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Matthew P Smeltzer



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    MA 04 - Advocacy: Listen to the Patients (ID 655)

    • Event: WCLC 2017
    • Type: Mini Oral
    • Track: Patient Advocacy
    • Presentations: 1
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      MA 04.01 - Prospective Comparative Evaluation of Patient and Caregiver Perspectives on a Multidisciplinary Model of Lung Cancer Care (ID 10279)

      11:00 - 12:30  |  Presenting Author(s): Matthew P Smeltzer

      • Abstract
      • Presentation
      • Slides

      Background:
      Coordinated multidisciplinary (MD) lung cancer care, with all key specialists concurrently providing early input to develop a consensus care plan in collaboration with patients and their caregivers, may improve patient-centered outcomes over the usual serial care (SC) model, but needs rigorous evaluation.

      Method:
      Prospective, longitudinal study comparing newly-diagnosed lung cancer patients receiving MD vs. SC within the same US healthcare system. The MD intervention was implemented from lung cancer care initiation until definitive treatment decision. After that, both cohorts of patients received their actual cancer treatments within the same environments. At baseline and 6 months, patients completed treatment-related satisfaction measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and the Functional Assessment of Cancer Therapy- Lung (FACT-L) quality of life instrument. All measures were coded so that larger scores are better. Time-specific comparisons were made with the Wilcoxon-Mann-Whitney test and changes from baseline to 6 months were compared between MD vs. SC patients in mixed linear models.

      Result:
      The 463 patients who participated (156 MD, 307 SC) were similar in sex and health insurance. MD cohort was slightly older (69 v 66 years), with more racial minorities (37% v 29%). Patients receiving MD care reported greater satisfaction with the treatment plan (p=0.0266) and overall quality of care (p<0.0010) at 6 months. Additionally, satisfaction with the treatment plan showed greater improvement over time for MD vs. SC (p-value for trend=0.0046). SC patients showed more improvement in satisfaction with overall care than MD patients, but did not reach the level of satisfaction of MD patients at 6 months (p-value for trend=0.0018). Caregivers of MD patients perceived receiving better quality of care compared to other lung cancer patients than caregivers of SC patients (p=0.0049). Caregiver satisfaction did not differ between MD and SC in the communication measures or overall quality, and did not have significant differences in the trend over time. Patient reported Health-Related Quality of Life (HRQOL) improved from baseline to 6 months for the lung cancer-specific scale compared with no change with SC (p-value for trend= 0.0334). Other HRQOL scales were similar between groups

      Conclusion:
      Compared with SC patients, MD patients experienced improved lung cancer-specific HRQOL and greater satisfaction with both treatment plan and quality of care received. MD patients’ caregivers were more likely than SC patients’ caregivers to think their care was better than that of other patients.

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    OA 15 - Diagnostic Radiology, Staging and Screening for Lung Cancer II (ID 684)

    • Event: WCLC 2017
    • Type: Oral
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      OA 15.08 - Thoroughness of Staging and the Outcomes of Surgical Resection Outcomes in Potentially Curable Non-Small Cell Lung Cancer (NSCLC) (ID 10059)

      14:30 - 16:15  |  Presenting Author(s): Matthew P Smeltzer

      • Abstract
      • Presentation
      • Slides

      Background:
      Substantial variation exists in the processes of care for potentially curable NSCLC. We examined the impact of thoroughness of staging for patients undergoing NSCLC surgery in a large, heterogeneous population within a lung cancer endemic region of the US.

      Method:
      We evaluated all surgically resected patients in the Mid-South Quality of Surgical Resection (MS-QSR) cohort from 2009-2017. MS-QSR is a population-based cohort including all curative-intent NSCLC resections at 11 hospitals in the mid-south US. Patients were classified into 8 groups based on use (Yes/No) of the following staging modalities: PET/CT, pre-operative invasive staging, operative mediastinal nodal examination (MLE). We compared stage distribution, adjuvant therapy, and overall survival outcomes across groups using the chi-square test and adjusted Proportional Hazards Models.

      Result:
      The 2,370 patients had a median age of 67 years, were 53% male. The racial distribution was: 70% White, 25% Black, 5% Other. Clinical N-stage was similar between the 8 groups. We found statistically significant differences in pathologic stage distribution, adjuvant therapy usage, and overall survival across the 8 groups (Table 1). Patients who received PET/CT, invasive staging, and MLE (Group 1) had significantly higher pathologic N-stage distribution compared to the other groups due to substantial nodal upstaging. Group 1 had 76% eligibility and 31% use of adjuvant chemotherapy compared to 51% and 8% in the Group 8 (No PET/CT, No Invasive Staging, No MLE). Use and eligibility for adjuvant radiation therapy was also highest in Group 1. There was an overall difference in survival across the groups (p-value=0.0019) which remained significant after adjusting for age, sex, race, histology, and path stage (p-value=0.0013). After adjustment, Group 8 had a 14% increased hazard of death compared with Group 1. Figure 1



      Conclusion:
      A less thorough approach to staging may lead to less nodal upstaging and less eligibility for adjuvant therapy, which could have implications for long term survival.

