Long-term Outcomes After Lung Cancer Resection in Smokers: Analysis of the National Lung Screening Trial.

BACKGROUND: Smoking is a known risk factor for perioperative complications after lung resection; however, little data exists looking at the impact of smoking status (current versus former) on long-term oncologic outcomes after lung cancer surgery. We sought to compare overall survival (OS), progression-free survival (PFS), and cancer-specific mortality (CSM) in current and former smokers using data from the National Lung Screening Trial (NLST). Additionally, we performed subset analysis in current smokers in order to evaluate the effect of modern surgical techniques on long-term outcomes. METHODS: Patients with clinical stage IA or IB NSCLC who underwent upfront resection within 180 days of diagnosis were identified in the NLST database. Cox proportional hazard regression models were used to assess differences in patient and treatment characteristics with respect to OS and PFS, with a cause-specific hazard model used for CSM. RESULTS: A total of 593 patients were included in the study (269 former smokers, 324 current smokers). Lobar resection (LR) was performed more often than sublobar resection (SLR) (481 vs. 112), and thoracotomy was performed more often than thoracoscopy (482 vs. 86). Comparison of current versus former smokers showed no difference in OS or PFS after resection. Higher CSM was seen in current smokers (p = 0.049). Subset analysis of current smokers revealed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Although higher CSM was associated with thoracoscopy versus thoracotomy in this group, this finding was limited by a relatively small thoracoscopy sample size of 44 patients (p = 0.026). CONCLUSION: Our analysis of the NLST database shows no significant difference in OS and PFS when comparing current and former smokers undergoing resection for stage I NSCLC. Active smoking status was associated with higher CSM. Subset analysis of current smokers showed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Higher CSM was seen in current smokers who underwent thoracoscopy compared to thoracotomy; however, this finding was limited by a small sample size.

Impact of postoperative complications on long-term survival after esophagectomy in older adults: A SEER-Medicare analysis.

BACKGROUND: Esophagectomy is a complex procedure associated with a high rate of postoperative complications. It is not clear whether postoperative complications effect long-term survival. Most studies report the results from single institutions. METHODS: We examined the Surveillance, Epidemiology and End Results (SEER)-Medicare database to assess whether long-term overall and cancer-specific mortality of patients undergoing esophagectomy for cancer is impacted by postoperative complications. RESULTS: Nine hundred and forty patients underwent esophagectomy from 2007 to 2014, of which 50 died, resulting in a cohort of 890 patients. Majority were males (n = 764, 85.8%) with adenocarcinoma of the lower esophagus. Almost 60% of the group had no neoadjuvant therapy. Four hundred and fifty-five patients had no major complications (51.1%), while 285 (32.0%) and 150 (16.9%) patients had one, two, or more major complications, respectively. Overall survival at 90 days was 93.1%. Multivariate analysis of patients followed up for a minimum of 90 days demonstrated that the number of complications was significantly associated with decreased overall survival but no impact on cancer-specific survival. CONCLUSIONS: Our population-based analysis with its inherent limitations suggests that patients undergoing esophagectomy who experience complications have worse overall survival but not cancer-specific survival if they survive at least 90 days from the date of surgery.

A Comparative Analysis of Long-Term Survival of Robotic Versus Thoracoscopic Lobectomy.

BACKGROUND: Minimally invasive lobectomy can be performed robotically or thoracoscopically. Short-term outcomes between the 2 approaches are reported to be similar; however, the comparative oncological effectiveness is not known. We sought to compare long-term survival after robotic and thoracoscopic lobectomy. METHODS: We performed a propensity-matched analysis of SEER (Surveillance, Epidemiology and End Results)-Medicare patients with non-small cell lung cancer from 2008 to 2013 who underwent minimally invasive lobectomy using either a thoracoscopic (n = 3881) or a robotic-assisted (n = 426) approach. Patients in the 2 groups were propensity matched 1:1 based on demographics, comorbidities, treatment, and tumor characteristics. We compared the overall survival (OS) and cancer-specific mortality (CSM) between the 2 groups. RESULTS: Within the matched cohort (n = 409 per group), the median age at surgery was 73 (range, 65-91) years, with a median follow-up of 35 months postsurgery. There was no difference in OS or CSM between the thoracoscopic and robotic-assisted groups (OS: 71.4% vs 73.1% at 3 years, overall P = .366; CSM: 16.6% vs 14.9% at 3 years, overall P = .639). CONCLUSIONS: Our propensity-matched analysis demonstrates that patients undergoing robotic-assisted lobectomy have similar OS and CSM compared with those patients undergoing thoracoscopic lobectomy. Oncologic outcomes are similar between the 2 minimally invasive approaches. These results demonstrate that further investigation is needed in the form of a randomized control trial, its variations, or additional large-scale registry analyses to verify these results.

Improving Self-Reported Preoperative Anxiety Through a Preoperative Education Program: A Quality Improvement Project.

BACKGROUND: Preoperative education is an important component of preparing patients for surgery. Preoperative anxiety is one of the most important problems for patients, because it causes emotional and psychiatric problems as well as physical problems. Anxiety has been associated with several pathophysiological responses such as hypertension and dysrhythmias, which can increase perioperative morbidity. Estimates suggest that between 11% and 80% of adult presurgical patients experience heightened levels of anxiety. OBJECTIVE: The purpose of this pilot project was to develop a preoperative education program for thoracic surgery patients and to assess the effectiveness of the program in decreasing patient's self-reported anxiety levels using the validated Patient-Reported Outcomes Measurement Information System (PROMIS) tool. METHODS: This quality improvement project used a pre- and posttest improvement design to evaluate patient's self-reported anxiety levels at three different timepoints during the preoperative and postoperative period. A total of 15 patients from a thoracic surgery practice participated in the study. RESULTS: The study showed no statistically significant change in patients' self-reported anxiety levels after completion of the preoperative education program (p = .538). Patients reported improvements in parameters such as expectations, pain, and preparedness. CONCLUSIONS: Although some studies have found that preoperative patient education decreases anxiety, this study supports others that indicate that anxiety is not affected by or associated with educational preparation prior to thoracic surgery. Though no statistical improvement in anxiety levels was demonstrated in this study, a majority of patients reported improvements in parameters such as expectations, pain, and preparedness. IMPLICATIONS FOR NURSING: As patient education is largely provided by the nursing profession, this article will help the profession to better understand what is important for patients to know in the preoperative setting. Setting patient expectations has a great impact on the patient's recovery and satisfaction with their surgical experience. As this is a pilot study, the goal is for continued research in the area of decreasing preoperative anxiety and preparing patients for surgery.