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R.U. Osarogiagbon



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    ED 09 - Tissue Is the Issue: Improving Diagnostic Yield in the Age of Minimally Invasive Procedures (ID 9)

    • Event: WCLC 2015
    • Type: Education Session
    • Track: Community Practice
    • Presentations: 1
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      ED09.02 - Difficulties Coordinating Care (ID 1807)

      14:40 - 15:00  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation

      Abstract:
      With 1.6 million new diagnoses and 1.4 million annual deaths worldwide, 230,000 annual cases and 160,000 deaths in the US, lung cancer is the oncologic scourge of the present age. It accounts for 23% of worldwide, and 28% of US, cancer deaths.1 Four decades of advances in diagnostic and treatment modalities, including the current ‘molecular’ decade of rapid-fire discovery of breakthrough therapeutics, have seen aggregate US 5-year survival improve from 12% to 17%.2 Although the deployment of effective population-based tobacco cessation and lung cancer screening programs can change these statistics, there remains the danger of blunted impact because of relatively little progress in the coordination of care, and major deficits in the use of curative-intent therapy. Lung cancer care is complicated. The disease is common and lethal; the primary at-risk population is ravaged by cumulative age- and tobacco-related comorbidities; the lungs and mediastinum are relatively inaccessible; multiple approaches and techniques for diagnosis, staging, and treatment exist, each requires different, highly-trained specialists (radiologists, pulmonologists, surgeons, medical oncologists, radiation oncologists, pathologists, palliative care specialists), using high-cost equipment, to perform high-risk procedures, any one of which may or may not be needed for specific patients. Determining which specific specialists and management approaches are needed for individual patients requires objective evaluation and careful coordination, in order to tailor management to patient needs. Prevailing nihilism about lung cancer care further complicates matters: ‘statistics suggest the patient will die anyway, so what’s the point?’, ‘he brought this on himself by smoking, whose problem is this?’ Care delivery must be better coordinated before we can achieve meaningful improvement in population-level survival statistics. All lung cancer care begins with an abnormal chest x-ray or CT scan. From then, it flows through certain ‘nodal points’: histologic confirmation, radiologic staging, histologic staging, selection of treatment, and (ultimately) outcomes. Each nodal point includes a myriad of options. Diagnosis is usually made by percutaneous (interventional radiologist), bronchoscopic (pulmonologist), or surgical (thoracic surgeon) biopsy ; radiologic staging often involves a PET/CT scan (nuclear radiologist), and brain MRI scan (neuro-radiologist); histologic staging requires an invasive biopsy procedure, which can be transbronchial needle biopsy during conventional bronchoscopy, endobronchial ultrasound-guided (EBUS) biopsy (pulmonologist), endoscopic ultrasound-guided (EUS) biopsy (gastroenterologist), percutaneous image-guided biopsy of a distant stage-defining lesion (interventional radiologist), mediastinoscopy, or other approaches to various parts of the mediastinum (surgeon). Treatment increasingly requires combinations of surgery, radiation therapy, chemotherapy and palliative care. Therefore lung cancer care demands a high degree of coordination. Major, well-described geographic, socio-economic, racial, and age-based disparities in diagnosis, staging, treatment, and outcomes suggest that healthcare systems fail to provide the required level of care coordination. The proportion of patients who make it to surgery, the most important curative treatment modality, varies from 9% in the UK, to 29% in the US.3 Use of invasive staging tests and surgical resection is significantly lower in African Americans than in Caucasians.4,5 Elderly patients are less likely to receive chemotherapy than younger patients.6 Although partly driven by patient choice, improvement in care coordination narrows or eliminates most disparities.7,8 Beyond disparities, access to high-quality care is generally low. ‘Trimodality’ staging (CT, PET/CT scan and invasive staging in combination) although associated with a 2-fold survival improvement was used in only 5% of US patients.9 In a high lung cancer mortality zone of the US, only 17% of curative-intent resections were preceded by invasive staging, including only one-third of patients with clinical N1, N2 or N3 disease (Osarogiagbon, unpublished data). Low rate of histologic confirmation of stage-defining lesions raises the danger of overuse and underuse of treatment modalities. At the extremes are primary surgical resection for patients with clinically evident mediastinal nodal disease, and palliative systemic chemotherapy for patients with false-positive radiologic staging tests or multiple primary cancers erroneously classified as stage IV. Avoiding misuse of diagnostic and staging modalities is equally difficult. The need to recognize and correctly act on non-diagnostic, false-negative and false-positive test results is great. Lung cancer care is often delayed when insufficient-quality diagnostic material or sampling error leads to erroneous reassurance that a high-risk radiologic lesion is benign. The problem is even greater in the use of invasive staging tests. More than half of US mediastinoscopy procedures fail to deliver lymph node tissue for pathology examination.10 This dismal statistic is probably worse with EBUS and EUS. The need for high-quality tissue rises as prognostic and response-predictive implications steadily increase our need for clear histologic categorization (and sub –categorization), and with the advent of molecular prognostication and treatment selection. The demand for high-quality tissue spans the stage spectrum. Therapeutic clinical trials now routinely demand tissue for molecular testing, surgical resection trials increasingly mandate a minimum quality of nodal staging. Patients’ eligibility for clinical trials and our ability to accelerate testing and deployment of novel treatments increasingly hinge on tissue procurement. Pathologists and interventionists who procure tissue must work collaboratively to increase tissue yield for the numerous purposes of treating clinicians. This must be achieved while maintaining patient safety and convenience. The countervailing forces of increasing adoption of minimally invasive diagnostic, staging and treatment modalities and ravenous hunger for high-quality tissue for prognostication and treatment selection collide within individual patients and healthcare systems. Only better coordination, involving all relevant clinicians in early strategic decision-making for each individual patient can prevent the delays, anxieties, exposure to harm, missed opportunity for better treatment outcomes, and looming medico-legal risk that the status quo in lung cancer care represents. Rising survival rates will only increase this conflict, as the need for re-characterization of disease rises, and lung cancer care evolves from a game of checkers to a chess match. REFERENCES 1. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69-90. 2. http://seer.cancer.gov/statfacts/html/lungb.html. Accessed May 28, 2015. 3. Moghissi K, Connolly CK. Resection rates in lung cancer patients. Eur Respir J 1996;9:5-6. 4. Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med 1999;341:1198-205. 5. Lathan CS, Neville BA, Earle CC. The effect of race on invasive staging and surgery in non-small-cell lung cancer. J Clin Oncol 2006;24:413-418. 6. Earle CC, Venditti LN, Neumann PJ, et al. Who gets chemotherapy for metastatic lung cancer? CHEST 2000;117;1239-1246. 7. Laroche C, Wells F, Coulden R, et al. Improving surgical resection rate in lung cancer. Thorax 1998;53:445-449. 8. Brawley OW. Lung cancer and race: equal treatment yields equal outcome among equal patients, but there is no equal treatment. J Clin Oncol 2006;24:332-333. 9. Farjah F, Flum DR, Ramsey SD, et al. Multi-modality mediastinal staging for lung cancer among Medicare beneficiaries. J Thorac Oncol 2009;4:355-363. 10. Little AG, Rusch VW, Bonner JA, et al. Patterns of surgical care of lung cancer patients. Ann Thorac Surg 2005;80:2051-6.

