difficult to predict. We discuss prognostic factors of survival after lung metastasectomy in CRC patients under several scenarios (with/ without prior liver metastases; repetitive pulmonary resections). We reviewed all studies (2005-2015) about pulmonary metastases surgical management with curative intent in CRC patients, with a minimum threshold on the number of patients reported (without prior liver metastases: n ≥ 100; with prior resection of liver metastases: n ≥ 50; repetitive thoracic surgery: n ≥ 30). The picture of the prognostic factors of survival is nuanced: surgical management demonstrates clear successes and steady progress, yet there is no single success criterion; stratification of patients and selection bias impact the conclusions. Surgical management of liver and lung metastases may prolong life or cure CRC patients, provided the lesions are fully resected and patients carefully selected. Repeat lung metastasectomy is a safe approach to treat patients in selected cases. In conclusion, there is no standard for surgical management in CRC patients with pulmonary metastases. Patients with isolated unilateral lung metastasis with normal CEA level and no lymph node involvement benefit the most from surgery. Most series report good results in highly selected patients, but instances of long-term disease-free survival remain exceptional.

A novel assessment tool for evaluating competence in video-assisted thoracoscopic surgery lobectomy.

BACKGROUND: Specific assessment tools can accelerate trainees' learning through structured feedback and ensure that trainees attain the knowledge and skills required to practice as competent, independent surgeons (competency-based surgical education). The objective was to develop an assessment tool for video-assisted thoracoscopic surgery (VATS) lobectomy by achieving consensus within an international group of VATS experts. METHOD: The Delphi method was used as a structured process for collecting and distilling knowledge from a group of internationally recognized VATS experts. Opinions were obtained in an iterative process involving answering repeated rounds of questionnaires. Responses to one round were summarized and integrated into the next round of questionnaires until consensus was reached. RESULTS: Thirty-one VATS experts were included and four Delphi rounds were conducted. The response rate for each round were 68.9% (31/45), 100% (31/31), 96.8% (30/31), and 93.3% (28/30) for the final round where consensus was reached. The first Delphi round contained 44 items and the final VATS lobectomy Assessment Tool (VATSAT) comprised eight items with rating anchors: (1) localization of tumor and other pathological tissue, (2) dissection of the hilum and veins, (3) dissection of the arteries, (4) dissection of the bronchus, (5) dissection of lymph nodes, (6) retrieval of lobe in bag, (7) respect for tissue and structures, and (8) technical skills in general. CONCLUSION: A novel and dedicated assessment tool for VATS lobectomy was developed based on VATS experts' consensus. The VATSAT can support the learning of VATS lobectomy by providing structured feedback and help supervisors make the important decision of when trainees have acquired VATS lobectomy competencies for independent performance.

Tailored management of stage IIIa non-small-cell lung cancer in the era of the 8th edition of the TNM classification for lung cancer.

Stage IIIA is a very heterogeneous group encompassing locally advanced disease with T3 and T4 tumors without any nodal involvement and very small T1a primary tumors with unilateral mediastinal lymphatic disease. Tailored management defines interdisciplinary management requiring board decisions, which can sometimes be difficult particularly in stage IIIa non-small-cell lung cancer (NSCLC). Lobectomy still is standard of care even for stage I NSCLC, which increasingly is implemented using minimally invasive surgical technique. On the other hand even locally extended tumors are today safely resected with low morbidity and mortality. According to the 2015 guidelines of the European Society of Thoracic Surgeons any kind of anatomical lung resection for lung cancer with curative intent has to be accompanied by formal mediastinal lymph node dissection. The transcervical route for complete bilateral mediastinal lymphadenectomy offers improved completeness of resection without the need for single lung ventilation and ideally supports the concept of minimally invasive surgery.

2016 Annual report from the Italian VATS Group.

This report highlights the results of the Italian video-assisted thoracoscopic surgery (VATS) Group, launched in mid 2013, which now has a website and an established database with over 4000 VATS lobectomy cases recruited from 67 thoracic surgery units across Italy. The year 2016 has been crucial for the following steps: inclusion of a dedicated biostatistician and a 'Survey Analysis & Data Quality Check'; the First Consensus Meeting with statements consequently adopted as Recommendations for the Italian Thoracic Surgery Society and published in a peer-reviewed journal; two papers published under the logo Italian VATS Group and seven abstracts accepted at annual international meetings (European Society of Thoracic Surgeons, European Association of Cardio-Thoracic Surgeons, European Lung Cancer Conference and European Respiratory Society); the institution of a Master Course on VATS lobectomy; the partnership with AME Publishing Company.

