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F.E. Rugless
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MINI 06 - Quality/Prognosis/Survival (ID 111)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:R. Meguid, J. Yoshida
- Coordinates: 9/07/2015, 16:45 - 18:15, 605+607
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MINI06.04 - Impact of Attainment of the American College of Surgeons Commission on Cancer Quality Measure on Patient Survival After Lung Cancer Resection (ID 2177)
17:00 - 17:05 | Author(s): F.E. Rugless
- Abstract
- Presentation
Background:
Institution-driven survival disparities persist among non-small cell lung cancer (NSCLC) patients who receive curative-intent surgical resection. Recently, the Commission on Cancer (CoC) established an institutional quality surveillance measure: the proportion of resected stage IA–IIB NSCLC with examination of ≥10 lymph nodes. We examined the potential impact of this measure on long-term patient survival.
Methods:
We analyzed all stage IA-IIB NSCLC resections in the Mid-South Quality of Surgical Resection cohort, a patient-level database of all lung cancer resections performed in 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, Northern Mississippi, and Western Tennessee from 2004-2013. We recorded pathologic staging details. Patients receiving pre-operative therapy were excluded. A trend analysis of quality and survival disparities was performed based on a Cox proportional hazard model, adjusted for age and pathologic stage.
Results:
Of 1,877 eligible patients, 77% were stage I and 23% stage II. The median number of lymph nodes retrieved during surgery was 6 (interquartile range [IQR]: 3-10). The CoC quality measure was achieved in 27.8% of cases. Conversely, 11% of resections had no lymph nodes examined (pNX). The proportion of cases meeting the CoC criteria increased from 18.8% in 2004 to 50% in 2013 (p<0.001). Large variations among institutions existed, ranging from 14% to 55% of institutional cases meeting the CoC measure. Compared to pNX resections, resections with at least one lymph node examined yielded some survival benefit (Hazard ratio (HR): 0.71, 95%CI: 0.54-0.93, p=0.014). Likewise, Patients with 10-12 lymph nodes examined had 43% overall survival benefit (HR: 0.57, 95%CI: 0.40-0.81, p=0.002), but survival did not significantly improve compared with 4-6 (the median) lymph nodes harvested (p=0.48). However, the survival benefit improved as more lymph nodes were examined, reaching an optimal point of a 72% benefit when 19-21 lymph nodes were harvested (HR: 0.28, 95%CI: 0.11-0.68, p=0.005). Compared with 4-6 lymph nodes, the survival benefit was 17% (p=0.06) (Figure 1). Furthermore, for those with any mediastinal lymph nodes sampled during the surgery, the survival benefit was 17% (HR: 0.82, 95%CI: 0.71-0.96, p=0.015). Figure 1
Conclusion:
Only 28% of NSCLC resections achieved the CoC measure, with large variations among institutions, but the overall rate of attainment has increased over time. Compared with no lymph nodes examined, meeting the CoC criteria provided a 43% overall survival benefit. However, more stringent measures, such as examining 20 lymph nodes (72%) or requiring mediastinal lymph node examination (17%), will have even greater survival impact.
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ORAL 08 - Smoking Cessation, Tobacco Control and Lung Cancer (ID 94)
- Event: WCLC 2015
- Type: Oral Session
- Track: Prevention and Tobacco Control
- Presentations: 1
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ORAL08.02 - Interest in Smoking Cessation Treatment among Patients in a Community-Based Multidisciplinary Thoracic Oncology Program (ID 2886)
10:56 - 11:07 | Author(s): F.E. Rugless
- Abstract
- Presentation
Background:
Cigarette smoking is the major cause of lung cancer. Many adults smoke at the time of a lung cancer diagnosis and continue to smoke during treatment although doing so adversely affects treatment response, quality of life, and survival time. While authoritative bodies recommend that tobacco use be addressed in lung cancer care, few patients receive effective treatment. The coordinated multidisciplinary model of care delivery, in which patients, their caregivers, and key specialists concurrently develop evidence-based care, offers an ideal setting to integrate high quality cessation treatment. To assess the need for and acceptability of cessation services, we surveyed patients about their smoking status, interest in quitting, and willingness to participate in a clinic-based cessation program.
