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Doug Brunk is a San Diego-based award-winning reporter who began covering health care in 1991. Before joining the company, he wrote for the health sciences division of Columbia University and was an associate editor at Contemporary Long Term Care magazine when it won a Jesse H. Neal Award. His work has been syndicated by the Los Angeles Times and he is the author of two books related to the University of Kentucky Wildcats men's basketball program. Doug has a master’s degree in magazine journalism from the S.I. Newhouse School of Public Communications at Syracuse University. Follow him on Twitter @dougbrunk.
Delaying Esophagectomy After CXRT May Be Okay, Study Finds
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
Delaying Esophagectomy After CXRT May Be Okay, Study Finds
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
Delaying Esophagectomy After CXRT May Be Okay, Study Finds
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
Lung Resection Mortality Rate Varies by Surgeon Specialty
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
Lung Resection Mortality Rate Varies by Surgeon Specialty
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
Lung Resection Mortality Rate Varies by Surgeon Specialty
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
Study Finds Long-Acting Beta-Agonist Combo Safe for Children
SAN FRANCISCO – Adding long-acting beta-agonists to a regimen consisting of inhaled corticosteroids did not increase the rate of admissions to the pediatric intensive care unit, results from a year-long study showed.
"This supports the guidelines from the National Asthma Education and Prevention Program," Dr. Tammy S. Jacobs said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "When you fail to have adequate control with inhaled corticosteroids alone, long-acting beta-agonists can be a very good medication to add."
While results from the U.K. Serevent Nationwide Surveillance study and the U.S. Salmeterol Multicenter Asthma Research Trial suggested that long-acting beta-agonists (LABAs) increase the risk of asthma-related mortality, neither trial was adequately powered to study the safety of LABAs when used in conjunction with inhaled corticosteroids (ICS), said Dr. Jacobs, a resident at Children’s Hospital of Pittsburgh. In an effort to evaluate the impact of LABA use in conjunction with inhaled corticosteroids on the risk of near-fatal asthma in children, she and her associates reviewed the medical charts of 363 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Cases and controls were determined by pediatric intensive care (PICU) and floor admissions, respectively. Exposure was defined by LABA use in combination with ICS vs. ICS alone.
After excluding patients with non–asthma-indicated admissions, complicated pneumonias, debilitating comorbid disorders, and multiple admissions, 85 PICU admissions and 96 floor admissions were included in the final analysis. The mean age of patients was 9 years, 54% were male, and 51% were white.
Dr. Jacobs reported that the use of LABA in conjunction with ICS did not significantly increase the risk of PICU admissions (odds ratio, 1.07), compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR, 0.85). No deaths occurred during the study period.
"Although this [study] does not directly evaluate increase in mortality (as in previous trials), risk of ICU admission may actually be a more clinically relevant outcome to evaluate LABA safety," the researchers concluded in their poster. "Findings are generalizable to a population of children with relatively higher-risk asthma/poorer asthma control since all subjects were admitted, and no outpatient subjects were included."
Dr. Jacobs acknowledged certain limitations of the study, including the fact that it was a retrospective chart review with the potential for missing data.
She said that she had no relevant financial conflicts to disclose.
Asthma, Dr. Tammy S. Jacobs, American Academy of Allergy, Asthma, and Immunology, inhaled corticosteroids, U.S. Salmeterol Multicenter Asthma Research Trial, long-acting beta-agonists, LABAs, asthma exacerbations
SAN FRANCISCO – Adding long-acting beta-agonists to a regimen consisting of inhaled corticosteroids did not increase the rate of admissions to the pediatric intensive care unit, results from a year-long study showed.
"This supports the guidelines from the National Asthma Education and Prevention Program," Dr. Tammy S. Jacobs said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "When you fail to have adequate control with inhaled corticosteroids alone, long-acting beta-agonists can be a very good medication to add."
While results from the U.K. Serevent Nationwide Surveillance study and the U.S. Salmeterol Multicenter Asthma Research Trial suggested that long-acting beta-agonists (LABAs) increase the risk of asthma-related mortality, neither trial was adequately powered to study the safety of LABAs when used in conjunction with inhaled corticosteroids (ICS), said Dr. Jacobs, a resident at Children’s Hospital of Pittsburgh. In an effort to evaluate the impact of LABA use in conjunction with inhaled corticosteroids on the risk of near-fatal asthma in children, she and her associates reviewed the medical charts of 363 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Cases and controls were determined by pediatric intensive care (PICU) and floor admissions, respectively. Exposure was defined by LABA use in combination with ICS vs. ICS alone.
After excluding patients with non–asthma-indicated admissions, complicated pneumonias, debilitating comorbid disorders, and multiple admissions, 85 PICU admissions and 96 floor admissions were included in the final analysis. The mean age of patients was 9 years, 54% were male, and 51% were white.
Dr. Jacobs reported that the use of LABA in conjunction with ICS did not significantly increase the risk of PICU admissions (odds ratio, 1.07), compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR, 0.85). No deaths occurred during the study period.
