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T. D'Amico
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P1.03 - Poster Session with Presenters Present (ID 455)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:
- Coordinates: 12/05/2016, 14:30 - 15:45, Hall B (Poster Area)
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P1.03-048 - A Structured Lung Cancer Screening Program Facilitates Patient and Provider Compliance (ID 5892)
14:30 - 15:45 | Author(s): T. D'Amico
- Abstract
Background:
In the United States, both private insurers and Medicare provide coverage for low-dose computed tomography (LDCT) screening for lung cancer. Medicare has defined specific criteria for coverage to include “lung cancer screening counseling and shared decision making visit”[1]. Currently, in many institutions, it is possible for LDCT screening to be performed without documentation of these discussions. We hypothesize that performing LDCT screening in the context of a structured lung cancer screening program results in improved compliance with coverage regulations.
Methods:
Medical records of patients undergoing LDCT screening at our institution between January 1, 2015 and June 30, 2016 were reviewed. Chart abstraction included eligibility criteria and documentation of shared decision making, discussion of adherence to annual screening and discussion of tobacco cessation/continued abstinence.
Results:
Of the 591 patients who had LDCT screening in the defined time period, 223 (37.7%) were seen in the Lung Cancer Screening Clinic and 368 (62.3%) had studies ordered by other providers. Within the Lung Cancer Screening Clinic (LCSC) cohort, 202/223 (90.6%) met Medicare eligibility and 17/223 (7.6%) met National Comprehensive Cancer Network (NCCN) “Category 2” criteria for lung cancer screening. In the “other provider” (OP) cohort, 281 (76.4%) met Medicare eligibility and 24 (6.5%) met NCCN “Category 2” criteria for screening (p<0.0001). Current smokers were more likely to have documented discussion of tobacco cessation counseling (99.2% vs. 64.2%, respectively; p<0.0001). Similarly, patients seen in the LCSC were more likely to have documentation of shared decision making than those in the OP cohort (97.3% vs. 19.3%, respectively; p<0.0001).Table 1. Compliance with Medicare criteria for LDCT screening.
LCSC (n = 223) OP (n = 368) p-value Medicare-eligible for screening NCCN “Category 2” Do not meet criteria for lung cancer screening 202 (90.6%) 17 (7.6%) 4 (1.8%) 281 (76.4%) 25 (6.8%) 62 (16.8%) <0.0001 Former smoker, quit within 15 years Current smoker 99 (44.4%) 124 (55.6%) 181 (49.2%) 187 (51.8%) 0.2958 Documented Tobacco Cessation Counseling (current smokers) 123/124 (99.2%) 119/187 (63.6%) <0.0001 Mean time spent in tobacco cessation counseling 23 minutes 5 minutes 0.0075 Documentation of shared decision making 182/187 (97.3%) 68/353 (19.3%) <0.0001
Conclusion:
LDCT screening conducted in the context of a dedicated lung cancer screening clinic facilitates compliance with Medicare criteria and improves patient education and decision-making. Opportunities exist for those providing LDCT to improve the elements of patient education that are essential to LDCT screening. References 1. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274
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P3.04 - Poster Session with Presenters Present (ID 474)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Surgery
- Presentations: 1
- Moderators:
- Coordinates: 12/07/2016, 14:30 - 15:45, Hall B (Poster Area)
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P3.04-013 - The Role of Extent of Surgical Resection and Lymph Node Assessment for Clinical Stage I Pulmonary Lepidic Adenocarcinoma (ID 6050)
14:30 - 15:45 | Author(s): T. D'Amico
- Abstract
Background:
This study examined the association of extent of lung resection, pathologic nodal evaluation, and survival for patients with clinical stage I (cT1-2N0M0) adenocarcinoma with lepidic histology in the National Cancer Database (NCDB).
Methods:
The association between extent of surgical resection and long-term survival for patients in the NCDB between the years of 2003-2006 with clinical stage I lepidic adenocarcinoma who underwent lobectomy or sublobar resection was evaluated using Kaplan-Meier and Cox proportional hazards regression analyses.
