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X. Yu
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MINI 20 - Surgery (ID 137)
- Event: WCLC 2015
- Type: Mini Oral
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 2
- Moderators:G. Veronesi, R. Flores
- Coordinates: 9/08/2015, 16:45 - 18:15, 201+203
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MINI20.02 - Risk-Adjusted Margin Positivity (RAMP) Rate as a Surgical Quality Metric for Non-Small-Cell Lung Cancer in the US National Cancer Data Base (NCDB) (ID 1247)
16:45 - 18:15 | Author(s): X. Yu
- Abstract
- Presentation
Background:
Surgical resection is the most important curative treatment modality for early-stage non-small-cell lung cancer (NSCLC). However, incomplete (margin-positive) resection is associated with inferior survival. We sought to develop a valid facility-based quality metric to measure surgical quality, adjusting related patient demographic and clinical characteristics.
Methods:
We identified facilities that performed cancer-directed surgery for patients diagnosed with AJCC stage I-IIIA NSCLC in the NCDB between 2004 and 2011. We used a multivariate logistic regression model, adjusting for patient risk-mix in each facility, to predict the expected number of risk-adjusted margin positivity (RAMP) cases for each facility. We divided the number of observed margin positivity (OMP) cases by the expected number of RAMP cases to obtain an observed: expected (O/E) ratio for each facility. We categorized facility performance as low outlier (O/E ratio<1 and p<.05), high outlier (O/E ratio>1 and p<.05), or non-outlier. Facility characteristics across performance categories were compared by chi-square test. Five-year unadjusted overall survival (OS) rates were estimated by Kaplan-Meier analyses and compared across categories with the log-rank test.
Results:
A total of 96,596 NSCLC stage I-IIIA patients underwent surgery in 941 facilities. The overall OMP rate was 4.6%. We identified 73 facilities as low outliers (mean O/E ratio=0.41), 755 as non-outliers (mean O/E ratio=1.28) and 113 as high outliers (mean O/E ratio=2.78). Compared to patients treated at high-outlier facilities, patients treated at low-outliers were more likely to be privately insured (34.7%[Low] vs. 32.9%[High]), reside in high-income neighborhoods, have no comorbidity (51.7% [Low] vs. 41.9 [High], p<.001), have adenocarcinoma (62.4%[Low] vs. 58.1%[High], p<.001), stage IA disease (41.6%[Low] vs. 39.6%[High], p<.001) and receive sub-lobectomy (11.7%[Low] vs. 9.9%[High], p<.001). Low-outlier facilities were more likely to be teaching/research or NCI-designated programs (54.8% [Low] vs. 18.5% [High], p<.001) and in the highest quartile of total cancer surgical volume (90.4% [Low] vs. 34.5% [High], p<.001) and lung cancer surgery volume (42.5% [Low] vs. 29.2% [High], p<.001) (Table 1). They also had smaller proportions of uninsured/Medicaid patients (45.2% [Low] vs. 36.2% [High], p=.006). The 5-year unadjusted OS estimates were: 0.62 (low-outliers), 0.58 (non-outliers), 0.57 (high-outliers); log-rank p<.001. Table 1. Facility characteristics across performance categoriesHigh-Outlier(N=113) Non-Outlier(N=755) Low-Outlier(N=73) p-value N(%) Census_region Northeast 18(15.9) 154(20.4) 19(26.0) 0.03 Midwest 39(34.5) 223(29.5) 15(20.6) South 37(32.7) 257(34.0) 35(48.0) West 19(16.8) 121(16.0) 4(5.5) Facility_type Community_Cancer_Program 23(20.4) 164(21.7) 0(0.0) <0.001 Comprehensive_Community_Cancer_Program 62(54.9) 419(55.5) 28(38.4) Teaching/Research 17(15.0) 128(17.0) 28(38.4) NCI_program 4(3.5) 17(2.3) 12(16.4) Other 7(6.2) 27(3.6) 5(6.9) Proportion_of_Medicaid/uninsure_patients Q1(low) 25(22.1) 206(27.3) 13(17.8) 0.006 Q2 16(14.2) 204(27.0) 20(27.4) Q3 41(36.3) 174(23.1) 21(28.8) Q4(high) 31(27.4) 171(22.7) 19(26.0) Lung_cancer_surgery_as_a_proportion of_all_surgery Q1(low) 8(7.1) 73(9.7) 0(0.0) <0.001 Q2 37(32.7) 224(29.7) 9(12.3) Q3 35(31.0) 226(29.9) 33(45.2) Q4(high) 33(29.2) 232(30.7) 31(42.5) Total_cancer_surgery_volume Q1(low) 12(10.6) 98(13.0) 0(0.0) <0.001 Q2 32(28.3) 193(25.6) 0(0.0) Q3 30(26.6) 253(33.5) 7(9.6) Q4(high) 39(34.5) 211(28.0) 66(90.4)
Conclusion:
Facility performance in lung cancer surgery can be captured by using the RAMP rate. Low-outlier facilities delivered superior OS than high-outliers. RAMP metrics could allow facilities to understand their performance and serve as a quality improvement benchmark.
