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A surgeon’s comfort level with a favored operation for non–small cell lung cancer can strongly influence whether the patient will have that operation, which, in turn, can affect the patient’s outcome and long-term survival, according to an analysis of a population-linked database. For patients whose surgeons have lower levels of experience, that could mean a greater chance they will have more invasive total lung removal rather than more difficult operations that spare part of the affected lung, according to investigators at McMaster University in Hamilton, Ontario.
“If a surgeon with high surgical volumes is less likely to perform higher-risk pneumonectomy procedures than one with lower volumes, this may translate to a significant reduction in adverse events,” said lead author Dr. Christian Finley and coauthors online in the Journal of Thoracic and Cardiovascular Surgery (2015 Jun 30 [doi: 10.1016/j.jtcvs.2015.04.060]). “Surgeon volume should be considered an important component in how care is delivered in this population.”
The McMaster investigators evaluated 8,070 patients in an Ontario population-based linked database who underwent surgical resection for non–small cell lung cancer during 2004-2011, including pneumonectomy, or total lung removal (842 patients), lobectomy (6,212 patients), and wedge resection (1,002 patients). Over the years of the study, the proportion of patients who underwent pneumonectomy fell by more than half, from 14.8% in 2004 to 7.6% in 2011.
Of the three procedures, pneumonectomy carries a threefold greater mortality and while the procedure is often avoidable, there may be cases where it’s necessary because of the location of the tumor, Dr. Finley and his colleagues said. Lobectomy is desirable because it spares the parenchyma and has lower recurrence rates than laser resections.
The study investigators aimed to explore the hypothesis that surgeons with less expertise are more inclined to perform the higher-risk pneumonectomy or sublobar resections such as a segmentectomy or a wedge resection than a lobectomy, the rationale being that these procedures can be less challenging than a standard or sleeve lobectomy. The study analyzed results from 124 different physicians at 45 institutions in Ontario.
Data analysis showed that physician volume, age, year of procedure, sex, and comorbidities were predictive of the surgeon performing a pneumonectomy. “Adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%,” Dr. Finley and his colleagues wrote. They also found no significant difference in stage distribution among low-, medium-, and high-volume surgeons.
“This is meaningful as pneumonectomy is known to have the highest mortality rate of lung cancer resection, found in this study to be 12.6%, demonstrating a potentially large impact on patient survival,” Dr. Finley and his colleagues said.
This analysis cites an earlier study that surgeon volume for many procedures was a key determinant in the link between hospital volume and operative mortality (N Engl J Med. 2003 Nov 27;349[2]:2117-27.). “This study suggests that a patient may improve their chance of survival substantially, even at high-volume institutions, by selecting surgeons who perform operations more frequently,” Dr. Finley and his colleagues said.
They said that despite their study’s limitations, the findings on how surgeon experience can influence the choice of lung resection for cancer warrant further study.
McMaster University, Division of Thoracic Surgery, provided funding for the study. The study authors had no disclosures.
Because the McMaster University study derived the reported outcomes from registry data, determining the reasons that influenced surgeons’ choices of lung resection is impossible, Dr. Eric Lim of the Imperial College of Medicine, London, said in his invited commentary (J Thorac Cardiovasc Surg. 2015 May 21 [doi:10.1016/j.jtcvs.2015.05.048]).
The study authors noted that lower-volume surgeons were more inclined to perform pneumonectomy, and, Dr. Lim noted, previous studies have found that higher-volume centers tended to see more patients with advanced-stage cancers and increased morbidities. “An alternative explanation is that higher-volume surgeons have better skill sets to undertake procedures such as sleeve lobectomies that would lower the pneumonectomy rates and possibly more segmentectomies to lower the wedge-resection rate,” Dr. Lim said.
Until better evidence exists on what procedure is best for central and peripheral tumors, “surgeons can argue either way,” Dr. Lim said. The questions that follow from the study should concentrate on the relative harm of each procedure and the level of practice variation that’s unacceptable.
“As a surgical community, it is incumbent on us to continue to evaluate surgical treatments generating the highest levels of evidence possible (randomized trials) and have sufficient humility to cross refer to colleagues when appropriate to ensure the best care for our patients,” Dr. Lim concluded.