Methods:
The study was conducted in the Multidisciplinary Thoracic Oncology Program at Baptist Cancer Center, Memphis TN. One-hundred eight consecutive new patients, seen between 7/31/13 and 9/24/14, completed a social history questionnaire. From this history, we extracted data related to sociodemographic characteristics (age, gender, race, marital status), smoking status, age of smoking initiation, and tobacco dependence (using the Heaviness of Smoking Index, consisting of cigarettes smoked per day and time of first cigarette of the day). Current smokers reported their level of interest in quitting, and how likely they would be to participate in a cessation program (‘I would not participate’; ‘I might participate but am not sure’; ‘I would participate’). Chi square tests were used to compare characteristics of those who would participate in the stop-smoking program vs. those who would not or were unsure whether they would participate.
Results:
Average age of patients was 65 years (range: 29-91), 41% were men, 58% were white, 39% black, and 15% had graduated college. Patients’ cancer stage broke down to stage I (16%), stage II (9%), stage III (18%), stage IV (28%), and undetermined (29%). 84% of patients had ever smoked cigarettes, 35% currently smoked, and 11% had quit smoking within the past year. Among current smokers, 71% (n=27) were “very interested” in quitting smoking in the next month and of these, 74% reported that they would be willing to participate in a smoking cessation program in the clinic. Willingness to participate in a cessation program was associated with greater interest in quitting (χ[2][1]= 13.3, p=.0003), but was not associated with sociodemographic characteristics, cancer stage, or smoking-related characteristics (amount smoked, age at smoking initiation, or dependence).
Conclusion:
Nearly half (46%) of patients in a community-based multidisciplinary thoracic oncology program were current cigarette smokers or had quit within the previous year, indicating a considerable need for cessation and relapse-prevention support. Encouragingly, a majority of current smokers were highly motivated to make a quit attempt in the next month, and most indicated that they would take advantage of a clinic-based cessation program. Willingness to participate in a cessation program was similar across a broad range of sociodemographic, cancer stage, and nicotine dependence levels. There is considerable need for, and interest in, smoking cessation services in the setting of community-based multidisciplinary lung cancer care.
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ORAL 27 - Care (ID 123)
- Event: WCLC 2015
- Type: Oral Session
- Track: Advocacy
- Presentations: 1
- Moderators:M.N. Mountain, J. Freeman-Daily
- Coordinates: 9/08/2015, 10:45 - 12:15, 708+710+712
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ORAL27.01 - Bridging the Quality Chasm in Lung Cancer Care: Stakeholder Perspectives on Multidisciplinary Care in a Community Hospital Setting (ID 848)
10:45 - 10:56 | Author(s): F.E. Rugless
- Abstract
- Presentation
Background:
The prevailing patient care model for lung cancer involves serial referrals among multiple clinical specialists. This practice may cause delays in diagnosis and treatment, patient/caregiver confusion and anxiety, poor communication among physicians, and diminished opportunities for patients to receive evidence-based care. The multidisciplinary care model may rectify these problems with the serial model, and thereby improve the quality and outcomes of care. However, the value of the multidisciplinary care model has not been objectively established. We collected the perspectives of key stakeholders on the 2 models of care. We sought to: examine the perceived strengths and weaknesses of each model; uncover potential barriers to establishing an effective multidisciplinary care program; and establish meaningful benchmarks with which to measure care delivery in both models. This work preceded a prospective comparative effectiveness study of the 2 models of care.
Methods:
We conducted 21 focus groups, involving 106 subjects (22 patients, 24 caregivers, 9 nurses, 8 hospital administrators, 4 executives of health insurance companies, and 39 physicians). The physicians included groups of medical and radiation oncologists, hospitalists, pulmonologists, thoracic surgeons, and primary care physicians. Patients had received care for a confirmed or suspected lung cancer in the Baptist Memorial Health Care System within the preceding 6 months. Disease stage ranged from early, with curative-intent treatment, to advanced-stage with palliative-intent care. Providers may or may not have had personal experience of the multidisciplinary model. We used verbatim transcripts of the audio recordings and field notes to analyze the content of each focus group session using Dedoose Software. We identified recurring themes and variants within and across the various stakeholder groups.
Results:
Several overlapping themes emerged. There was a perception that the multidisciplinary care improved physician collaboration, care coordination, accuracy of diagnosis, concordance with treatment recommendations, timeliness of care, efficiency of care-delivery, and patient satisfaction. Potential obstacles to successful implementation of the multidisciplinary care model included problems with physician reimbursement, the duration of the patient-physician interaction, and acceptability/integration of the model within the current health care infrastructure. These concerns were especially prevalent among physicians. Overcoming these barriers would require physician and patient education, efficient use of electronic medical records, and improving general awareness about the multidisciplinary care model. Identified evaluative benchmarks included measures of patient/caregiver experience and satisfaction, survival rates, timeliness of care, the quality of patient-physician communication, consistency of recommendations among physicians, and the adequacy of consultation times.