"Although this [study] does not directly evaluate increase in mortality (as in previous trials), risk of ICU admission may actually be a more clinically relevant outcome to evaluate LABA safety," the researchers concluded in their poster. "Findings are generalizable to a population of children with relatively higher-risk asthma/poorer asthma control since all subjects were admitted, and no outpatient subjects were included."
Dr. Jacobs acknowledged certain limitations of the study, including the fact that it was a retrospective chart review with the potential for missing data.
She said that she had no relevant financial conflicts to disclose.
SAN FRANCISCO – Adding long-acting beta-agonists to a regimen consisting of inhaled corticosteroids did not increase the rate of admissions to the pediatric intensive care unit, results from a year-long study showed.
"This supports the guidelines from the National Asthma Education and Prevention Program," Dr. Tammy S. Jacobs said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "When you fail to have adequate control with inhaled corticosteroids alone, long-acting beta-agonists can be a very good medication to add."
While results from the U.K. Serevent Nationwide Surveillance study and the U.S. Salmeterol Multicenter Asthma Research Trial suggested that long-acting beta-agonists (LABAs) increase the risk of asthma-related mortality, neither trial was adequately powered to study the safety of LABAs when used in conjunction with inhaled corticosteroids (ICS), said Dr. Jacobs, a resident at Children’s Hospital of Pittsburgh. In an effort to evaluate the impact of LABA use in conjunction with inhaled corticosteroids on the risk of near-fatal asthma in children, she and her associates reviewed the medical charts of 363 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Cases and controls were determined by pediatric intensive care (PICU) and floor admissions, respectively. Exposure was defined by LABA use in combination with ICS vs. ICS alone.
After excluding patients with non–asthma-indicated admissions, complicated pneumonias, debilitating comorbid disorders, and multiple admissions, 85 PICU admissions and 96 floor admissions were included in the final analysis. The mean age of patients was 9 years, 54% were male, and 51% were white.
Dr. Jacobs reported that the use of LABA in conjunction with ICS did not significantly increase the risk of PICU admissions (odds ratio, 1.07), compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR, 0.85). No deaths occurred during the study period.
"Although this [study] does not directly evaluate increase in mortality (as in previous trials), risk of ICU admission may actually be a more clinically relevant outcome to evaluate LABA safety," the researchers concluded in their poster. "Findings are generalizable to a population of children with relatively higher-risk asthma/poorer asthma control since all subjects were admitted, and no outpatient subjects were included."
Dr. Jacobs acknowledged certain limitations of the study, including the fact that it was a retrospective chart review with the potential for missing data.
She said that she had no relevant financial conflicts to disclose.
Asthma, Dr. Tammy S. Jacobs, American Academy of Allergy, Asthma, and Immunology, inhaled corticosteroids, U.S. Salmeterol Multicenter Asthma Research Trial, long-acting beta-agonists, LABAs, asthma exacerbations
Asthma, Dr. Tammy S. Jacobs, American Academy of Allergy, Asthma, and Immunology, inhaled corticosteroids, U.S. Salmeterol Multicenter Asthma Research Trial, long-acting beta-agonists, LABAs, asthma exacerbations
FROM THE ANNUAL MEETING OF THE AMERICAN ACADEMY OF ALLERGY, ASTHMA, AND IMMUNOLOGY
Study Finds Long-Acting Beta-Agonist Combo Safe for Children
SAN FRANCISCO – Adding long-acting beta-agonists to a regimen consisting of inhaled corticosteroids did not increase the rate of admissions to the pediatric intensive care unit, results from a year-long study showed.
"This supports the guidelines from the National Asthma Education and Prevention Program," Dr. Tammy S. Jacobs said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "When you fail to have adequate control with inhaled corticosteroids alone, long-acting beta-agonists can be a very good medication to add."
While results from the U.K. Serevent Nationwide Surveillance study and the U.S. Salmeterol Multicenter Asthma Research Trial suggested that long-acting beta-agonists (LABAs) increase the risk of asthma-related mortality, neither trial was adequately powered to study the safety of LABAs when used in conjunction with inhaled corticosteroids (ICS), said Dr. Jacobs, a resident at Children’s Hospital of Pittsburgh. In an effort to evaluate the impact of LABA use in conjunction with inhaled corticosteroids on the risk of near-fatal asthma in children, she and her associates reviewed the medical charts of 363 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Cases and controls were determined by pediatric intensive care (PICU) and floor admissions, respectively. Exposure was defined by LABA use in combination with ICS vs. ICS alone.
After excluding patients with non–asthma-indicated admissions, complicated pneumonias, debilitating comorbid disorders, and multiple admissions, 85 PICU admissions and 96 floor admissions were included in the final analysis. The mean age of patients was 9 years, 54% were male, and 51% were white.
Dr. Jacobs reported that the use of LABA in conjunction with ICS did not significantly increase the risk of PICU admissions (odds ratio, 1.07), compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR, 0.85). No deaths occurred during the study period.