Results:
Of the 1,991 patients with cT1-2N0M0 lepidic adenocarcinoma who met study criteria, 1,544 patients underwent lobectomy and 447 underwent sublobar resections. Patients treated with sublobar resection were older, more likely to be female, had higher Charlson/Deyo comorbidity scores, but had smaller tumors and lower T-status. Of patients treated with lobectomy, 6% (n=92) were upstaged due to positive nodal disease, with a median of 6 lymph nodes sampled (IQR: 3,10). In an analysis of the entire cohort, lobectomy was associated with a significant survival advantage over sublobar resection in univariate analysis (median survival 9.2 vs. 7.5 years, p=0.022; 5-year survival 70.5% vs. 67.8%) and following multivariable adjustment (hazard ratio [HR]: 0.81 [95% [CI]: 0.68-0.95], p=0.011), (Figure 1). However, lobectomy was no longer independently associated with improved survival when compared to sublobar resection (HR: 0.99 [95% CI: 0.77-1.27], p= 0.905) in a multivariable analysis of a subset of patients that compared only those patients who underwent sublobar resection that included lymph node sampling to patients treated with lobectomy. Figure 1
Conclusion:
Surgeons treating patients with stage I lung adenocarcinoma with lepidic features should cautiously utilize sublobar resection rather than lobectomy and must always perform adequate pathologic lymph node evaluation.
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P3.07 - Poster Session with Presenters Present (ID 493)
- Event: WCLC 2016
- Type: Poster Presenters Present
- Track: Regional Aspects/Health Policy/Public Health
- Presentations: 1
- Moderators:
- Coordinates: 12/07/2016, 14:30 - 15:45, Hall B (Poster Area)
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P3.07-012 - Disparities in Guideline-Concordant Treatment for Node-positive Non-Small Cell Lung Cancer Following Surgery (ID 4382)
14:30 - 15:45 | Author(s): T. D'Amico
- Abstract
Background:
To examine guideline concordance across a national sample and to determine the relationship between socioeconomic factors, use of recommended post-operative therapy, and outcomes for patients with pN1 or pN2 non-small cell lung cancer (NSCLC).
Methods:
All margin-negative pT1-3 N1-2 M0 NSCLC treated with lobectomy or pneumonectomy without induction therapy in the National Cancer Data Base (NCDB) between 2006-2011 were included for analysis. Use of guideline-concordant adjuvant therapy, defined as chemotherapy for pN1 disease and chemoradiation therapy for pN2 disease, were examined regarding pathologic, demographic, and socioeconomic factors. Multivariable regression models were developed to estimate predictors of guideline adherence and outcomes. Survival was estimated using the Kaplan-Meier method.
Results:
A total of 9,300 patients were identified. Of these, 7,137 had pN1 disease and 2,163 had pN2 disease. Guideline-concordant adjuvant therapy was utilized in 4,477 (62.7%) pN1 patients and 646 (29.9%) pN2 patients. After multivariable adjustment, patient age (OR 0.59 per decade, 95% confidence interval [CI]: 0.56-0.63), uninsured status (OR 0.52, 95%CI:0.39-0.71), N2 disease (OR 0.21, 95%CI:0.18-0.23), pneumonectomy (OR 0.75, 95%CI:0.65-0.86), longer postoperative length of stay (OR 0.96/day, 95%CI:0.95-0.97) and unplanned readmission (OR 0.76, 95%CI:0.61-0.95) were associated with significantly worse guideline concordance, while higher education levels (OR 1.07 per quartile, 95%CI:1.01-1.14) and increasing T-stage (OR 1.08, 95%CI:1.01-1.16) were associated with significantly higher concordance. Overall, patients treated with guideline-concordant therapy had superior survival (5-year survival: 50.4 vs. 35.3%, p<0.001; Figure).Figure 1
Conclusion:
Socioeconomic factors, including lack of insurance, are associated with disparities in use of adjuvant therapy as recommended by National Comprehensive Cancer Network guidelines. These disparities have significant impact on patient outcomes. Future work should focus on improving access to appropriate adjuvant therapies among the uninsured and socioeconomically disadvantaged.
