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F. Lu
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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. Lu
- 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 30 - Community Practice (ID 141)
- Event: WCLC 2015
- Type: Oral Session
- Track: Community Practice
- Presentations: 1
- Moderators:P.S.S. Kho, R. Jotte
- Coordinates: 9/08/2015, 16:45 - 18:15, Mile High Ballroom 2c-3c
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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): F. Lu
- Abstract
- Presentation
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: 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. Lu
- 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. Lu
- 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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P1.12 - 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. Lu
- 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.