Because the McMaster University study derived the reported outcomes from registry data, determining the reasons that influenced surgeons’ choices of lung resection is impossible, Dr. Eric Lim of the Imperial College of Medicine, London, said in his invited commentary (J Thorac Cardiovasc Surg. 2015 May 21 [doi:10.1016/j.jtcvs.2015.05.048]).
The study authors noted that lower-volume surgeons were more inclined to perform pneumonectomy, and, Dr. Lim noted, previous studies have found that higher-volume centers tended to see more patients with advanced-stage cancers and increased morbidities. “An alternative explanation is that higher-volume surgeons have better skill sets to undertake procedures such as sleeve lobectomies that would lower the pneumonectomy rates and possibly more segmentectomies to lower the wedge-resection rate,” Dr. Lim said.
Until better evidence exists on what procedure is best for central and peripheral tumors, “surgeons can argue either way,” Dr. Lim said. The questions that follow from the study should concentrate on the relative harm of each procedure and the level of practice variation that’s unacceptable.
“As a surgical community, it is incumbent on us to continue to evaluate surgical treatments generating the highest levels of evidence possible (randomized trials) and have sufficient humility to cross refer to colleagues when appropriate to ensure the best care for our patients,” Dr. Lim concluded.
Because the McMaster University study derived the reported outcomes from registry data, determining the reasons that influenced surgeons’ choices of lung resection is impossible, Dr. Eric Lim of the Imperial College of Medicine, London, said in his invited commentary (J Thorac Cardiovasc Surg. 2015 May 21 [doi:10.1016/j.jtcvs.2015.05.048]).
The study authors noted that lower-volume surgeons were more inclined to perform pneumonectomy, and, Dr. Lim noted, previous studies have found that higher-volume centers tended to see more patients with advanced-stage cancers and increased morbidities. “An alternative explanation is that higher-volume surgeons have better skill sets to undertake procedures such as sleeve lobectomies that would lower the pneumonectomy rates and possibly more segmentectomies to lower the wedge-resection rate,” Dr. Lim said.
Until better evidence exists on what procedure is best for central and peripheral tumors, “surgeons can argue either way,” Dr. Lim said. The questions that follow from the study should concentrate on the relative harm of each procedure and the level of practice variation that’s unacceptable.
“As a surgical community, it is incumbent on us to continue to evaluate surgical treatments generating the highest levels of evidence possible (randomized trials) and have sufficient humility to cross refer to colleagues when appropriate to ensure the best care for our patients,” Dr. Lim concluded.
A surgeon’s comfort level with a favored operation for non–small cell lung cancer can strongly influence whether the patient will have that operation, which, in turn, can affect the patient’s outcome and long-term survival, according to an analysis of a population-linked database. For patients whose surgeons have lower levels of experience, that could mean a greater chance they will have more invasive total lung removal rather than more difficult operations that spare part of the affected lung, according to investigators at McMaster University in Hamilton, Ontario.
“If a surgeon with high surgical volumes is less likely to perform higher-risk pneumonectomy procedures than one with lower volumes, this may translate to a significant reduction in adverse events,” said lead author Dr. Christian Finley and coauthors online in the Journal of Thoracic and Cardiovascular Surgery (2015 Jun 30 [doi: 10.1016/j.jtcvs.2015.04.060]). “Surgeon volume should be considered an important component in how care is delivered in this population.”
The McMaster investigators evaluated 8,070 patients in an Ontario population-based linked database who underwent surgical resection for non–small cell lung cancer during 2004-2011, including pneumonectomy, or total lung removal (842 patients), lobectomy (6,212 patients), and wedge resection (1,002 patients). Over the years of the study, the proportion of patients who underwent pneumonectomy fell by more than half, from 14.8% in 2004 to 7.6% in 2011.
Of the three procedures, pneumonectomy carries a threefold greater mortality and while the procedure is often avoidable, there may be cases where it’s necessary because of the location of the tumor, Dr. Finley and his colleagues said. Lobectomy is desirable because it spares the parenchyma and has lower recurrence rates than laser resections.
The study investigators aimed to explore the hypothesis that surgeons with less expertise are more inclined to perform the higher-risk pneumonectomy or sublobar resections such as a segmentectomy or a wedge resection than a lobectomy, the rationale being that these procedures can be less challenging than a standard or sleeve lobectomy. The study analyzed results from 124 different physicians at 45 institutions in Ontario.