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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
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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): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      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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    MINI 20 - Surgery (ID 137)

    • Event: WCLC 2015
    • Type: Mini Oral
    • Track: Treatment of Locoregional Disease – NSCLC
    • Presentations: 2
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      MINI20.02 - Risk-Adjusted Margin Positivity (RAMP) Rate as a Surgical Quality Metric for Non-Small-Cell Lung Cancer in the US National Cancer Data Base (NCDB) (ID 1247)

      16:50 - 16:55  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      Background:
      Surgical resection is the most important curative treatment modality for early-stage non-small-cell lung cancer (NSCLC). However, incomplete (margin-positive) resection is associated with inferior survival. We sought to develop a valid facility-based quality metric to measure surgical quality, adjusting related patient demographic and clinical characteristics.

      Methods:
      We identified facilities that performed cancer-directed surgery for patients diagnosed with AJCC stage I-IIIA NSCLC in the NCDB between 2004 and 2011. We used a multivariate logistic regression model, adjusting for patient risk-mix in each facility, to predict the expected number of risk-adjusted margin positivity (RAMP) cases for each facility. We divided the number of observed margin positivity (OMP) cases by the expected number of RAMP cases to obtain an observed: expected (O/E) ratio for each facility. We categorized facility performance as low outlier (O/E ratio<1 and p<.05), high outlier (O/E ratio>1 and p<.05), or non-outlier. Facility characteristics across performance categories were compared by chi-square test. Five-year unadjusted overall survival (OS) rates were estimated by Kaplan-Meier analyses and compared across categories with the log-rank test.