"Although this [study] does not directly evaluate increase in mortality (as in previous trials), risk of ICU admission may actually be a more clinically relevant outcome to evaluate LABA safety," the researchers concluded in their poster. "Findings are generalizable to a population of children with relatively higher-risk asthma/poorer asthma control since all subjects were admitted, and no outpatient subjects were included."
Dr. Jacobs acknowledged certain limitations of the study, including the fact that it was a retrospective chart review with the potential for missing data.
She said that she had no relevant financial conflicts to disclose.
Asthma, Dr. Tammy S. Jacobs, American Academy of Allergy, Asthma, and Immunology, inhaled corticosteroids, U.S. Salmeterol Multicenter Asthma Research Trial, long-acting beta-agonists, LABAs, asthma exacerbations
SAN FRANCISCO – Adding long-acting beta-agonists to a regimen consisting of inhaled corticosteroids did not increase the rate of admissions to the pediatric intensive care unit, results from a year-long study showed.
"This supports the guidelines from the National Asthma Education and Prevention Program," Dr. Tammy S. Jacobs said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "When you fail to have adequate control with inhaled corticosteroids alone, long-acting beta-agonists can be a very good medication to add."
While results from the U.K. Serevent Nationwide Surveillance study and the U.S. Salmeterol Multicenter Asthma Research Trial suggested that long-acting beta-agonists (LABAs) increase the risk of asthma-related mortality, neither trial was adequately powered to study the safety of LABAs when used in conjunction with inhaled corticosteroids (ICS), said Dr. Jacobs, a resident at Children’s Hospital of Pittsburgh. In an effort to evaluate the impact of LABA use in conjunction with inhaled corticosteroids on the risk of near-fatal asthma in children, she and her associates reviewed the medical charts of 363 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Cases and controls were determined by pediatric intensive care (PICU) and floor admissions, respectively. Exposure was defined by LABA use in combination with ICS vs. ICS alone.
After excluding patients with non–asthma-indicated admissions, complicated pneumonias, debilitating comorbid disorders, and multiple admissions, 85 PICU admissions and 96 floor admissions were included in the final analysis. The mean age of patients was 9 years, 54% were male, and 51% were white.
Dr. Jacobs reported that the use of LABA in conjunction with ICS did not significantly increase the risk of PICU admissions (odds ratio, 1.07), compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR, 0.85). No deaths occurred during the study period.
"Although this [study] does not directly evaluate increase in mortality (as in previous trials), risk of ICU admission may actually be a more clinically relevant outcome to evaluate LABA safety," the researchers concluded in their poster. "Findings are generalizable to a population of children with relatively higher-risk asthma/poorer asthma control since all subjects were admitted, and no outpatient subjects were included."
Dr. Jacobs acknowledged certain limitations of the study, including the fact that it was a retrospective chart review with the potential for missing data.
She said that she had no relevant financial conflicts to disclose.
SAN FRANCISCO – Adding long-acting beta-agonists to a regimen consisting of inhaled corticosteroids did not increase the rate of admissions to the pediatric intensive care unit, results from a year-long study showed.
"This supports the guidelines from the National Asthma Education and Prevention Program," Dr. Tammy S. Jacobs said in an interview during a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "When you fail to have adequate control with inhaled corticosteroids alone, long-acting beta-agonists can be a very good medication to add."
While results from the U.K. Serevent Nationwide Surveillance study and the U.S. Salmeterol Multicenter Asthma Research Trial suggested that long-acting beta-agonists (LABAs) increase the risk of asthma-related mortality, neither trial was adequately powered to study the safety of LABAs when used in conjunction with inhaled corticosteroids (ICS), said Dr. Jacobs, a resident at Children’s Hospital of Pittsburgh. In an effort to evaluate the impact of LABA use in conjunction with inhaled corticosteroids on the risk of near-fatal asthma in children, she and her associates reviewed the medical charts of 363 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Cases and controls were determined by pediatric intensive care (PICU) and floor admissions, respectively. Exposure was defined by LABA use in combination with ICS vs. ICS alone.
After excluding patients with non–asthma-indicated admissions, complicated pneumonias, debilitating comorbid disorders, and multiple admissions, 85 PICU admissions and 96 floor admissions were included in the final analysis. The mean age of patients was 9 years, 54% were male, and 51% were white.
Dr. Jacobs reported that the use of LABA in conjunction with ICS did not significantly increase the risk of PICU admissions (odds ratio, 1.07), compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR, 0.85). No deaths occurred during the study period.
"Although this [study] does not directly evaluate increase in mortality (as in previous trials), risk of ICU admission may actually be a more clinically relevant outcome to evaluate LABA safety," the researchers concluded in their poster. "Findings are generalizable to a population of children with relatively higher-risk asthma/poorer asthma control since all subjects were admitted, and no outpatient subjects were included."
Dr. Jacobs acknowledged certain limitations of the study, including the fact that it was a retrospective chart review with the potential for missing data.
She said that she had no relevant financial conflicts to disclose.
