Many Patients Aren't Getting Best Quality Lung Cancer Surgery: Study
A surgeon's skill has a direct impact on whether a patient will survive early-stage lung cancer.
Unfortunately, many surgeons are failing to follow a playbook that increase the odds of a successful outcome, a new study argues.
The quality of surgery for lung cancer varies widely across the United States, and patients whose procedures fall short of treatment guidelines suffer significantly worse outcomes, said lead researcher Dr. Brendan Heiden, a thoracic surgeon at Washington University School of Medicine in St. Louis.
"When you do all of those things, patients have much better outcomes," Heiden said of treatment standards. "We know what to do, and the key is to do it as often as we can. We're never going to reach 100%, but there is room for improvement here."
Lung cancer remains the leading cause of cancer-related death in the United States, but new screening guidelines have been adopted to change that, researchers said in background notes.
Regular chest scans of longtime smokers are catching lung tumors earlier, while they are still relatively small and before they've had a chance to spread to other organs, Heiden said.
Heiden and his team identified five important steps in lung cancer surgery that give a patient a better chance:
- Performing surgery in a timely fashion.
- Surgically removing the appropriate amount of lung tissue, without taking too much.
- Sampling at least 10 lymph nodes, to make sure the cancer hasn't spread.
- Using minimally invasive surgery to reduce pain and speed recovery.
- Making sure all the cancer is surgically removed.
To see how closely surgeons adhere to those steps, the researchers analyzed the Veterans Affairs (VA) hospital charts of more than 9,600 veterans who underwent lung cancer surgery between 2006 and 2016. The vets were an average age of 67.
The researchers also checked their findings against more than 107,000 non-veteran patients listed in the National Cancer Database between 2010 and 2016.
Results showed that patients whose surgeons stuck to the treatment playbook survived at least seven years, on average, while the overall survival for people with the lowest surgical quality scores was an average of 2.6 years.
Sticking to the guidelines also increased a patient's odds of relapse-free survival by 61%, compared to those who received the poorest treatment, researchers found.
The new study was published recently in the journal JAMA Surgery.
Dr. Arif Kamal, chief patient officer for the American Cancer Society, said, "This is one of the first times I've seen a quality measure" in cancer surgery that directly influences a patient's overall survival.
"I think what's really most exciting about the study is that it finds a direct relationship between what the surgeon is doing in the operating room and whether a person lives as long as they could, and we just don't see that in other parts of oncology as clearly," Kamal said.
Unfortunately, surgeons are routinely skipping important steps that could improve survival.
For example, enough lymph nodes were taken during surgery only 34% of the time.
That step is critically important because a person's cancer team bases their follow-up care on the size of the tumor and the extent to which the cancer has spread into the lymph nodes, Kamal said.
"We may think their cancer is stage one, but if you sample 10 lymph nodes and see that the cancer has moved into several of those, it might actually be a stage two or three," Kamal explained. "In that case, the treatment is not just surgical resection. It involves chemotherapy or immunotherapy, and potentially even radiation as well."
Further, about 71% of patients had an entire lobe of their lung surgically removed, while only 5% had a surgery that limited the amount of lung tissue taken, researchers found.
"We want to take out enough tissue so the cancer's gone, but not take out so much tissue that it really limits the patient in terms of their breathing and symptoms after surgery," Heiden said.
Only 41% of surgeries were minimally invasive to the patient, and timely surgeries occurred in only 69% of cases.
However, Heiden and Kamal noted that the quality scores for VA surgeons improved in nearly every part of the nation between 2006 and 2019, with the sole exception being a VA region that includes Kansas, Missouri and central Illinois.
"It's very rare that the Deep South does well in terms of health outcomes, and oftentimes that is a reflection of insurance and sociodemographics," Kamal said. "But in this case the Deep South actually doesn't do poorly."
In addition, the VA system provides veterans with a quality of care comparable to or better than that provided in civilian hospitals, Heiden added.
"The VA has a very bad rap in this country," Heiden said. “These findings really go against that whole mantra where veterans are getting inferior care at the medical centers."
The nationwide rate of improvement in VA lung cancer surgeries shows that when insurance status isn't an issue -- all veterans receive free health care -- people are more likely to receive better care, Kamal said.
Quality also is more likely to improve for lung cancer surgery if surgeons are allowed to get more experience, Kamal added.
"We know in ovarian cancer that gynecologic surgeons that do more than 100 ovarian cancer resections per year have a better survival for their patients. It speaks to expertise and experience and familiarity," Kamal said. "As volume goes up, people can pay attention to those quality measures and improve on them over time."
Linking surgical skill directly to patient outcomes also might encourage hospitals to enforce these quality measures and provide additional training to struggling surgeons, Kamal added.
"What you're going to start to see is that health systems will make decisions based on performance about who do we want on our team, who do we want to help improve, who needs to have their performance reviewed or needs to work with another surgeon who does a little better on this measure to help them improve," Kamal said.
The American Lung Association has more about lung cancer surgery.
SOURCES: Brendan Heiden, MD, thoracic surgeon, Washington University School of Medicine, St. Louis; Arif Kamal, MD, MBA, chief patient officer, American Cancer Society; JAMA Surgery, Jan. 18, 2023