Inaccurate Clinical Stage is Common and Associated With Poor Survival in Patients With Lung Cancer.

INTRODUCTION: Clinical staging in lung cancer has implications for treatment planning and prognosis. We sought to determine the rate of inaccurate clinical stage (relative to pathologic), identify risk factors for inaccuracy, and evaluate the association of inaccuracy on survival. We hypothesized that inaccurate staging was associated with poor survival. METHODS: In this retrospective cohort study, adult patients who received surgical resection without neoadjuvant treatment for nonsmall cell lung cancer from 2004 to 2020 in the National Cancer Database were categorized by accuracy of clinical stage (relative to pathologic stage). Multivariate models were used to determine risk factors for inaccuracy. The association between inaccuracy and overall survival was also analyzed. RESULTS: We identified 255,598 patients with lung cancer, including 84,543 patients (33.1%) who were inaccurately staged. Stage inaccuracy was associated with higher tumor, node, metastasis stage (T-category 3: odds ratio [OR] = 1.2, 95% confidence interval [CI] 1.15-1.28; N-category 2: OR = 2.6, 95% CI 2.47-2.79), greater quantity of lymph nodes evaluated, and more extensive resection (extended lobectomy/bilobectomy: OR = 1.3, 95% CI 1.20-1.37; pneumonectomy: OR = 1.6, 95% CI 1.54-1.74). Patients undergoing robotic surgery were less likely to be inaccurately staged (OR = 0.89, 95% CI 0.852-0.939). Inaccurate staging was associated with worse overall survival (5-y 67.5% accurate versus 55.4% inaccurate, P < 0.001). Inaccurate staging was also associated with worse survival in a multivariate Cox model (hazard ratio [HR] = 1.3, 95% CI 1.29-1.33). Both "understaging" (path > clinical) and "overstaging" (clinical > path) were associated with inferior survival. CONCLUSIONS: Inaccurate clinical stage (relative to pathologic) occurs in one-third of patients receiving surgery for lung cancer. Inaccuracy is associated with poor survival. Quality improvement initiatives should focus on improving clinical staging accuracy.

The Society of Thoracic Surgeons Database Analysis: Comparing Sublobar Techniques in Stage IA Lung Cancer.

BACKGROUND: This study compares sublobar resections-wedge resection and segmentectomy-in clinical stage IA lung cancers. It tests the hypothesis that overall survival after wedge resection is similar to segmentectomy. METHODS: Adults undergoing wedge resection or segmentectomy for clinical stage IA lung cancer were identified from The Society of Thoracic Surgeons General Thoracic Surgery Database. Eligible patients were linked to the Centers for Medicare and Medicaid Services database using a matching algorithm. The primary outcome was long-term overall survival. Propensity scores overlap weighting (PSOW) adjustment of wedge resection using validated covariates was used for group difference mitigation. Kaplan-Meier and Cox regression models analyzed survival. All-cause first readmission, and morbidity and mortality were examined using PSOW regression models. RESULTS: Of 9756 patients, 6141 met inclusion criteria, comprising 2154 segmentectomies and 3987 wedge resections. PSOW reduced differences between the groups. Unadjusted perioperative mortality was comparable, but wedge resection showed lower major morbidity rates. Weighted regression analysis indicated reduced mortality and major morbidity risks in wedge resection. Kaplan-Meier analysis revealed no mortality difference between groups, which was confirmed by PSOW Cox regression models. The cumulative risk of readmission was also comparable for both groups, with Cox Fine-Gray models showing no difference in rehospitalization risks. CONCLUSIONS: In clinical stage IA lung cancer, relative to segmentectomy, wedge resection has comparable overall survival and lower perioperative morbidity, suggesting it is an equally effective option for the broader population of patients with clinical stage IA lung cancer, not only those at highest risk of complications.

Risk Factors for Chronic Atrial Fibrillation Following Lung Lobectomy.