Asthma, Dr. Tammy S. Jacobs, American Academy of Allergy, Asthma, and Immunology, inhaled corticosteroids, U.S. Salmeterol Multicenter Asthma Research Trial, long-acting beta-agonists, LABAs, asthma exacerbations
Asthma, Dr. Tammy S. Jacobs, American Academy of Allergy, Asthma, and Immunology, inhaled corticosteroids, U.S. Salmeterol Multicenter Asthma Research Trial, long-acting beta-agonists, LABAs, asthma exacerbations
FROM THE ANNUAL MEETING OF THE AMERICAN ACADEMY OF ALLERGY, ASTHMA, AND IMMUNOLOGY
Major Finding: The use of long-acting beta-agonists in conjunction with inhaled corticosteroids did not significantly increase the risk of pediatric ICU admissions (odds ratio 1.07) compared with ICS alone. After the researchers adjusted for demographics, asthma severity, history of PICU admissions, and concurrent infection, they found that the use of LABA in conjunction with ICS may have decreased the risk of PICU admission, compared with ICS alone (OR 0.85).
Data Source: A study of 181 children aged 4-18 years who were admitted for asthma exacerbations to Children’s Hospital of Pittsburgh in 2005.
Disclosures: Dr. Jacobs said that she had no relevant financial disclosures to make.
Low-Intensity Treadmill Exercise Benefits Walking in Parkinson’s Disease
Results from a randomized trial show that low-intensity treadmill exercise leads to more consistent improvements in the gait and mobility of patients with Parkinson’s disease than does high-intensity treadmill exercise or stretching and resistance exercise.
However, only patients who participated in stretching and resistance exercise experienced significant improvements in the motor component of the Unified Parkinson’s Disease Rating Scale (UPDRS).
"There isn’t a neurologist who cares for patients with Parkinson’s that doesn’t have their patients ask them, ‘What should I do to help myself? What kind of exercise, if any, should I do?’ " Dr. Lisa M. Shulman said in an interview in advance of the annual meeting of the American Academy of Neurology, where the research was presented. "We haven’t had a good answer to that question for years. This study is a good start in terms of telling patients what they can do to help themselves. I’ve begun to tell my patients that they should do a combination of low-intensity treadmill exercise and stretching resistance training to get the range of benefits that we demonstrated in our study."
Dr. Shulman, a professor of neurology at the University of Maryland, Baltimore, and her associates enrolled 67 Parkinson’s patients who had trouble walking into one of three groups: high-intensity treadmill (30 minutes at 70%-80% heart rate reserve); low-intensity treadmill (50 minutes at 40%-50% heart rate reserve); or stretching and resistance exercises (two sets of 10 repetitions of leg presses, extensions, and curls performed on exercise machines). The study participants exercised three times a week for 3 months and were supervised by exercise physiologists at the Baltimore Veterans Affairs Medical Center.
Baseline pre- and posttraining measures included the 6-minute walk; 10-meter and 50-foot gait speeds; peak oxygen consumption; and the UPDRS, which evaluates disease symptoms such as tremor, rigidity, loss of dexterity, slowness, walking, and balance.
The mean age of patients was 66 years and 75% were male. Dr. Shulman reported that at the end of 3 months, all modes of exercise improved distance on the 6-minute walk, with significant improvements in the low-intensity treadmill group and in the stretching/resistance group, and a trend toward significance in the high-intensity treadmill group. The greatest improvement was seen in the low-intensity treadmill group, in which patients walked 11% further over 6 minutes, a distance equivalent to half a city block.
Both treadmill groups significantly improved their 10-meter fast gait, but the low-intensity treadmill group demonstrated greater improvement on the 50-foot fast gait. Both treadmill groups improved peak oxygen consumption.
Only patients in the stretching/resistance group experienced significant improvements in the motor component of the UPDRS, the key measure of Parkinsonian motor symptoms.
"The fact that the low-intensity treadmill group had more consistent benefit in terms of gait and mobility was surprising," Dr. Shulman said. "Our main interest was improvement in gait and mobility, because those are the most disabling symptoms of Parkinson’s disease. A key fact is that it wasn’t necessary to greatly increase the intensity of walking to achieve benefit. That means that more people with a greater range of disability can benefit from exercise in Parkinson’s disease."
The positive impact of stretching and resistance exercise was also surprising, she said. "People with Parkinson’s who have rigidity tend to develop a stooped posture; they tend to lose their range of motion and general mobility because they’re stiff and slow," Dr. Shulman said. "One possibility is that the stretching and strengthening exercises in that group relieved symptoms of loss of range of motion and stiffness over time."
She acknowledged certain limitations of the study, including the fact that outcomes were evaluated only at 90 days and that it was a single-blinded (not a double-blinded) analysis. "There isn’t any way to get around that, since patients in exercise trials are aware of their exercise training," she noted. "It’s ironic that all of our patients were hoping that they would be assigned to the high-intensity treadmill group. They all wanted to be in that group because it was clearly the most strenuous group. When they were assigned to the low-intensity group or to the stretching/resistance group, they were somewhat disappointed, yet those were precisely the groups that were most effective."
The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center.
Dr. Shulman said that she had no relevant financial conflicts to disclose.