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    P1.13 - Radiology/Staging/Screening (ID 699)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Radiology/Staging/Screening
    • Presentations: 1
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      P1.13-011 - Prospective Cohort Study of Patterns of Staging and Treatment Selection with or Without Multidisciplinary (MD) Care (ID 10099)

      09:30 - 16:00  |  Author(s): Matthew P Smeltzer

      • Abstract
      • Slides

      Background:
      Lung cancer survival depends on accurate staging and treatment selection. Because staging and treatment are increasingly multi-modal, we examined staging and treatment selection practices with or without MD care in a single healthcare system.

      Method:
      Eligible patients had untreated lung cancer, ECOG performance status of 0-2, and gave informed consent. Comparisons were made between patients seen in a co-located MD clinic (MDC) and those receiving standard care (SC). Some SC patients were discussed at a multidisciplinary tumor conference (MDTC), thus allowing comparison of MD care to pure SC and MDTC. Diagnostic, staging, treatment procedures and patient outcomes were prospectively recorded. Staging thoroughness was defined as biopsy of stage-defining lesion; bimodality staging (PET+CT or CT+invasive staging biopsy); trimodality staging (PET+CT+invasive staging biopsy). Stage migration was determined comparing baseline stage (from first radiologic scan) to final clinical stage prior to treatment. Stage-appropriate treatment was defined by NCCN guidelines using final, pre-treatment stage. Chi-squared test and multivariable logistic regressions adjusted for age, sex, and histology were used to examine differences between patient cohorts.

      Result:
      Of 527 patients, 178 were MDC, 77 MDTC, 272 SC. Race and gender were similar but median age (67 v 66 v 69 (p=0.0032) and insurance distribution (p=0.0021) differed across groups. MDC tended to have more thorough staging than MDTC and SC. Significant differences were observed in staging migration and appropriate treatment, favoring MDC and MDTC patients (Table 1). After adjusting for age, sex, and histology, MCD and MDTC were 2-3 times more likely to have more thorough staging and overall stage appropriate treatment (Table 1). Figure 1



      Conclusion:
      Care within a structured MDC environment (whether co-located MDC or MDTC) was associated with significantly more thorough staging processes and higher rates of stage-appropriate use of treatment modalities than usual care. Survival analysis will be reported when data are mature.

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    P2.16 - Surgery (ID 717)

    • Event: WCLC 2017
    • Type: Poster Session with Presenters Present
    • Track: Surgery
    • Presentations: 1
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      P2.16-019 - Improving Survival with a Lymph Node (LN) Collection Kit for Non-Small Cell Lung Cancer (NSCLC) Resections (ID 10000)

      09:30 - 16:00  |  Author(s): Matthew P Smeltzer

      • Abstract
      • Slides

      Background:
      Poor pathologic nodal staging impairs overall survival (OS) after curative-intent surgical resection of NSCLC. We implemented a LN collection kit and previously demonstrated how it improves pathologic nodal staging. We now report its survival impact.

      Method:
      Using a prospective step-wedge design, kits were implemented for curative-intent surgical resections from 2009-2017 in 11 hospitals within 4 contiguous US Dartmouth Hospital Referral Regions. OS was analyzed with the Kaplan-Meier method. Crude (HR) and adjusted (aHR) hazard ratios with 95% confidence intervals (CI) are presented from Proportional Hazards Models adjusted for clustering by surgeon. Covariates in adjusted models include: age, sex, histology, tumor grade, extent of resection, T and M categories, and number of comorbidities.

      Result:
      The LN kit was used in 734 of 2,547 (29%) resections. All demographic and clinical characteristics, including age, sex, race, health insurance coverage and preoperative stage distribution were similar between kit and non-kit cases. Aggregate 1, 3, 5-year OS: 89%, 74%, 66%(kit) vs. 83%, 65%, 53% (non-kit) (p< 0.0001, Fig.1). Clinical stage stratification (kit v non-), 5-year OS: I, 68% vs. 58%, (p-value=0.0038); II, 68% vs. 40%, (p=0.0045); III, 57% vs. 42%, (p=0.0412). Pathologic stage stratification (kit v non-) 5-year OS: I, 72% vs. 59% (p=0.0082), II, 60% vs. 44% (p=0.0403); III, 48% vs. 36%, p =0.0179). For both clinical and pathologic Stage IV, survival did not differ. Kit cases had a 30% lower hazard of death compared to non-kit cases: HR 0.67 (CI[0.55,0.80], p<0.0001) and aHR: 0.70 (CI[0.54,0.92], p<0.0001). Results remained statistically significant after multiple sensitivity analyses excluding sub-lobar resections, 60-day mortality, non-adopting surgeons, and excluding the 48 months of retrospective baseline control data (aHR: 0.28 to 0.73). Operating time, perioperative complication rates, and duration of hospitalization were similar between groups. Figure 1



      Conclusion:
      Intraoperative specimen collection with a LN kit improves long-term NSCLC survival.

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