INTRODUCTION: Postoperative atrial fibrillation (POAF) is a common complication following lung lobectomy and is associated with increased risk of stroke, mortality, and prolonged hospital length of stay. The purpose of this study was to define the risk factors for POAF after lobectomy, hypothesizing that operative approach would be associated with risk of chronic POAF. METHODS: The TriNetX database was used to identify adult patients with no history of arrythmia receiving elective lung lobectomy for cancer from 7/6/2003-7/6/2023. Patients were categorized by approach: video-assisted thoracoscopic surgery (VATS) or open. The outcome of interest was the presence of POAF occurring at 1-3 months ("early") and 12-24 months postop ("chronic"). Propensity matching was performed to reduce bias between cohorts. RESULTS: We identified 22,998 patients: 8472 (36.8%) who received open and 14,526 (63.2%) VATS lobectomy. The rate of early POAF was 3.7% of VATS and 5.3% of open patients. The rate of chronic POAF was 5.5 % of VATS patients and 6.2% of open lobectomy patients. Propensity matching decreased bias between the approach groups, creating 7942 pairs for analysis. After matching, the risk of early POAF was greater in the open approach (5.5% open vs 3.4% VATS, risk ratio 1.607 (95% confidence interval 1.385-1.865), P < 0.001). Chronic POAF was (also) higher in the open approach (6.3% open vs 5.2% VATS, Risk Ratio 1.211 (95%CI 1.067-1.374), P = 0.003). CONCLUSIONS: Postoperative atrial fibrillation (POAF) occurs more commonly after open lobectomy, both acutely and chronically. Providers should counsel patients about the risk of chronic arrythmia after lung resection.

National enrollment of lung cancer clinical trials is disproportionate based on race and health care access.

OBJECTIVE: Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives. METHODS: We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx_summ_other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering. RESULTS: A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll. CONCLUSIONS: Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies.

Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis.

INTRODUCTION: Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC. MATERIALS AND METHODS: In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery. RESULTS: Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001). CONCLUSIONS: This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.

Disparities and access to thoracic surgeons among esophagectomy patients in the United States.

Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.

Disparities in Access to Thoracic Surgeons among Patients Receiving Lung Lobectomy in the United States.

OBJECTIVE: Lung lobectomy is the standard of care for early-stage lung cancer. Studies have suggested improved outcomes associated with lobectomy performed by specialized thoracic surgery providers. We hypothesized that disparities would exist regarding access to thoracic surgeons among patients receiving lung lobectomy for cancer. METHODS: The Premier Hospital Database was used to identify adult inpatients receiving lung lobectomy from 2009 to 2019. Patients were categorized as receiving their lobectomy from a thoracic surgeon, cardiovascular surgeon, or general surgeon. Sample-weighted multivariable analysis was performed to identify factors associated with provider type. RESULTS: When adjusted for sampling, 121,711 patients were analyzed, including 71,709 (58.9%) who received lobectomy by a thoracic surgeon, 36,630 (30.1%) by a cardiovascular surgeon, and 13,373 (11.0%) by a general surgeon. Multivariable analysis showed that thoracic surgeon provider type was less likely with Black patients, Medicaid insurance, smaller hospital size, in the western region, and in rural areas. In addition, non-thoracic surgery specialty was less likely to perform minimally-invasive (MIS) lobectomy (cardiovascular OR 0.80, p < 0.001, general surgery OR 0.85, p = 0.003). CONCLUSIONS: In this nationally representative analysis, smaller, rural, non-teaching hospitals, and certain regions of the United States are less likely to receive lobectomy from a thoracic surgeon. Thoracic surgeon specialization is also independently associated with utilization of minimally invasive lobectomy. Combined, there are significant disparities in access to guideline-directed surgical care of patients receiving lung lobectomy.

Surgical Repair vs Stent for Esophageal Perforation: A Multi-institutional Database Analysis.