Results from a randomized trial show that low-intensity treadmill exercise leads to more consistent improvements in the gait and mobility of patients with Parkinson’s disease than does high-intensity treadmill exercise or stretching and resistance exercise.
However, only patients who participated in stretching and resistance exercise experienced significant improvements in the motor component of the Unified Parkinson’s Disease Rating Scale (UPDRS).
"There isn’t a neurologist who cares for patients with Parkinson’s that doesn’t have their patients ask them, ‘What should I do to help myself? What kind of exercise, if any, should I do?’ " Dr. Lisa M. Shulman said in an interview in advance of the annual meeting of the American Academy of Neurology, where the research was presented. "We haven’t had a good answer to that question for years. This study is a good start in terms of telling patients what they can do to help themselves. I’ve begun to tell my patients that they should do a combination of low-intensity treadmill exercise and stretching resistance training to get the range of benefits that we demonstrated in our study."
Dr. Shulman, a professor of neurology at the University of Maryland, Baltimore, and her associates enrolled 67 Parkinson’s patients who had trouble walking into one of three groups: high-intensity treadmill (30 minutes at 70%-80% heart rate reserve); low-intensity treadmill (50 minutes at 40%-50% heart rate reserve); or stretching and resistance exercises (two sets of 10 repetitions of leg presses, extensions, and curls performed on exercise machines). The study participants exercised three times a week for 3 months and were supervised by exercise physiologists at the Baltimore Veterans Affairs Medical Center.
Baseline pre- and posttraining measures included the 6-minute walk; 10-meter and 50-foot gait speeds; peak oxygen consumption; and the UPDRS, which evaluates disease symptoms such as tremor, rigidity, loss of dexterity, slowness, walking, and balance.
The mean age of patients was 66 years and 75% were male. Dr. Shulman reported that at the end of 3 months, all modes of exercise improved distance on the 6-minute walk, with significant improvements in the low-intensity treadmill group and in the stretching/resistance group, and a trend toward significance in the high-intensity treadmill group. The greatest improvement was seen in the low-intensity treadmill group, in which patients walked 11% further over 6 minutes, a distance equivalent to half a city block.
Both treadmill groups significantly improved their 10-meter fast gait, but the low-intensity treadmill group demonstrated greater improvement on the 50-foot fast gait. Both treadmill groups improved peak oxygen consumption.
Only patients in the stretching/resistance group experienced significant improvements in the motor component of the UPDRS, the key measure of Parkinsonian motor symptoms.
"The fact that the low-intensity treadmill group had more consistent benefit in terms of gait and mobility was surprising," Dr. Shulman said. "Our main interest was improvement in gait and mobility, because those are the most disabling symptoms of Parkinson’s disease. A key fact is that it wasn’t necessary to greatly increase the intensity of walking to achieve benefit. That means that more people with a greater range of disability can benefit from exercise in Parkinson’s disease."
The positive impact of stretching and resistance exercise was also surprising, she said. "People with Parkinson’s who have rigidity tend to develop a stooped posture; they tend to lose their range of motion and general mobility because they’re stiff and slow," Dr. Shulman said. "One possibility is that the stretching and strengthening exercises in that group relieved symptoms of loss of range of motion and stiffness over time."
She acknowledged certain limitations of the study, including the fact that outcomes were evaluated only at 90 days and that it was a single-blinded (not a double-blinded) analysis. "There isn’t any way to get around that, since patients in exercise trials are aware of their exercise training," she noted. "It’s ironic that all of our patients were hoping that they would be assigned to the high-intensity treadmill group. They all wanted to be in that group because it was clearly the most strenuous group. When they were assigned to the low-intensity group or to the stretching/resistance group, they were somewhat disappointed, yet those were precisely the groups that were most effective."
The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center.
Dr. Shulman said that she had no relevant financial conflicts to disclose.
Results from a randomized trial show that low-intensity treadmill exercise leads to more consistent improvements in the gait and mobility of patients with Parkinson’s disease than does high-intensity treadmill exercise or stretching and resistance exercise.
However, only patients who participated in stretching and resistance exercise experienced significant improvements in the motor component of the Unified Parkinson’s Disease Rating Scale (UPDRS).
"There isn’t a neurologist who cares for patients with Parkinson’s that doesn’t have their patients ask them, ‘What should I do to help myself? What kind of exercise, if any, should I do?’ " Dr. Lisa M. Shulman said in an interview in advance of the annual meeting of the American Academy of Neurology, where the research was presented. "We haven’t had a good answer to that question for years. This study is a good start in terms of telling patients what they can do to help themselves. I’ve begun to tell my patients that they should do a combination of low-intensity treadmill exercise and stretching resistance training to get the range of benefits that we demonstrated in our study."
Dr. Shulman, a professor of neurology at the University of Maryland, Baltimore, and her associates enrolled 67 Parkinson’s patients who had trouble walking into one of three groups: high-intensity treadmill (30 minutes at 70%-80% heart rate reserve); low-intensity treadmill (50 minutes at 40%-50% heart rate reserve); or stretching and resistance exercises (two sets of 10 repetitions of leg presses, extensions, and curls performed on exercise machines). The study participants exercised three times a week for 3 months and were supervised by exercise physiologists at the Baltimore Veterans Affairs Medical Center.