Conclusion:
The stakeholders in lung cancer care had broadly overlapping beliefs about optimal care delivery for lung cancer. However, they also had different expectations, and motivations. These competing factors have the potential to influence perceptions about the quality, efficiency, and effectiveness of lung cancer care delivery. Patients, caregivers, clinicians, administrators, and third-party payers were in favor of the multidisciplinary model for lung cancer care. However, key barriers must be addressed for optimal implementation. Meaningful stakeholder input is essential to improving the quality of lung cancer care.
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ORAL 34 - Quality/Survival/Prognosis in Localized Lung Cancer (ID 153)
- Event: WCLC 2015
- Type: Oral Session
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 2
- Moderators:B.C. Cho, R.L. Keith
- Coordinates: 9/09/2015, 16:45 - 18:15, 201+203
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ORAL34.02 - Impact of Attainment of National Comprehensive Cancer Network (NCCN) Quality Parameters on Patient Survival after Resection of Lung Cancer (ID 2190)
16:56 - 17:07 | Author(s): F.E. Rugless
- Abstract
- Presentation
Background:
The NCCN surgical resection guidelines for non-small cell lung cancer (NSCLC) recommend lobectomy or greater extent of resection, negative margins, and examination of lymph nodes from the hilum, and 3 or more mediastinal stations. We sought to determine the impact of these guidelines on patients’ long-term survival.
Methods:
We conducted a retrospective review of patient-level data from all curative-intent NSCLC resections at 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, North Mississippi, and Western Tennessee from 2004 to 2013. Following a descriptive analysis of the cohort, we used a Cox proportional hazard model to assess the overall survival impact of attaining the NCCN guidelines. All models were adjusted for patient age and pathologic stage.
Results:
Of the 2,410 eligible resections, 314 (13.1%) were sub-lobar, 86.9% were lobectomy or greater; 90.2% had negative margins, 5.8% had positive margins, 4% unknown margin status; 73.2% had hilar nodes sampled; but only 25.9% of surgeries had three or more mediastinal nodal stations sampled. Overall, although only 18% of surgeries met all four criteria, there was a significant increasing trend from 4% in 2004 and 12% in 2009, to 39% in 2013 (p<0.001). Patients whose surgery met all four criteria had a 23% survival benefit compared with those who did not (Hazard Ratio [HR]: 0.77, 95%CI: 0.64-0.94, p=0.009). Patients with negative margins had 15% survival benefit compared to those with positive margins (HR: 0.85, 95%CI: 0.66-1.08, p=0.18); those with lobectomy or greater resection had a 14% survival benefit over those with sub-lobar resection (HR: 0.86, 95%CI: 0.70-1.04, p=0.12); those with hilar node sampling had a 3% survival benefit (HR: 0.97, 95%CI: 0.83-1.13, p=0.68); and those with three or more mediastinal stations examined had a 17% survival benefit over those without (HR: 0.84, 95%CI: 0.71-0.98, p=0.03). Figure 1
Conclusion:
Although only 18% of NSCLC resections in this cohort from a high lung cancer mortality region of the US met all four NCCN good-quality surgical resection criteria, the rate of quality attainment has significantly increased during the past decade. Patients whose resections met NCCN quality criteria had a substantially survival benefit, which is particularly driven by the recommendation for sampling of ≥3 mediastinal nodal stations. Intraoperative mediastinal lymph node retrieval should be a focus of quality improvement for NSCLC resections.
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ORAL34.06 - Impact of Surgeons' Attainment of Quality Resection Parameters on Non-Small-Cell Lung Cancer (NSCLC) Patients' Survival (ID 2189)
17:39 - 17:50 | Author(s): F.E. Rugless
- Abstract
- Presentation
Background:
The 60,000 patients who annually undergo curative-intent resection for lung cancer in the US constitute the vast majority of long-term NSCLC survivors. However, >50% of patients die within 5 years after curative-intent resection. We sought to directly measure the effect of variability in surgeon practice on patients’ survival.
