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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Concerns About Surgery for Lung Cancer in the US: A Hard Look in the Mirror
Wed, 06/18/2008 - 23:45
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

As a conclusion to the string of posts on the topic of lymph nodes removed at the time of surgery, I wanted to touch on the issue of what our representative experience is in the US, because I described the results of specialized centers in Japan and Italy that typically yielded large numbers of lymph nodes, often more than 10. What is the US lung surgery experience?

Perhaps the best answer we can get is from a seminal paper by Dr. Alex Little and colleagues that was published in 2005 in the Annals of Thoracic Surgery (abstract here). This describes the results of a survey done of 729 US-based hospitals (all over), some academic but mostly community-based, of surgeries from 11,668 patients with lung cancer, nearly 60% of whom had stage I disease, and most of the rest with stage II or III NSCLC, and 6% stage IV (this could include surgery with curative or palliative intent, and likely included many patients suspected as being earlier stage prior to surgery). Consistent with the demographics of lung cancer today, 46.8% of patients who underwent surgery were 70 or older, and 9.5% were 80 or older. Surgeons clearly were willing to treat at least a subset of elderly NSCLC patients aggressively.

One of the most discussed findings since the paper was published is that only 27% of patients with NSCLC underwent a pre-operative mediastinoscopy, which is something that most specialty-trained thoracic surgeons recommend for all but the lowest risk patients for mediastinal node involvement (such as a nodule less than a cm or two, particularly squamous (less likely to spread early), and maybe with a negative PET scan. But at my center, for instance, the very well trained lung surgeons do a mediastinoscopy on the vast majority of lung cancer patients, because it’s not that uncommon to find unsuspected nodal involvement at a mediastinoscopy, even in patients who had a PET scan that appeared negative (no suggestion of uptake consistent with cancer in the mediastinum).

Another major issue was that of the patients who did undergo a pre-operative mediastinoscopy, less than half (46.8%) had even a single lymph node removed at that time. Taking a look but not doing a biopsy of a single node, let alone the several that are considered a requirement for a proper medistinoscopy, is really tantamount to not doing the procedure at all. And even at the time of surgery, only 57.8% had any lymph nodes removed from the mediastinum. So more than 40% of patients had a clearly inadequate pathologic staging, at least from the perspective of nearly all leading surgical experts.

In addition, 7.8% of patients had a positive surgical margin, something we really hate to see in someone who undergoes surgery for lung cancer. This is sometimes unavoidable, but in this case it happened at more than twice the frequency you’d expect to see. One problem that may explain the high rate of positive margins was that only 65% of patients had a preliminary assessment of the surgical margins for residual disease involvement at the time of surgery. This is a standard method, by using something called “frozen sections”, when a surgeon sends a little frozen piece of the edge of his resected area to the pathologist to see if there is still cancer, in which case the surgeon can try to cut more around the area and remove ALL of the cancer.

As you’d expect and as we’ve seen previously (see prior post), patients who underwent surgery at higher volume centers had significantly lower rates of death around the time of surgery than was seen at lower volume centers. The level of experience and specialization appears to translate to significant differences in outcomes.

In a commentary that followed the presentation of this paper, thoracic surgeon Dr. Carolyn Reed stated succinctly, “This survey leads me to conclude that we aren’t giving excellent care to our lung cancer patients.” My impression is that I would refine that statement to say that, in the US at least, we don’t have a consistent standard of excellence, because there are a wide range of surgeons who resect lung cancers, some of whom rigorously trained and others treating a little of everything. Training and experience really matter a lot for lung cancer surgery. Any competent medical oncologist can give standard chemo. Any competent general surgeon can remove an appendix or repair a hernia. But removing a lung cancer is finesse work, and I advise my patients to seek out someone with excellent specialty training as a thoracic surgeon, who has a good deal of experience in lung cancer resections, because that can translate to some meaningful differences in terms of the level of care you end up getting.

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