      Results:
      A total of 96,596 NSCLC stage I-IIIA patients underwent surgery in 941 facilities. The overall OMP rate was 4.6%. We identified 73 facilities as low outliers (mean O/E ratio=0.41), 755 as non-outliers (mean O/E ratio=1.28) and 113 as high outliers (mean O/E ratio=2.78). Compared to patients treated at high-outlier facilities, patients treated at low-outliers were more likely to be privately insured (34.7%[Low] vs. 32.9%[High]), reside in high-income neighborhoods, have no comorbidity (51.7% [Low] vs. 41.9 [High], p<.001), have adenocarcinoma (62.4%[Low] vs. 58.1%[High], p<.001), stage IA disease (41.6%[Low] vs. 39.6%[High], p<.001) and receive sub-lobectomy (11.7%[Low] vs. 9.9%[High], p<.001). Low-outlier facilities were more likely to be teaching/research or NCI-designated programs (54.8% [Low] vs. 18.5% [High], p<.001) and in the highest quartile of total cancer surgical volume (90.4% [Low] vs. 34.5% [High], p<.001) and lung cancer surgery volume (42.5% [Low] vs. 29.2% [High], p<.001) (Table 1). They also had smaller proportions of uninsured/Medicaid patients (45.2% [Low] vs. 36.2% [High], p=.006). The 5-year unadjusted OS estimates were: 0.62 (low-outliers), 0.58 (non-outliers), 0.57 (high-outliers); log-rank p<.001. Table 1. Facility characteristics across performance categories

      High-Outlier(N=113) Non-Outlier(N=755) Low-Outlier(N=73) p-value
      N(%)
      Census_region
      Northeast 18(15.9) 154(20.4) 19(26.0) 0.03
      Midwest 39(34.5) 223(29.5) 15(20.6)
      South 37(32.7) 257(34.0) 35(48.0)
      West 19(16.8) 121(16.0) 4(5.5)
      Facility_type
      Community_Cancer_Program 23(20.4) 164(21.7) 0(0.0) <0.001
      Comprehensive_Community_Cancer_Program 62(54.9) 419(55.5) 28(38.4)
      Teaching/Research 17(15.0) 128(17.0) 28(38.4)
      NCI_program 4(3.5) 17(2.3) 12(16.4)
      Other 7(6.2) 27(3.6) 5(6.9)
      Proportion_of_Medicaid/uninsure_patients
      Q1(low) 25(22.1) 206(27.3) 13(17.8) 0.006
      Q2 16(14.2) 204(27.0) 20(27.4)
      Q3 41(36.3) 174(23.1) 21(28.8)
      Q4(high) 31(27.4) 171(22.7) 19(26.0)
      Lung_cancer_surgery_as_a_proportion of_all_surgery
      Q1(low) 8(7.1) 73(9.7) 0(0.0) <0.001
      Q2 37(32.7) 224(29.7) 9(12.3)
      Q3 35(31.0) 226(29.9) 33(45.2)
      Q4(high) 33(29.2) 232(30.7) 31(42.5)
      Total_cancer_surgery_volume
      Q1(low) 12(10.6) 98(13.0) 0(0.0) <0.001
      Q2 32(28.3) 193(25.6) 0(0.0)
      Q3 30(26.6) 253(33.5) 7(9.6)
      Q4(high) 39(34.5) 211(28.0) 66(90.4)


      Conclusion:
      Facility performance in lung cancer surgery can be captured by using the RAMP rate. Low-outlier facilities delivered superior OS than high-outliers. RAMP metrics could allow facilities to understand their performance and serve as a quality improvement benchmark.

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      MINI20.03 - The Survival Impact of Missed Lymph Node Metastasis in Surgically Resected Non-Small Cell Lung Cancer (NSCLC) (ID 2204)

      16:55 - 17:00  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      Background:
      Lymph node (LN) metastasis is an important prognostic factor for patients with surgically resected NSCLC. We have previously described the extent of missed N1 LN metastasis in a cohort of patients treated at metropolitan institutions. With long-term follow up, we now quantify the survival impact of missed LN metastasis.