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MINI20.03 - The Survival Impact of Missed Lymph Node Metastasis in Surgically Resected Non-Small Cell Lung Cancer (NSCLC) (ID 2204)
16:45 - 18:15 | Author(s): X. Yu
- Abstract
- Presentation
Background:
Lymph node (LN) metastasis is an important prognostic factor for patients with surgically resected NSCLC. We have previously described the extent of missed N1 LN metastasis in a cohort of patients treated at metropolitan institutions. With long-term follow up, we now quantify the survival impact of missed LN metastasis.
Methods:
We conducted a prospective cohort study to retrieve intrapulmonary LNs from discarded NSCLC resection specimens after completion of routine pathology examination. Retrieved materials were histologically examined and classified as LNs with and without metastasis. Survival information was retrieved from institutional tumor registries. Survival distributions were plotted using the Kaplan-Meier method and evaluated with proportional hazards models controlling for gender, race, pathologic N-category, tumor size, margin status, and Charlson score.
Results:
We evaluated 111 patients who were 47% male with a median age of 66 years. Clinical characteristics are summarized in Table 1. Discarded LNs with metastasis were found after re-dissection in 25 (23%) patients. Patients with discarded LN metastasis had an increased risk of death (Figure 1) with an unadjusted hazard ratio (HR) of 2.0 (p-value=0.06) and an adjusted HR of 1.8 (p-value=0.23) compared to those with no discarded LNs with metastasis. When >2 discarded LNs with metastasis were found, patients had 4.8 (p-value=0.0002) times the hazard of death compared to those with no discarded LNs with metastasis (adjusted HR=4.4, p-value=0.0032).
Figure 1N(%) No LN Metastasis LN Metastasis Total Bi-lobectomy 8 2 10 9% 8% Lobectomy 75 16 91 87% 64% Pneumonectomy 3 7 10 3% 28% N0 71 6 77 83% 24% N1 6 12 18 7% 48% N2 9 7 16 10% 28% T1 45 3 48 52% 12% T2 29 11 40 34% 44% T3 10 8 18 12% 32% T4 2 2 4 2% 8% Margin Negative 83 22 105 97% 88% Margin Positive 3 3 6 3% 12% Mean(SD) Charlson Score 1.8 1.8 1.8 1.6 1.7 1.6 Tumor Size(cm) 3.2 5.0 3.6 1.8 2.1 2.0
Conclusion:
The presence of metastasis in inadvertently discarded LNs in NSCLC resection specimens has significant implications for patients’ post-operative clinical course. Additional LN metastasis found on re-dissection was associated with reduced survival. A more rigorous protocol for gross dissection of lung resection specimens is needed, and should prove beneficial to patients’ long-term survival.
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ORAL 34 - Quality/Survival/Prognosis in Localized Lung Cancer (ID 153)
- Event: WCLC 2015
- Type: Oral Session
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:B.C. Cho, R.L. Keith
- Coordinates: 9/09/2015, 16:45 - 18:15, 201+203
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ORAL34.06 - Impact of Surgeons' Attainment of Quality Resection Parameters on Non-Small-Cell Lung Cancer (NSCLC) Patients' Survival (ID 2189)
16:45 - 18:15 | Author(s): X. Yu
- Abstract
- Presentation
Background:
The 60,000 patients who annually undergo curative-intent resection for lung cancer in the US constitute the vast majority of long-term NSCLC survivors. However, >50% of patients die within 5 years after curative-intent resection. We sought to directly measure the effect of variability in surgeon practice on patients’ survival.
Methods:
We collected patient-level data from all NSCLC resections performed in 8 mid-south hospitals from 2009 to 2013. Recipients of preoperative adjuvant therapy were ineligible. We grouped surgeons by their resection proportions for pneumonectomy and wedge resection, resections with positive margins, and resections without mediastinal lymph nodes. We assigned scores of 1 = <5%, 2 = 5-15%, and 3 = ≥ 15% for pneumonectomy and wedge resection rates; 1 = <5%, 2 = 5-10%, and 3 = ≥ 10% for resections with positive margins; 1 = < 10%, 2 = 10-50%, and 3 = ≥ 50% for resections without mediastinal lymph node examination. The individual scores were then combined for an aggregate surgeon score. Surgeons were then grouped into three tiers: 1 =≤6, 2 = 7-8, and 3 = ≥9. A survival analysis was conducted for patients aggregated by surgeon score tier, adjusted for patient race, gender, and age at surgery, pathologic stage, and surgeon’s case-volume.