Baseline pre- and posttraining measures included the 6-minute walk; 10-meter and 50-foot gait speeds; peak oxygen consumption; and the UPDRS, which evaluates disease symptoms such as tremor, rigidity, loss of dexterity, slowness, walking, and balance.
The mean age of patients was 66 years and 75% were male. Dr. Shulman reported that at the end of 3 months, all modes of exercise improved distance on the 6-minute walk, with significant improvements in the low-intensity treadmill group and in the stretching/resistance group, and a trend toward significance in the high-intensity treadmill group. The greatest improvement was seen in the low-intensity treadmill group, in which patients walked 11% further over 6 minutes, a distance equivalent to half a city block.
Both treadmill groups significantly improved their 10-meter fast gait, but the low-intensity treadmill group demonstrated greater improvement on the 50-foot fast gait. Both treadmill groups improved peak oxygen consumption.
Only patients in the stretching/resistance group experienced significant improvements in the motor component of the UPDRS, the key measure of Parkinsonian motor symptoms.
"The fact that the low-intensity treadmill group had more consistent benefit in terms of gait and mobility was surprising," Dr. Shulman said. "Our main interest was improvement in gait and mobility, because those are the most disabling symptoms of Parkinson’s disease. A key fact is that it wasn’t necessary to greatly increase the intensity of walking to achieve benefit. That means that more people with a greater range of disability can benefit from exercise in Parkinson’s disease."
The positive impact of stretching and resistance exercise was also surprising, she said. "People with Parkinson’s who have rigidity tend to develop a stooped posture; they tend to lose their range of motion and general mobility because they’re stiff and slow," Dr. Shulman said. "One possibility is that the stretching and strengthening exercises in that group relieved symptoms of loss of range of motion and stiffness over time."
She acknowledged certain limitations of the study, including the fact that outcomes were evaluated only at 90 days and that it was a single-blinded (not a double-blinded) analysis. "There isn’t any way to get around that, since patients in exercise trials are aware of their exercise training," she noted. "It’s ironic that all of our patients were hoping that they would be assigned to the high-intensity treadmill group. They all wanted to be in that group because it was clearly the most strenuous group. When they were assigned to the low-intensity group or to the stretching/resistance group, they were somewhat disappointed, yet those were precisely the groups that were most effective."
The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center.
Dr. Shulman said that she had no relevant financial conflicts to disclose.
Major Finding: Patients with Parkinson’s disease who performed low-intensity treadmill exercise significantly improved their walking ability on several assessments more than did those who did high-intensity treadmill exercise or stretching and resistance exercise, including walking 11% further during a 6-minute walk test, a distance equivalent to half of a city block.
Data Source: A 3-month, randomized study of 67 Parkinson’s disease patients.
Disclosures: The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center. Dr. Shulman said that she had no relevant financial conflicts.
Low-Intensity Treadmill Exercise Benefits Walking in Parkinson’s Disease
Results from a randomized trial show that low-intensity treadmill exercise leads to more consistent improvements in the gait and mobility of patients with Parkinson’s disease than does high-intensity treadmill exercise or stretching and resistance exercise.
However, only patients who participated in stretching and resistance exercise experienced significant improvements in the motor component of the Unified Parkinson’s Disease Rating Scale (UPDRS).
"There isn’t a neurologist who cares for patients with Parkinson’s that doesn’t have their patients ask them, ‘What should I do to help myself? What kind of exercise, if any, should I do?’ " Dr. Lisa M. Shulman said in an interview in advance of the annual meeting of the American Academy of Neurology, where the research was presented. "We haven’t had a good answer to that question for years. This study is a good start in terms of telling patients what they can do to help themselves. I’ve begun to tell my patients that they should do a combination of low-intensity treadmill exercise and stretching resistance training to get the range of benefits that we demonstrated in our study."
Dr. Shulman, a professor of neurology at the University of Maryland, Baltimore, and her associates enrolled 67 Parkinson’s patients who had trouble walking into one of three groups: high-intensity treadmill (30 minutes at 70%-80% heart rate reserve); low-intensity treadmill (50 minutes at 40%-50% heart rate reserve); or stretching and resistance exercises (two sets of 10 repetitions of leg presses, extensions, and curls performed on exercise machines). The study participants exercised three times a week for 3 months and were supervised by exercise physiologists at the Baltimore Veterans Affairs Medical Center.
Baseline pre- and posttraining measures included the 6-minute walk; 10-meter and 50-foot gait speeds; peak oxygen consumption; and the UPDRS, which evaluates disease symptoms such as tremor, rigidity, loss of dexterity, slowness, walking, and balance.
The mean age of patients was 66 years and 75% were male. Dr. Shulman reported that at the end of 3 months, all modes of exercise improved distance on the 6-minute walk, with significant improvements in the low-intensity treadmill group and in the stretching/resistance group, and a trend toward significance in the high-intensity treadmill group. The greatest improvement was seen in the low-intensity treadmill group, in which patients walked 11% further over 6 minutes, a distance equivalent to half a city block.