      Methods:
      We conducted a prospective cohort study to retrieve intrapulmonary LNs from discarded NSCLC resection specimens after completion of routine pathology examination. Retrieved materials were histologically examined and classified as LNs with and without metastasis. Survival information was retrieved from institutional tumor registries. Survival distributions were plotted using the Kaplan-Meier method and evaluated with proportional hazards models controlling for gender, race, pathologic N-category, tumor size, margin status, and Charlson score.

      Results:
      We evaluated 111 patients who were 47% male with a median age of 66 years. Clinical characteristics are summarized in Table 1. Discarded LNs with metastasis were found after re-dissection in 25 (23%) patients. Patients with discarded LN metastasis had an increased risk of death (Figure 1) with an unadjusted hazard ratio (HR) of 2.0 (p-value=0.06) and an adjusted HR of 1.8 (p-value=0.23) compared to those with no discarded LNs with metastasis. When >2 discarded LNs with metastasis were found, patients had 4.8 (p-value=0.0002) times the hazard of death compared to those with no discarded LNs with metastasis (adjusted HR=4.4, p-value=0.0032).

      N(%) No LN Metastasis LN Metastasis Total
      Bi-lobectomy 8 2 10
      9% 8%
      Lobectomy 75 16 91
      87% 64%
      Pneumonectomy 3 7 10
      3% 28%
      N0 71 6 77
      83% 24%
      N1 6 12 18
      7% 48%
      N2 9 7 16
      10% 28%
      T1 45 3 48
      52% 12%
      T2 29 11 40
      34% 44%
      T3 10 8 18
      12% 32%
      T4 2 2 4
      2% 8%
      Margin Negative 83 22 105
      97% 88%
      Margin Positive 3 3 6
      3% 12%
      Mean(SD)
      Charlson Score 1.8 1.8 1.8
      1.6 1.7 1.6
      Tumor Size(cm) 3.2 5.0 3.6
      1.8 2.1 2.0
      Figure 1



      Conclusion:
      The presence of metastasis in inadvertently discarded LNs in NSCLC resection specimens has significant implications for patients’ post-operative clinical course. Additional LN metastasis found on re-dissection was associated with reduced survival. A more rigorous protocol for gross dissection of lung resection specimens is needed, and should prove beneficial to patients’ long-term survival.

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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): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      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 20 - Chemoradiotherapy (ID 124)

    • Event: WCLC 2015
    • Type: Oral Session
    • Track: Treatment of Locoregional Disease – NSCLC
    • Presentations: 1
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      ORAL20.07 - Survival Impact of Post-Operative Therapy Modalities after Incomplete and Complete Surgical Resection for Non-Small Cell Lung Cancer in the US (ID 1417)

      11:39 - 11:50  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      Background:
      Incomplete resection of potentially curable Non-Small Cell Lung Cancer (NSCLC) is a significantly negative clinical event for which adjuvant radiotherapy, chemotherapy, or combined chemo-radiotherapy is often used to reduce mortality risk. After complete (R0) resection, randomized controlled trials and the PORT meta-analysis show radiotherapy to be harmful to patients with stage I-II disease, and of marginal benefit in patients with N2-positive stage IIIA. After incomplete resection (R1/R2), current National Comprehensive Cancer Network (NCCN) guidelines recommend radiotherapy for stage IA/IB and chemo-radiotherapy for patients with stage IIA-IIIA. Adjuvant therapy recommendations after R1/R2 resection have never been verified.

      Methods:
      With the objective of validating NCCN post-operative therapy guidelines, we evaluated patients with surgically resected pathologic stage I-IIIA NSCLC in the National Cancer Data Base from 2004-2011. Recipients of pre-operative adjuvant therapy and those with no lymph nodes examined were excluded. Post-operative therapy modalities were classified as chemotherapy, radiotherapy, chemo-radiotherapy, or no treatment. Analyses were adjusted for patient demographic, clinical, and surgical characteristics, as well as institutional characteristics. Analyses were conducted by margin status and stage groups based on NCCN classifications (Table I). Unadjusted stage-specific 5-year overall survival (OS) estimates were calculated based on the Kaplan-Meier method and compared across post-treatment modalities with the log-rank test. Survival was modeled with Extended Cox Regression to adjust for all covariates and allow for non-proportional hazards.

