The quality of lung cancer treatment varies across US - study

Despite rapidly evolving treatment and diagnostic tools, lung cancer remains the leading cause of cancer deaths and is the second most common cancer in the US.

Lung cancer maliciously inserted into image in Ben-Gurion University of the Negev study (photo credit: BGU)
Lung cancer maliciously inserted into image in Ben-Gurion University of the Negev study
(photo credit: BGU)

The quality of lung cancer surgery in the United States varies widely with patients whose surgery failed to meet established guidelines experiencing significantly worse outcomes, according to research published Wednesday in the peer-reviewed JAMA Surgery journal.

“It is crucial to have a solid understanding of what constitutes a high-quality lung cancer surgery,” said Varun Puri, MD, a Washington University thoracic surgeon and professor of surgery, who is the lead author of the study. “Improving adherence to surgical quality measures is critical to optimize long-term outcomes among patients with early-stage lung cancer seeking treatment intended to cure their cancer.”

Lung cancer remains the leading cause of cancer deaths and is the second most common cancer in the United States, according the American Cancer Society, despite rapidly evolving treatment and diagnostic tools.

The Washington University researchers expressed hope that their study will shed light on the five surgical quality metrics based on guidelines established by the National Comprehensive Cancer Network (NCCN) and other cancer groups, finding that adherence to these quality metrics was associated with improved overall survival rates. 

The five recommended quality metrics identified by researchers include performing surgery in a timely manner, shortly after diagnosis; determining the appropriate amount of lung tissue to be surgically removed; sampling multiple lymph nodes to confirm the cancer is staged correctly and has not spread to them; using minimally invasive surgery to reduce postsurgical pain and accelerate the recovery process; and ensuring that no cancer is left within the body, also known as a positive margin.

 An image of lung with breast cancer metastasis, surrounded by inflammatory complement protein: Cyan: Cell nuclei; Red: Complement protein; Green: blood vessels; (credit: LEA MONTERAN) An image of lung with breast cancer metastasis, surrounded by inflammatory complement protein: Cyan: Cell nuclei; Red: Complement protein; Green: blood vessels; (credit: LEA MONTERAN)

How was the lung cancer research conducted?

Researchers examined de-identified medical records of 9,628 patients from the US Veterans Health Administration. The patients all underwent surgery for early-stage non-small cell lung cancer (NSCLC) over the course of ten years from 2006 to 2016. In order to determine the relative quality of surgical care received by the patients, the WashU team developing a quality scoring system to show the association between the five NCCN recommended surgery metrics and overall patient survival.

The patients were predominantly male and white, and on average 67.8 years old; however, statistical modeling controlled for different ages, genders and races. 

Furthermore, the research analyzed quality metrics and overall survival rates among 107,674 nonveteran patients who were listed in the National Cancer Database as patients from 2010 to 2016.

"It is important to try to standardize and optimize adherence to quality measures whenever possible. Early-stage lung cancer treatments are rapidly evolving with the introduction of exciting new therapies. Central to these advances, however, is the foundational principle of performing high-quality, evidence-based surgery.

As our study demonstrates, adherence to surgical quality metrics can have a disproportionate impact on patients with lung cancer receiving surgical treatment aimed at curing the cancer.”

Brendan Heiden, MD

The study concluded that there is poor adherence to several quality measures, both within VA and civilian hospitals. For example, only about a third of patients in both cohorts received adequate lymph node sampling, and only about 40% received minimally invasive surgery.

“Many patient- and tumor-specific factors can influence the apparent quality of surgical care for lung cancer,” said the study’s first author, Brendan Heiden, MD, a surgical resident and research fellow at Washington University.

“Nevertheless, it is important to try to standardize and optimize adherence to quality measures whenever possible," he said. "Early-stage lung cancer treatments are rapidly evolving with the introduction of exciting new therapies. Central to these advances, however, is the foundational principle of performing high-quality, evidence-based surgery.

"As our study demonstrates, adherence to surgical quality metrics can have a disproportionate impact on patients with lung cancer receiving surgical treatment aimed at curing the cancer.”