Both treadmill groups significantly improved their 10-meter fast gait, but the low-intensity treadmill group demonstrated greater improvement on the 50-foot fast gait. Both treadmill groups improved peak oxygen consumption.
Only patients in the stretching/resistance group experienced significant improvements in the motor component of the UPDRS, the key measure of Parkinsonian motor symptoms.
"The fact that the low-intensity treadmill group had more consistent benefit in terms of gait and mobility was surprising," Dr. Shulman said. "Our main interest was improvement in gait and mobility, because those are the most disabling symptoms of Parkinson’s disease. A key fact is that it wasn’t necessary to greatly increase the intensity of walking to achieve benefit. That means that more people with a greater range of disability can benefit from exercise in Parkinson’s disease."
The positive impact of stretching and resistance exercise was also surprising, she said. "People with Parkinson’s who have rigidity tend to develop a stooped posture; they tend to lose their range of motion and general mobility because they’re stiff and slow," Dr. Shulman said. "One possibility is that the stretching and strengthening exercises in that group relieved symptoms of loss of range of motion and stiffness over time."
She acknowledged certain limitations of the study, including the fact that outcomes were evaluated only at 90 days and that it was a single-blinded (not a double-blinded) analysis. "There isn’t any way to get around that, since patients in exercise trials are aware of their exercise training," she noted. "It’s ironic that all of our patients were hoping that they would be assigned to the high-intensity treadmill group. They all wanted to be in that group because it was clearly the most strenuous group. When they were assigned to the low-intensity group or to the stretching/resistance group, they were somewhat disappointed, yet those were precisely the groups that were most effective."
The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center.
Dr. Shulman said that she had no relevant financial conflicts to disclose.
Results from a randomized trial show that low-intensity treadmill exercise leads to more consistent improvements in the gait and mobility of patients with Parkinson’s disease than does high-intensity treadmill exercise or stretching and resistance exercise.
However, only patients who participated in stretching and resistance exercise experienced significant improvements in the motor component of the Unified Parkinson’s Disease Rating Scale (UPDRS).
"There isn’t a neurologist who cares for patients with Parkinson’s that doesn’t have their patients ask them, ‘What should I do to help myself? What kind of exercise, if any, should I do?’ " Dr. Lisa M. Shulman said in an interview in advance of the annual meeting of the American Academy of Neurology, where the research was presented. "We haven’t had a good answer to that question for years. This study is a good start in terms of telling patients what they can do to help themselves. I’ve begun to tell my patients that they should do a combination of low-intensity treadmill exercise and stretching resistance training to get the range of benefits that we demonstrated in our study."
Dr. Shulman, a professor of neurology at the University of Maryland, Baltimore, and her associates enrolled 67 Parkinson’s patients who had trouble walking into one of three groups: high-intensity treadmill (30 minutes at 70%-80% heart rate reserve); low-intensity treadmill (50 minutes at 40%-50% heart rate reserve); or stretching and resistance exercises (two sets of 10 repetitions of leg presses, extensions, and curls performed on exercise machines). The study participants exercised three times a week for 3 months and were supervised by exercise physiologists at the Baltimore Veterans Affairs Medical Center.
Baseline pre- and posttraining measures included the 6-minute walk; 10-meter and 50-foot gait speeds; peak oxygen consumption; and the UPDRS, which evaluates disease symptoms such as tremor, rigidity, loss of dexterity, slowness, walking, and balance.
The mean age of patients was 66 years and 75% were male. Dr. Shulman reported that at the end of 3 months, all modes of exercise improved distance on the 6-minute walk, with significant improvements in the low-intensity treadmill group and in the stretching/resistance group, and a trend toward significance in the high-intensity treadmill group. The greatest improvement was seen in the low-intensity treadmill group, in which patients walked 11% further over 6 minutes, a distance equivalent to half a city block.
Both treadmill groups significantly improved their 10-meter fast gait, but the low-intensity treadmill group demonstrated greater improvement on the 50-foot fast gait. Both treadmill groups improved peak oxygen consumption.
Only patients in the stretching/resistance group experienced significant improvements in the motor component of the UPDRS, the key measure of Parkinsonian motor symptoms.
"The fact that the low-intensity treadmill group had more consistent benefit in terms of gait and mobility was surprising," Dr. Shulman said. "Our main interest was improvement in gait and mobility, because those are the most disabling symptoms of Parkinson’s disease. A key fact is that it wasn’t necessary to greatly increase the intensity of walking to achieve benefit. That means that more people with a greater range of disability can benefit from exercise in Parkinson’s disease."
The positive impact of stretching and resistance exercise was also surprising, she said. "People with Parkinson’s who have rigidity tend to develop a stooped posture; they tend to lose their range of motion and general mobility because they’re stiff and slow," Dr. Shulman said. "One possibility is that the stretching and strengthening exercises in that group relieved symptoms of loss of range of motion and stiffness over time."