      Results:
      Among 98,176 NSCLC patients who underwent curative-intent surgery during 2004-2011, 48% were male, 79% white, 34% privately insured, and 58% Medicare insured, with a median age of 68 years. The 5-year OS estimates by treatment modality are shown in Table I (NCCN recommendations highlighted). Margin negative patients with stage IA or IB/IIA who received post-operative radiotherapy had significantly lower OS compared to those with no treatment (both p-values<0.0001). We also observed lower OS with post-operative radiotherapy in margin positive patients with stage IA (p-value=0.0006) and IB/IIA (p-value=0.0302). Survival was significantly higher in persons with stages IB-IIIA who received post-operative chemotherapy compared to no treatment (all p-values<0.0001). Fully adjusted modeling analyses (not shown) yielded similar results.

      5 Year Survival (P-Value)
      NCCN Categorized Group Margin Positive Margin Negative
      Stage IA (T1ab,N0) No Treatment 60%(Ref) 71%(Ref)
      Chemo-Only 64%(0.86) 74%(0.33)
      Radiotherapy-Only 24%(0.0006) 47%(<0.0001)
      Chemo+Rad 44%(0.17) 43%(<0.0001)
      (N=458) (N=41279)
      Stage IB (T2a,N0) & Stage IIA (T2b,N0) No Treatment 48%(Ref) 57%(Ref)
      Chemo-Only 66%(0.0002) 69%(<0.0001)
      Radiotherapy-Only 30%(0.0302) 41%(<0.0001)
      Chemo+Rad 39%(0.28) 48%(<0.0001)
      (N=1016) (N=29111)
      Stage IIA (T1ab-T2a,N1) & Stage IIB (T3,N0;T2b,N1) No Treatment 27%(Ref) 39%(Ref)
      Chemo-Only 35%(<0.0001) 55%(<0.0001)
      Radiotherapy-Only 26%(0.84) 29%(<0.0001)
      Chemo+Rad 36%(<0.0001) 43%(0.0194)
      (N=1549) (N=15543)
      Stage IIIA (T1-3,N2;T3,N1) No Treatment 15%(Ref) 26%(Ref)
      Chemo-Only 25%(0.0013) 41%(<0.0001)
      Radiotherapy-Only 11%(0.76) 19%(0.0551)
      Chemo+Rad 26%(<0.0001) 39%(<0.0001)
      (N=1109) (N=8111)


      Conclusion:
      In patients with negative margins, results from the NCDB are consistent with randomized clinical trials and stage-specific NCCN post-operative adjuvant therapy recommendations. However, the NCCN recommendation of post-operative adjuvant radiotherapy for patients with early stage NSCLC with a positive resection margin is not supported by our results and should be further investigated in a randomized clinical trial.

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    ORAL 27 - Care (ID 123)

    • Event: WCLC 2015
    • Type: Oral Session
    • Track: Advocacy
    • Presentations: 1
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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): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      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 30 - Community Practice (ID 141)

    • Event: WCLC 2015
    • Type: Oral Session
    • Track: Community Practice
    • Presentations: 1
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      ORAL30.01 - Evolution in the Surgical Care of Non-Small Cell Lung Cancer (NSCLC) Patients in the Mid-South Quality of Surgical Resection (MS-QSR) Cohort (ID 2980)

      16:45 - 16:56  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      Background:
      Surgical resection is the most important curative modality for NSCLC. However, gaps in the quality of surgery adversely affect patients’ survival. In the Mid-South region, at the center of the US lung cancer mortality belt, we began a project in 2009 to improve the quality of surgery and pathology examination across all hospitals. We report the evolution of surgical quality in this region from 2004-2013.

      Methods:
      The MS-QSR database includes patient-level details from all NSCLC resections in 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, North Mississippi, and Western Tennessee. Data span the care delivery process from initial radiographic detection, through diagnostic and staging tests, to surgical treatment and post-operative outcomes. We performed trend analysis and comparisons among institutions.