Methods:
We collected patient-level data from all NSCLC resections performed in 8 mid-south hospitals from 2009 to 2013. Recipients of preoperative adjuvant therapy were ineligible. We grouped surgeons by their resection proportions for pneumonectomy and wedge resection, resections with positive margins, and resections without mediastinal lymph nodes. We assigned scores of 1 = <5%, 2 = 5-15%, and 3 = ≥ 15% for pneumonectomy and wedge resection rates; 1 = <5%, 2 = 5-10%, and 3 = ≥ 10% for resections with positive margins; 1 = < 10%, 2 = 10-50%, and 3 = ≥ 50% for resections without mediastinal lymph node examination. The individual scores were then combined for an aggregate surgeon score. Surgeons were then grouped into three tiers: 1 =≤6, 2 = 7-8, and 3 = ≥9. A survival analysis was conducted for patients aggregated by surgeon score tier, adjusted for patient race, gender, and age at surgery, pathologic stage, and surgeon’s case-volume.
Results:
1,339 resections were performed by 39 surgeons: 17 surgeons (43.6%) in tier 1(aggregate score ≤ 6) operated on 623 patients (44.5%); 14 surgeons (35.9%) in tier 2 operated on 669 patients (47.8%); and 8 surgeons (25.5%) in tier 3 operated on 107 patients (7.65%). Figure 1 plots the Kaplan – Meier survival curve for patients in each surgeon tier. Tiers 2 and 3 patients had significantly higher hazard rates than tier 1 patients, with Hazard Ratio (HR)=1.76, 95%CI: 1.17, 2.64, p=.007 and HR=1.39, 95%CI: 1.11, 1.75, p=.004, respectively. Hazard rates between patients in surgeon tiers 3 and 2 were not significantly different, HR=1.26, 95%CI: 0.87, 1.82, p=.221. Figure 1
Conclusion:
We have developed a simple method of measuring the effect of variability in surgeon practice on patient outcomes. Patients who had resection by surgeons with lower rates of pneumonectomy and wedge resections, positive margins, and non-examination of mediastinal lymph nodes show improved survival over patients operated by surgeons with higher rates. Deficiency in attaining these quality parameters can be corrected at the individual surgeon level. Surgeon-level corrective interventions are warranted.
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P1.10 - Poster Session/ Advocacy (ID 228)
- Event: WCLC 2015
- Type: Poster
- Track: Advocacy
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.10-002 - Lung Cancer Patients' Perspectives on Multi-Disciplinary Care in a Community Setting (ID 2183)
09:30 - 09:30 | Author(s): F.E. Rugless
- Abstract
Background:
Lung cancer causes 27% of all cancer deaths in the United States, with very modest improvement in patient survival in the past 30 years. In addition to cancer biology, adverse patient factors such as cumulative age- and tobacco-related co-morbidities, and care-delivery factors such as the need for multiple physician involvement, contribute to the paucity of progress. The standard serial model of care, involving sequential referrals to specific care providers, if not carefully coordinated, may delay care and enable discordance between patient needs and provider priorities. The multidisciplinary model, widely touted as potentially superior, has never been rigorously evaluated. Leading up to a comparative effectiveness study of the serial and multidisciplinary care models, we closely examined patient experiences with lung cancer care delivery.
Methods:
We conducted a qualitative study, in 5 focus groups of 22 patients (10 males/12 females; 15 White/7 Black) receiving care within the previous 6 months for confirmed or suspected lung cancer at a community-based hospital, the Baptist Memorial Health Care System. Stage distribution was: 6 stage I lung cancer, 2 stage II, 3 stage III, 3 stage IV, 5 undetermined; 3 patients had a non-lung primary malignant lung lesion. A standardized script was used to ensure consistency of questions across all focus groups. Saturation of emergent themes determined the number of focus groups conducted. We used verbatim transcripts and field notes to analyze the content of each focus group, and Dedoose Software to identify recurring themes and variants.
Results:
Patients perceived that the multidisciplinary care approach enabled more timely care-delivery, better physical collaboration, improved patient-physician communication, and reduced redundant testing. Use of a nurse navigator in this model also helped decrease confusion, stress, and anxiety associated with care-coordination. There was a perception of the multidisciplinary model as providing a ‘one-stop shop’, a central point of contact that reduces the amount of travel and coordination required between multiple specialists. Among those patients who had prior encounters with serial care, some had experienced insensitive disclosure of diagnosis, poor physician communication, redundant testing, delays in diagnosis and treatment, misdiagnosis, and mistreatment. Patients involved in serial care were also more likely to seek a second opinion after initial diagnosis. The multidisciplinary care model was believed to provide multiple opinions in one visit.