Data analysis showed that physician volume, age, year of procedure, sex, and comorbidities were predictive of the surgeon performing a pneumonectomy. “Adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%,” Dr. Finley and his colleagues wrote. They also found no significant difference in stage distribution among low-, medium-, and high-volume surgeons.
“This is meaningful as pneumonectomy is known to have the highest mortality rate of lung cancer resection, found in this study to be 12.6%, demonstrating a potentially large impact on patient survival,” Dr. Finley and his colleagues said.
This analysis cites an earlier study that surgeon volume for many procedures was a key determinant in the link between hospital volume and operative mortality (N Engl J Med. 2003 Nov 27;349[2]:2117-27.). “This study suggests that a patient may improve their chance of survival substantially, even at high-volume institutions, by selecting surgeons who perform operations more frequently,” Dr. Finley and his colleagues said.
They said that despite their study’s limitations, the findings on how surgeon experience can influence the choice of lung resection for cancer warrant further study.
McMaster University, Division of Thoracic Surgery, provided funding for the study. The study authors had no disclosures.
A surgeon’s comfort level with a favored operation for non–small cell lung cancer can strongly influence whether the patient will have that operation, which, in turn, can affect the patient’s outcome and long-term survival, according to an analysis of a population-linked database. For patients whose surgeons have lower levels of experience, that could mean a greater chance they will have more invasive total lung removal rather than more difficult operations that spare part of the affected lung, according to investigators at McMaster University in Hamilton, Ontario.
“If a surgeon with high surgical volumes is less likely to perform higher-risk pneumonectomy procedures than one with lower volumes, this may translate to a significant reduction in adverse events,” said lead author Dr. Christian Finley and coauthors online in the Journal of Thoracic and Cardiovascular Surgery (2015 Jun 30 [doi: 10.1016/j.jtcvs.2015.04.060]). “Surgeon volume should be considered an important component in how care is delivered in this population.”
The McMaster investigators evaluated 8,070 patients in an Ontario population-based linked database who underwent surgical resection for non–small cell lung cancer during 2004-2011, including pneumonectomy, or total lung removal (842 patients), lobectomy (6,212 patients), and wedge resection (1,002 patients). Over the years of the study, the proportion of patients who underwent pneumonectomy fell by more than half, from 14.8% in 2004 to 7.6% in 2011.
Of the three procedures, pneumonectomy carries a threefold greater mortality and while the procedure is often avoidable, there may be cases where it’s necessary because of the location of the tumor, Dr. Finley and his colleagues said. Lobectomy is desirable because it spares the parenchyma and has lower recurrence rates than laser resections.
The study investigators aimed to explore the hypothesis that surgeons with less expertise are more inclined to perform the higher-risk pneumonectomy or sublobar resections such as a segmentectomy or a wedge resection than a lobectomy, the rationale being that these procedures can be less challenging than a standard or sleeve lobectomy. The study analyzed results from 124 different physicians at 45 institutions in Ontario.
Data analysis showed that physician volume, age, year of procedure, sex, and comorbidities were predictive of the surgeon performing a pneumonectomy. “Adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%,” Dr. Finley and his colleagues wrote. They also found no significant difference in stage distribution among low-, medium-, and high-volume surgeons.
“This is meaningful as pneumonectomy is known to have the highest mortality rate of lung cancer resection, found in this study to be 12.6%, demonstrating a potentially large impact on patient survival,” Dr. Finley and his colleagues said.
This analysis cites an earlier study that surgeon volume for many procedures was a key determinant in the link between hospital volume and operative mortality (N Engl J Med. 2003 Nov 27;349[2]:2117-27.). “This study suggests that a patient may improve their chance of survival substantially, even at high-volume institutions, by selecting surgeons who perform operations more frequently,” Dr. Finley and his colleagues said.
They said that despite their study’s limitations, the findings on how surgeon experience can influence the choice of lung resection for cancer warrant further study.
McMaster University, Division of Thoracic Surgery, provided funding for the study. The study authors had no disclosures.
FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
Key clinical point: Surgeon volume is a predictor of procedure selection for lung cancer surgery and has implications on outcomes.
Major finding: For each 10 unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%.
Data source: Dataset of 8,070 patients constructed from Ontario population-based linked databases accessed via the Institute for Clinical Evaluate Sciences.
Disclosures: McMaster University, Division of Thoracic Surgery, provided study funding. The authors had no disclosures.