      Results:
      There were 2,410 curative-intent NSCLC resections. Patient demographics, rates of non-invasive staging tests and pre-operative adjuvant therapy did not change. 92% of patients had a pre-operative CT, 80% had a PET-CT scan. The use of invasive staging tests (endobronchial ultrasound, mediastinoscopy, etc.) increased from 11.3% in 2009 to 22.3% in 2013 (p<0.001). The pneumonectomy rate decreased from 12% in 2004 to 6.2% in 2013 (p=0.05). The margin positivity rate remained stable at 5.8%. Stage distributions remained unchanged, with 63% stage I, 18% stage II, and 19% stage III or above. The total number of lymph nodes retrieved during resection remained unchanged until 2010 (median 4-5 from 2004 to 2010), after which, it increased significantly (median 7 in 2011, 9.5 in 2012, and 10 in 2013) (p<0.001) (figure 1). The mediastinal lymph node (MLN) examination rate increased from 53% in 2004 to 82% in 2013 (p<0.001). However, the rate of non-examination of lymph nodes (pNX) remained stable at 10%. Although the proportion of patients with N1 disease remained stable (17.6%), the proportion with N2 disease increased during a pilot testing phase with a MLN specimen collection kit implementation (10.8% in 2010 and 2011, and 7-8% in all other years). Finally, the re-hospitalization rate was 13.3%; the 60-day mortality rate was 6.4%. Figure 1



      Conclusion:
      In this population-based cohort, pre-operative and intraoperative nodal staging practice improved significantly. However, other quality measures (margin positivity and pNX rates) need further improvement. This early analysis suggests that a regional quality improvement project can improve overall patient survival in this high lung cancer mortality zone of the US.

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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: 5
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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): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      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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      ORAL34.04 - Discussant for ORAL34.01, ORAL34.02, ORAL34.03 (ID 3373)

      17:18 - 17:28  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation

      Abstract not provided

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      ORAL34.05 - Survival Implications of Variation in the Lymph Node (LN) Count in ACOSOG Z0030 (Alliance) (ID 654)

      17:28 - 17:39  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation

      Background:
      Variation in the thoroughness and accuracy of pathologic lymph node (LN) staging may contribute to within-stage variation in survival after curative-intent resection of non-small-cell lung cancer. Accurate staging mandates effective collaboration between surgeons and pathologists. ACOSOG Z0030 tightly controlled surgeon practice, but not pathology practice. We tested the impact of the thoroughness of pathologic examination (using the number of examined LNs as a surrogate) on detection of LN metastasis and survival.

      Methods:
      We reanalyzed the mediastinal LN dissection arm of ACOSOG Z0030, using linear regression to examine the clinical and demographic factors associated with LN count, Cox proportional hazards models to determine the association between the number of LNs examined and survival of patients with pN0 and pN1 disease, and logistic regression to determine association of number of LN examined and the discovery of unexpected N2 LN metastasis. Overall (OS) and recurrence-free survival (RFS), were analyzed without and with adjustment for T-category.

      Results:
      The 524 patients, had a mean age of 66.8 years, and were 52% male. Forty-four percent had adenocarcinoma, 27% squamous, 4% large cell, and 25% ‘other’ histology; 96% had T1/2 disease. Four hundred and thirty-nine (84%) were pN0, 63 (12%) pN1, and 21 (4%) pN2. In patients with pN0, pN1, and pN2 respectively, the mean number of mediastinal LNs examined was 13.5, 12.9, and 17.4; station 10 LNs were 2.4, 2.7, and 2.5; station 11-14 LNs were 4.6, 6.2, and 6.2; total LNs (from all stations) were 19.7, 21.3, 25. Tumor histology and pN-category were the only factors associated with the number of LNs examined: patients with squamous histology tended to have the most number of non-hilar N1 LNs examined (p<0.001); patients with pN1/N2 had more non-hilar N1 nodes than those with pN0 (p=0.005); those with pN2 had more N2 nodes examined than those with pN0 or pN1 (p=0.085). There was a consistent association between the number of LNs examined and survival. Patients with pN0 had better OS (HR 0.96; p=0.12) and RFS (HR 0.97; p=0.2) with examination of more non-hilar nodes; patients with pN1, had better OS and RFS with increased examination of LNs from N2 (OS HR=0.96, p=0.059; RFS HR=0.95, p=0.03) and all stations (OS HR=0.97, p=0.048; RFS HR=0.96, p==0.012). Adjustment for T-category strengthened these relationships between the number of LNs, pN-stage and survival. The likelihood of discovering N2 disease was associated with increased examination of LNs from mediastinal (odds ratio=1.04; p=0.035) and all stations (OR=1.03; p=0.035).