BACKGROUND: Endoscopic esophageal stenting is used as an alternative to surgical repair for esophageal perforation. Multi-institutional studies supporting stenting are lacking. The purpose of this study was to compare the outcomes of surgical repair and esophageal stenting in patients with esophageal perforation using a nationally representative database. We hypothesized that mortality between these approaches would not be different. METHODS: The Premier Healthcare Database was used to compare adult inpatients with esophageal perforation receiving either surgical repair or esophageal stenting from 2009 to 2019. Patients receiving intervention ≤7 days of admission were included in the analysis. Patients receiving both stent and repair on the same day were excluded. The composite outcome of interest was death or discharge to hospice. Logistic regression was used to evaluate independent predictors of death or hospice, adjusting for comorbidities. RESULTS: There were 2543 patients with esophageal perforation identified who received repair (1314 [51.7%]) or stenting (1229 [48.3%]). Stenting increased from 7.0% in 2009 to 78.1% in 2019. Patients receiving repair were more likely to be female and White and had fewer Elixhauser comorbidities. Death or discharge to hospice was more common after stent (134/1314 [10.2%] repair vs 199/1229 [16.2%] stent; P < .001); however, after adjustment for comorbidities, logistic regression suggested that death or hospice discharge was similar between approaches (stent vs repair: odds ratio, 1.074; 95% CI, 0.81-1.42; P = .622). Hospital length of stay was shorter after stenting (stent vs repair coefficient, -4.09; P < .001). CONCLUSIONS: In patients with esophageal perforation, the odds for death or discharge to hospice were similar for esophageal stenting compared with surgical repair.

Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database.

BACKGROUND: Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. METHODS: The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. RESULTS: Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001). CONCLUSIONS: In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.

Drain Amylase: A Simple and Versatile Method of Detecting Esophageal Anastomotic Leaks.

BACKGROUND: Anastomotic leak after esophagectomy is a significant cause of morbidity. Perianastomotic drain amylase is accurate in detecting leaks, but it is unclear whether its accuracy is affected by comorbid conditions, anastomotic method, or anastomotic location. We hypothesized that drain amylase would accurately discriminate leak in a variety of settings. METHODS: We reviewed 290 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. Patient comorbidities, operative variables, and drain amylase were collected. The diagnosis of a leak was based on the level of intervention required, and was characterized as clinically significant if it required wound opening or endoscopic or surgical intervention. Receiver-operating characteristic curves analysis was performed to determine the accuracy of amylase to detect leak for each patient variable. RESULTS: A total of 53 (18.3%) of 290 esophagectomies had an anastomotic leak, of which 33 (11.4%) of 290 were clinically significant. Drain amylase was a strong predictor of anastomotic leak on postoperative day (POD) 3 to POD 7, regardless of patient comorbidities, location of anastomosis, or technique of anastomosis, but was less accurate in the diagnosis of leak in current smokers (area under the receiver-operating characteristic curve, 0.530 vs 0.752; P = .006). A maximum drain amylase value no higher than 35 on POD 3, POD 4, or POD 5 was 88% sensitive in detecting leak at any point postoperatively. A value greater than or equal to 150 was 88% specific in diagnosing leak. CONCLUSIONS: Drain amylase is a versatile method for early detection of anastomotic leaks. Its accuracy is unaffected by neoadjuvant treatment, location or type of anastomosis, or patient comorbidities but may be less accurate in active smokers.

Robotic Approach Has Improved Outcomes for Minimally Invasive Resection of Mediastinal Tumors.

BACKGROUND: The optimal minimally invasive surgical approach to mediastinal tumors is unknown. There are limited reports comparing the outcomes of resection with robotic-assisted thoracoscopic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) surgery. We hypothesized that patients who underwent RATS would have improved outcomes. METHODS: The National Cancer Database was queried for all patients who underwent a minimally invasive surgical approach for any mediastinal tumor from 2010 to 2016. Patients were determined to have an adverse composite outcome if they had any of the adverse perioperative outcomes: conversion to open procedure, 90-day mortality, 30-day readmission, and positive pathologic margins. Secondary outcomes of interest were length of stay and overall survival. Multivariable logistic regression was used to assess likelihood of having a composite adverse outcome based on surgical approach. RESULTS: The study included 856 patients: 402 (47%) underwent VATS and 454 (53%) underwent RATS. RATS resections were associated with fewer conversions (4.9% vs 14.7%, P < .001), fewer positive margins (24.3% vs 31.6%, P = .02), shorter length of stay (3.8 days vs 4.3 days, P = .01), and fewer composite adverse events (36.7% vs 51.3%, P < .001). Multivariate analysis showed RATS (odds ratio, 0.44; P < .001) was independently associated with a decreased likelihood of a composite adverse outcome, even among tumors exceeding 4 cm (odds ratio, 0.45; P = .001). Overall survival was similar between the 2 groups. CONCLUSIONS: Among patients who underwent a minimally invasive surgical approach for a mediastinal tumor, RATS had fewer adverse outcomes than VATS, even for tumors 4 cm or larger. These data suggests that RATS may be the preferred technique for patients who are candidates for minimally invasive resection of mediastinal tumors.