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SC01 - Staging Before and After Induction Therapy for N2 Disease (ID 325)
- Event: WCLC 2016
- Type: Science Session
- Track: Radiology/Staging/Screening
- Presentations: 1
- Moderators:G. Mostbeck, E. Fadel
- Coordinates: 12/05/2016, 11:00 - 12:30, Lehar 3-4
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SC01.05 - Video-Thoracoscopy for Staging of N2 NSCLC During Induction Therapy (ID 6602)
11:00 - 12:30 | Author(s): T. D'Amico
- Abstract
Abstract:
The optimal strategy for patients with stage III non-small cell lung cancer (NSCLC) is not well-established and significant variation in practice exists across the United States and Europe. In the U.S., the majority of National Comprehensive Cancer Network (NCCN) member institutions consider surgery to be indicated in stage IIIA patients with involvement of a single N2 lymph node station smaller than 3 cm who have undergone induction chemotherapy. However, there is no agreement among institutions regarding treatment for other manifestations of stage IIIA-N2 involvement (e.g., multi-station or bulky disease) and both NCCN and European Society of Medical Oncology (ESMO) guidelines recommend that the role of surgery be discussed in a multidisciplinary tumor board setting. The use of induction chemotherapy vs induction chemoradiotherapy is currently of great interest worldwide, and the use of the latter is still common despite the results of numerous clinical trials and meta-analysis. The lack of consensus regarding treatment strategies for stage III NSCLC is in part due to the relatively low number of randomized studies available to guide decision-making, as well as institutional biases despite evidence. One important issue is the role and methods of restaging after induction therapy for patients with potentially resectable Stage IIIA (N2) disease. While all would agree that pathologic confirmation of N2 disease prior to induction chemotherapy is mandatory, using EBUS or mediastinoscopy, not all surgeons believe that restaging after induction therapy to confirm response to chemotherapy is necessary, despite evidence that the overall and cancer-specific survival of non-responders is quite low. There are 2 dominant strategies for staging and restaging patients with N2 disease: EBUS prior to induction therapy and restaging with videomediastinoscopy or mediastinoscopy prior to induction therapy and restaging with thoracoscopy or repeat mediastinoscopy. There may be a role for each strategy depending on individual patient characteristics. Advantages of thoracoscopic restaging after induction therapy include the ability to resect all ipsilateral nodes to most accurately assess response and the resection of nodal tissue at thoracoscopy is the first step in thoracoscopic resection and thus greatly facilitates the procedure. The role of thoracoscopic restaging after induction therapy will be reviewed, and the technical aspects for successful restaging and thoracoscopic lobectomy after induction therapy are demonstrated in videos. References 1. Martins RG, D'Amico TA, Loo BW, Jr., et al. The management of patients with stage IIIA non-small cell lung cancer with N2 mediastinal node involvement. Journal of the National Comprehensive Cancer Network : JNCCN. 2012;10(5):599-613. 2. Vansteenkiste J, De Ruysscher, D, Eberhardt WEE, Lim E, Senan S, Felip E, Peters s. Early-Stage and Locally Advanced (non-metastatic) Non-Small-Cell Lung Cancer: ESMO Clinical Practice Guidelines. Annals of Oncology. 2013;24((suppl 6)):vi 89-98. 3. Ettinger DS, Wood DE, Akerley W, et al. Non-small cell lung cancer, version 6.2015. Journal of the National Comprehensive Cancer Network : JNCCN. 2015;13(5):515-524. 4. Weeks JC, Uno H, Taback N, et al. Interinstitutional variation in management decisions for treatment of 4 common types of cancer: A multi-institutional cohort study. Annals of internal medicine. 2014;161(1):20-30. 5. Pless M, Stupp R, Ris HB, et al. Induction chemoradiation in stage IIIA/N2 non-small-cell lung cancer: a phase 3 randomised trial. Lancet. 2015;386(9998):1049-1056. 6. Katakami N, Tada H, Mitsudomi T, et al. A phase 3 study of induction treatment with concurrent chemoradiotherapy versus chemotherapy before surgery in patients with pathologically confirmed N2 stage IIIA nonsmall cell lung cancer (WJTOG9903). Cancer. 2012;118(24):6126-6135. 7. Girard N, Mornex F, Douillard JY, et al. Is neoadjuvant chemoradiotherapy a feasible strategy for stage IIIA-N2 non-small cell lung cancer? Mature results of the randomized IFCT-0101 phase II trial. Lung Cancer. 2010;69(1):86-93. 8 Jaklitsch MT, Gu L, Harpole DH, D'Amico TA, et al. Prospective phase II trial of pre-resection thoracoscopic restaging following neoadjuvant therapy for IIIA(N2) non-small cell lung cancer: Results of CALGB 39803. J Thorac Cardiovasc Surg 2013;146: 9-16 9. Yang CF, Gulack BC, Gu L, et al. Adding radiation to induction chemotherapy does not improve survival of patients with operable clinical N2 non-small cell lung cancer. The Journal of thoracic and cardiovascular surgery. 2015;150(6):1484-1492; discussion 1492-1483. 10. Shah AA, Berry MF, Tzao C, et al. Induction chemoradiation is not superior to induction chemotherapy alone in stage IIIA lung cancer. Ann Thorac Surg. 2012;93(6):1807-1812.