Results:
1,339 resections were performed by 39 surgeons: 17 surgeons (43.6%) in tier 1(aggregate score ≤ 6) operated on 623 patients (44.5%); 14 surgeons (35.9%) in tier 2 operated on 669 patients (47.8%); and 8 surgeons (25.5%) in tier 3 operated on 107 patients (7.65%). Figure 1 plots the Kaplan – Meier survival curve for patients in each surgeon tier. Tiers 2 and 3 patients had significantly higher hazard rates than tier 1 patients, with Hazard Ratio (HR)=1.76, 95%CI: 1.17, 2.64, p=.007 and HR=1.39, 95%CI: 1.11, 1.75, p=.004, respectively. Hazard rates between patients in surgeon tiers 3 and 2 were not significantly different, HR=1.26, 95%CI: 0.87, 1.82, p=.221. Figure 1
Conclusion:
We have developed a simple method of measuring the effect of variability in surgeon practice on patient outcomes. Patients who had resection by surgeons with lower rates of pneumonectomy and wedge resections, positive margins, and non-examination of mediastinal lymph nodes show improved survival over patients operated by surgeons with higher rates. Deficiency in attaining these quality parameters can be corrected at the individual surgeon level. Surgeon-level corrective interventions are warranted.
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P1.12 - Poster Session/ Community Practice (ID 232)
- Event: WCLC 2015
- Type: Poster
- Track: Community Practice
- Presentations: 1
- Moderators:
- Coordinates: 9/07/2015, 09:30 - 17:00, Exhibit Hall (Hall B+C)
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P1.12-001 - Trends in Accuracy and Comprehensiveness of Pathology Reports of Resected Non-Small Cell Lung Cancer (NSCLC) in a High Mortality Area of the US (ID 1571)
09:30 - 17:00 | Author(s): X. Yu
- Abstract
Background:
Pathologic examination of NSCLC resection specimens is vital to optimal treatment. In 2004, the College of American Pathologists (CAP) issued guidelines for NSCLC reporting, which were most recently updated in 2013. We evaluated the adoption of CAP reporting elements in a regional database.
Methods:
The Mid-South Quality of Surgical Resection (MS-QSR) database includes detailed information on 2,593 NSCLC resections in 11 institutions in 5 Dartmouth Hospital Referral Regions in Eastern Arkansas, North Mississippi and Western Tennessee from 2009-2014. In 2009, we started a multifaceted educational intervention: 1. Analyzed 2004-2008 pathology reports demonstrating the quality deficit in pathology reporting. 2. Recommended adoption of synoptic reporting of CAP checklist items. 3. Embedded a surgical intervention to improve mediastinal lymph node examination at some institutions. To allow for comparisons between eras and across the post-intervention era by intervention and type of hospital, we evaluated 4 groups: pre-intervention (pre-int), post-intervention participating hospital with surgical intervention (post-int/surg), post-intervention participating hospital without surgical intervention (post-int/non-surg), and non-participating non-surgical intervention hospital (post-int/non-part). We evaluated the inclusion of each CAP checklist item and the percent of cases with all items and 6 key items reported. We also evaluated the accuracy of T and N-stage categorization. Proportions reporting each item were compared between groups using Fisher’s Exact test.
Results:
Details of the completeness of pathology reporting are shown in Table 1 by group. The percent reporting the 6 key checklist items improved significantly from 63% pre-int to 76% post-int/non-part, 86% post-int/non-surg, and 95% post-int/surg (p-value<0.0001). A similar pattern of improvement was observed for N-stage (p-value<0.0001) and T-stage (p-value<0.0001) reporting. However, we observed significant decreases in the reporting of M-stage, and therefore all key items, post-intervention (p-value<0.0001). The accuracy of N-stage reporting improved significantly from 66% pre-int to 72% post-int/non-part, 86% post-int/non-surg, and 97% post-int/surg (p-value<0.0001). A similar trend was observed for T-stage accuracy (p-Value<0.0001).%Reporting Pre-Int (N=1390) Post-Int/ Non-Part (N=271) Post-Int/ No-Surg (N=645) Post-Int/ With-Surg (N=310) P-Value Specimen* 98.4 100 100 100 <0.0001 TumorSize* 97.2 99.6 98.1 99.4 0.0094 Histology* 99.8 99.6 99.5 99.7 0.59 MarginStatus* 97.1 98.5 92.6 98.7 <0.0001 T-Stage* 67.8 76.4 92.1 97.1 <0.0001 N-Stage* 66.3 76.8 89.8 97.7 <0.0001 *All Key-Items 62.7 75.7 85.7 94.8 <0.0001 Laterality 99.8 100 99.5 100 0.56 HistologicGrade 99.9 100 99.5 100 0.18 M-Stage 75.8 31.4 25 21.6 <0.0001 VascularInvasion 28.6 10.7 25 11.9 <0.0001 All Items 10.7 4.1 6.2 3.2 <0.0001 %Accurate N-Stage 66.2 71.6 86.2 96.8 <0.0001 T-Stage 55.3 61.6 83 84.8 <0.0001
Conclusion:
There was significant improvement in reporting of CAP checklist items and the accuracy of pT- and pN-categorization. After the introduction of synoptic reporting, we observed a secular trend of improvement, shown by our post-int/non-part external control. Direct educational intervention in 2009-2010 further improved the completeness and accuracy of reports in participating hospitals. The surgical intervention provided additional benefit. Interventions to improve the quality of reporting for NSCLC are impactful on accuracy and thoroughness of reporting, thereby improving the quality of care.