Conclusion:
Lung cancer patients strongly preferred the multidisciplinary model of care, perceiving it to be more patient-centered and efficient than serial care. These data provide useful information on important patient-centered benchmarks that should be incorporated into rigorous comparisons of the effectiveness of these two care delivery models. Additional work is needed to examine barriers to program development through meaningful input from other key stakeholders, such as healthcare providers, institutional administrators, third party payers, and healthcare policymakers.
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P1.12 - Poster Session/ Community Practice (ID 232)
- Event: WCLC 2015
- Type: Poster
- Track: Community Practice
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.12-001 - Trends in Accuracy and Comprehensiveness of Pathology Reports of Resected Non-Small Cell Lung Cancer (NSCLC) in a High Mortality Area of the US (ID 1571)
09:30 - 09:30 | Author(s): F.E. Rugless
- Abstract
Background:
Pathologic examination of NSCLC resection specimens is vital to optimal treatment. In 2004, the College of American Pathologists (CAP) issued guidelines for NSCLC reporting, which were most recently updated in 2013. We evaluated the adoption of CAP reporting elements in a regional database.
Methods:
The Mid-South Quality of Surgical Resection (MS-QSR) database includes detailed information on 2,593 NSCLC resections in 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, North Mississippi and Western Tennessee from 2009-2014. In 2009, we started a multifaceted educational intervention: 1. Analyzed 2004-2008 pathology reports demonstrating the quality deficit in pathology reporting. 2. Recommended adoption of synoptic reporting of CAP checklist items. 3. Embedded a surgical intervention to improve mediastinal lymph node examination at some institutions. To allow for comparisons between eras and across the post-intervention era by intervention and type of hospital, we evaluated 4 groups: pre-intervention (pre-int), post-intervention participating hospital with surgical intervention (post-int/surg), post-intervention participating hospital without surgical intervention (post-int/non-surg), and non-participating non-surgical intervention hospital (post-int/non-part). We evaluated the inclusion of each CAP checklist item and the percent of cases with all items and 6 key items reported. We also evaluated the accuracy of T and N-stage categorization. Proportions reporting each item were compared between groups using Fisher’s Exact test.
Results:
Details of the completeness of pathology reporting are shown in Table 1 by group. The percent reporting the 6 key checklist items improved significantly from 63% pre-int to 76% post-int/non-part, 86% post-int/non-surg, and 95% post-int/surg (p-value<0.0001). A similar pattern of improvement was observed for N-stage (p-value<0.0001) and T-stage (p-value<0.0001) reporting. However, we observed significant decreases in the reporting of M-stage, and therefore all key items, post-intervention (p-value<0.0001). The accuracy of N-stage reporting improved significantly from 66% pre-int to 72% post-int/non-part, 86% post-int/non-surg, and 97% post-int/surg (p-value<0.0001). A similar trend was observed for T-stage accuracy (p-Value<0.0001).%Reporting Pre-Int (N=1390) Post-Int/ Non-Part (N=271) Post-Int/ No-Surg (N=645) Post-Int/ With-Surg (N=310) P-Value Specimen* 98.4 100 100 100 <0.0001 TumorSize* 97.2 99.6 98.1 99.4 0.0094 Histology* 99.8 99.6 99.5 99.7 0.59 MarginStatus* 97.1 98.5 92.6 98.7 <0.0001 T-Stage* 67.8 76.4 92.1 97.1 <0.0001 N-Stage* 66.3 76.8 89.8 97.7 <0.0001 *All Key-Items 62.7 75.7 85.7 94.8 <0.0001 Laterality 99.8 100 99.5 100 0.56 HistologicGrade 99.9 100 99.5 100 0.18 M-Stage 75.8 31.4 25 21.6 <0.0001 VascularInvasion 28.6 10.7 25 11.9 <0.0001 All Items 10.7 4.1 6.2 3.2 <0.0001 %Accurate N-Stage 66.2 71.6 86.2 96.8 <0.0001 T-Stage 55.3 61.6 83 84.8 <0.0001
Conclusion:
There was significant improvement in reporting of CAP checklist items and the accuracy of pT- and pN-categorization. After the introduction of synoptic reporting, we observed a secular trend of improvement, shown by our post-int/non-part external control. Direct educational intervention in 2009-2010 further improved the completeness and accuracy of reports in participating hospitals. The surgical intervention provided additional benefit. Interventions to improve the quality of reporting for NSCLC are impactful on accuracy and thoroughness of reporting, thereby improving the quality of care.