She acknowledged certain limitations of the study, including the fact that outcomes were evaluated only at 90 days and that it was a single-blinded (not a double-blinded) analysis. "There isn’t any way to get around that, since patients in exercise trials are aware of their exercise training," she noted. "It’s ironic that all of our patients were hoping that they would be assigned to the high-intensity treadmill group. They all wanted to be in that group because it was clearly the most strenuous group. When they were assigned to the low-intensity group or to the stretching/resistance group, they were somewhat disappointed, yet those were precisely the groups that were most effective."
The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center.
Dr. Shulman said that she had no relevant financial conflicts to disclose.
Results from a randomized trial show that low-intensity treadmill exercise leads to more consistent improvements in the gait and mobility of patients with Parkinson’s disease than does high-intensity treadmill exercise or stretching and resistance exercise.
However, only patients who participated in stretching and resistance exercise experienced significant improvements in the motor component of the Unified Parkinson’s Disease Rating Scale (UPDRS).
"There isn’t a neurologist who cares for patients with Parkinson’s that doesn’t have their patients ask them, ‘What should I do to help myself? What kind of exercise, if any, should I do?’ " Dr. Lisa M. Shulman said in an interview in advance of the annual meeting of the American Academy of Neurology, where the research was presented. "We haven’t had a good answer to that question for years. This study is a good start in terms of telling patients what they can do to help themselves. I’ve begun to tell my patients that they should do a combination of low-intensity treadmill exercise and stretching resistance training to get the range of benefits that we demonstrated in our study."
Dr. Shulman, a professor of neurology at the University of Maryland, Baltimore, and her associates enrolled 67 Parkinson’s patients who had trouble walking into one of three groups: high-intensity treadmill (30 minutes at 70%-80% heart rate reserve); low-intensity treadmill (50 minutes at 40%-50% heart rate reserve); or stretching and resistance exercises (two sets of 10 repetitions of leg presses, extensions, and curls performed on exercise machines). The study participants exercised three times a week for 3 months and were supervised by exercise physiologists at the Baltimore Veterans Affairs Medical Center.
Baseline pre- and posttraining measures included the 6-minute walk; 10-meter and 50-foot gait speeds; peak oxygen consumption; and the UPDRS, which evaluates disease symptoms such as tremor, rigidity, loss of dexterity, slowness, walking, and balance.
The mean age of patients was 66 years and 75% were male. Dr. Shulman reported that at the end of 3 months, all modes of exercise improved distance on the 6-minute walk, with significant improvements in the low-intensity treadmill group and in the stretching/resistance group, and a trend toward significance in the high-intensity treadmill group. The greatest improvement was seen in the low-intensity treadmill group, in which patients walked 11% further over 6 minutes, a distance equivalent to half a city block.
Both treadmill groups significantly improved their 10-meter fast gait, but the low-intensity treadmill group demonstrated greater improvement on the 50-foot fast gait. Both treadmill groups improved peak oxygen consumption.
Only patients in the stretching/resistance group experienced significant improvements in the motor component of the UPDRS, the key measure of Parkinsonian motor symptoms.
"The fact that the low-intensity treadmill group had more consistent benefit in terms of gait and mobility was surprising," Dr. Shulman said. "Our main interest was improvement in gait and mobility, because those are the most disabling symptoms of Parkinson’s disease. A key fact is that it wasn’t necessary to greatly increase the intensity of walking to achieve benefit. That means that more people with a greater range of disability can benefit from exercise in Parkinson’s disease."
The positive impact of stretching and resistance exercise was also surprising, she said. "People with Parkinson’s who have rigidity tend to develop a stooped posture; they tend to lose their range of motion and general mobility because they’re stiff and slow," Dr. Shulman said. "One possibility is that the stretching and strengthening exercises in that group relieved symptoms of loss of range of motion and stiffness over time."
She acknowledged certain limitations of the study, including the fact that outcomes were evaluated only at 90 days and that it was a single-blinded (not a double-blinded) analysis. "There isn’t any way to get around that, since patients in exercise trials are aware of their exercise training," she noted. "It’s ironic that all of our patients were hoping that they would be assigned to the high-intensity treadmill group. They all wanted to be in that group because it was clearly the most strenuous group. When they were assigned to the low-intensity group or to the stretching/resistance group, they were somewhat disappointed, yet those were precisely the groups that were most effective."
The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center.
Dr. Shulman said that she had no relevant financial conflicts to disclose.
Major Finding: Patients with Parkinson’s disease who performed low-intensity treadmill exercise significantly improved their walking ability on several assessments more than did those who did high-intensity treadmill exercise or stretching and resistance exercise, including walking 11% further during a 6-minute walk test, a distance equivalent to half of a city block.
Data Source: A 3-month, randomized study of 67 Parkinson’s disease patients.
Disclosures: The study was funded by the Michael J. Fox Foundation for Parkinson’s Research, the VA Center of Excellence in Exercise and Robotics for Neurological Disorders, and the Baltimore VA Medical Center’s Geriatric Research, Education, and Clinical Center. Dr. Shulman said that she had no relevant financial conflicts.