      Conclusion:
      Despite uniformly thorough surgical hilar/mediastinal LN harvesting, the number of LNs examined was associated with the likelihood of detecting nodal metastasis, and survival. Patients with more LNs examined were more likely to have LN metastasis, examination of more LNs was associated with better survival in patients within the same pN-category. This may indicate an effect of variable thoroughness in pathologic examination processes on the accuracy and prognostic value of the pathology nodal staging system. Heterogeneity in the cancer immune response may be an alternative hypothesis to explain these findings.

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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): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      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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      ORAL34.07 - Prevalence, Prognostic Implications and Survival Modulators of Incompletely Resected Non-Small Cell Lung Cancer (NSCLC) in the US (ID 650)

      17:50 - 18:01  |  Author(s): R.U. Osarogiagbon

      • Abstract
      • Presentation
      • Slides

      Background:
      The survival impact of incomplete resection of NSCLC has never been systematically quantified, nor has the value of postoperative adjuvant therapy in this situation. Current clinical practice guidelines are based on single-institutional retrospective studies with few patients. The studies have contradictory findings about the survival impact of non-R0 resection and the benefit of adjuvant therapy.

      Methods:
      We analyzed pathologic stage I-IIIA NSCLC resections in the National Cancer Data Base from 2004 to 2011 to determine clinical, socio-demographic and institutional factors associated with margin involvement using multivariate logistic regression models. We compared the survival of patients with and without positive margins and evaluated the impact of postoperative adjuvant therapy, using proportional hazards models.

      Results:
      Of 112,998 resections over 8 years, 5335 (4.72%) had positive margins. This population represents >4-fold the sum of all previous English-language publications on margin-positive resections. The annual incomplete resection rate was stable over the 8-year time-span, ranging between 4.38% and 5.23% (trend-test p=0.07). Patient demographic and clinical factors associated with increased adjusted odds ratio (aOR) of incomplete resection included black race (p=0.006), age-based Medicare insurance (p=0.006), urban residence (p=0.01), squamous histology, high tumor grade, tumor overlapping more than 1 lobe, tumor location in the main bronchus, and advanced pathologic stage (p < .001 for all clinical factors). Surgery performed at Community Cancer Programs (p=0.002), institutions with high proportions of underinsured patients (p=0.01), and institutions with lower cancer resection volumes (p=0.006), also had increased aOR. The crude 5-year survival rate of patients with complete v incomplete resection was 58.5% v 33.8% (p < 0.001). The survival difference persisted when patients were stratified by tumor size, T-category and aggregate American Joint Committee on Cancer stage. The survival curve of patients with margin-positive stage I disease overlapped that of patients with completely resected stage II. Patients with incompletely resected stage II disease had worse survival than those with completely resected stage III disease. The survival detriment was consistent at 1, 3, and 5 years. After incomplete resection, adjuvant chemotherapy was associated with improved 5-year survival across all stages (p<0.01); radiotherapy was associated with worse survival in stage I patients (p<0.001), and had no significant impact in patients with stage II and III disease; chemo-radiation therapy had no significant impact in patients with stage I, but was associated with improved survival in patients with stage II and III disease (p<0.001).

      Conclusion:
      Margin involvement significantly impaired survival after NSCLC resection, irrespective of stage. Causative institutional and provider practices should be identified, to minimize this adverse outcome. Postoperative adjuvant chemotherapy mitigated the mortality risk independently of stage, whilst postoperative radiotherapy exacerbated the risk in patients with stage I disease, and chemoradiation therapy was associated with improved survival in patients with stage II and III disease. These findings need validation in prospective clinical trials.

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    P1.10 - Poster Session/ Advocacy (ID 228)

    • Event: WCLC 2015
    • Type: Poster
    • Track: Advocacy
    • Presentations: 1
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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): R.U. Osarogiagbon

      • Abstract
      • Slides

      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
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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): R.U. Osarogiagbon

      • Abstract
      • Slides

      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.

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