Trends and Outcomes of Thoracoscopic Lobectomy or Segmentectomy: A National Surgical Quality Improvement Project Analysis.

Video-assisted thoracoscopic surgery may be associated with less morbidity than open lobectomy or segmentectomy, but some studies have questioned the benefit of thoracoscopic surgery. This study aimed to determine trends and factors associated with patient's likelihood of undergoing thoracoscopic lobectomy or segmentectomy and to compare outcomes with each approach. This retrospective study included adult patients undergoing pulmonary lobectomy or segmentectomy from the American College of Surgeons National Surgical Quality Improvement Project from 2007 to 2015 (n = 14,717). Logistic regression analysis was conducted to determine the association of patient demographics, clinical characteristics, and surgeon specialty with thoracoscopic lobectomy or segmentectomy. Propensity score matching was performed to evaluate outcomes for thoracoscopic and open lobectomy or segmentectomy. Use of thoracoscopic lobectomy or segmentectomy increased from 11.6% in 2007 to 60.6% in 2015 (P< 0.0001). Older patients, females, and Hispanics were more likely to undergo thoracoscopic lobectomy, whereas morbidly obese patients, patients with higher American Society of Anesthesiology class, and patients with 4-6 frailty conditions had a lower likelihood of receiving thoracoscopic lobectomy or segmentectomy. Thoracic surgeons had 57% (odds ratio 1.57, 95% confidence interval 1.36-1.81) higher odds of performing thoracoscopic surgery than other surgeons. Thoracoscopic lobectomy or segmentectomy reduced risk of 30-day mortality (1.0% vs 1.9%; odds ratio 0.51, 95% confidence interval 0.37-0.70) and resulted in shorter length of stay (4 days vs 6 days; Beta coefficient = -0.37, P < 0.0001), and fewer complications. The frequency of thoracoscopic lobectomy or segmentectomy has increased substantially over the last 10 years and now accounts for over half of lobectomies. Video-assisted thoracoscopic surgery showed better outcomes than open lobectomy or segmentectomy.

Are minimum volume standards appropriate for lung and esophageal surgery?

BACKGROUND: Several medical systems have adopted minimum volume standards for surgical procedures, including lung and esophageal resection. We sought to determine whether these proposed hospital cutoffs are associated with differences in outcomes. METHODS: Analyzing the State Inpatient Databases and Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, we evaluated all patients (aged ≥ 18 years) who underwent lobectomy/pneumonectomy or esophagectomy for cancer in California, Florida, and New York (2009-2011). Hospitals were defined as low volume for each procedure per proposed minimum volume standards by year: <40 lung resections and <20 esophagectomies. We compared demographic data and determined the incidence of complications and mortality between patients operated on at low- versus high-volume hospitals. Propensity matching (of demographic characteristics, income, payer, and comorbidities) was performed to balance the cohorts for analysis. RESULTS: During the time period, 20,138 patients underwent lobectomy/pneumonectomy of which 12,432 operations (61.7%) were performed at low-volume hospitals (n = 456) and 7706 operations were performed at high-volume hospitals (n = 48). Of 1324 patients undergoing esophagectomy, 1087 operations (82.1%) were performed at low-volume hospitals (n = 184), whereas only 237 operations were at high-volume hospitals (n = 6). After propensity matching (lung 1:1 and esophagus 2:1), no major differences were apparent for in-hospital mortality nor major complications for either lung or esophageal resection. Length of stay was longer in low-volume hospitals after lung resection (median 6 vs 5 days; P < .001), but not after esophageal resection. DISCUSSION: Although several groups have publicly called for minimum volume requirements for surgical procedures, the majority of patients undergo lung and esophageal resection at hospitals below the proposed cutoffs. The proposed standards for lung and esophageal resection are not associated with a difference in outcomes in this large administrative database. Efforts should be made to determine more meaningful minimum volume requirements and to determine whether such standards are appropriate.