Monitoring for Recurrence After Esophagectomy.

BACKGROUND: Current guidelines for follow-up after esophagectomy suggest only history and physical examination (HPE). With recent advances in chemotherapy and immunotherapy for patients with recurrent esophageal cancer, we hypothesized that surveillance imaging (SI) would identify patients with cancer recurrence earlier and improve long-term survival. METHODS: A retrospective review of all patients undergoing esophagectomy for esophageal cancer at a single institution between 2007 and 2018 was conducted. Patients were categorized as recurrence detected through SI or recurrence detected through HPE alone. Patients were excluded if recurrence occurred within 3 months of esophagectomy. RESULTS: During the study period, 225 esophageal cancer patients underwent an esophagectomy. Among these, 101 (44.9%) had SI and 124 (55.1%) had routine follow-up with HPE. There were 88 recurrences (39.1%) with median follow-up of 12 months. Rate of recurrence was similar based on screening method: 41 of 101 (40.6%) by SI and 47 of 124 (37.9%) by HPE (P = .68). Among patients with recurrence, recipients of additional treatment were also similar between groups, 36 of 41 (87.8%) by SI and 34 of 47 (72.3%) by HPE (P = .468). Among those who had a recurrence, the median overall survival was significantly longer in those undergoing SI at 23 months compared with those who received HPE at 16 months (P = .047). CONCLUSIONS: SI after esophagectomy is not associated with improved detection of recurrence, but is associated with improved overall survival once recurrence is detected. These data suggest that earlier identification of esophageal cancer recurrence may have survival benefit. Standardizing SI may prove beneficial for patients after esophagectomy.

Prophylactic Gynecologic Surgery at Time of Colectomy Benefits Women with Lynch Syndrome and Colon Cancer: A Markov Cost-Effectiveness Analysis.

BACKGROUND: Women with Lynch syndrome who have completed childbearing should be offered prophylactic hysterectomy and bilateral salpingo-oophorectomy for gynecologic cancer prevention. The benefit of prophylactic gynecologic surgery at the time of colon cancer resection is unclear. OBJECTIVE: This study aimed to compare the cost, quality of life, and likelihood of being alive and free from colon, endometrial, and ovarian cancer between operative choices for patients with Lynch syndrome undergoing surgery for colon cancer. DESIGN: A Markov decision tree spanning 40 years was constructed for a hypothetical cohort of 30-year-old women with Lynch syndrome who had been diagnosed with colon cancer. Outcomes of 6 surgical strategies were compared, including segmental or total abdominal colectomy with or without hysterectomy alone or combined with bilateral salpingo-oophorectomy. SETTINGS: A Markov cost-effectiveness analysis was performed at a single center. PATIENTS: A literature search was performed identifying studies of patients with genetically diagnosed Lynch syndrome that described cost, risk of mortality, and quality of life after colon cancer resection and prophylactic gynecologic surgery. MAIN OUTCOME MEASURES: The primary outcomes measured were quality-adjusted life-years and the likelihood of being alive and free from colon, endometrial, and ovarian cancer 40 years after surgery. RESULTS: Women with Lynch syndrome who underwent a total abdominal colectomy and hysterectomy with bilateral salpingo-oophorectomy had the highest likelihood of being alive and cancer free. Total abdominal colectomy with hysterectomy was a close second, but yielded the largest amount of quality-adjusted life-years and lowest cost. LIMITATIONS: This study is limited by the statistical method and quality of studies used. CONCLUSIONS: Total abdominal colectomy with prophylactic hysterectomy at 30 years of age was the most cost-effective surgical choice in women with Lynch syndrome and colon cancer. The addition of bilateral salpingo-oophorectomy offered the highest event-free survival and lowest mortality. However, the additional morbidity of premature menopause of prophylactic salpingo-oophorectomy for younger women outweighed the benefit of ovarian cancer prevention. See Video Abstract at http://links.lww.com/DCR/B287. LA CIRUGÍA GINECOLÓGICA PROFILÁCTICA EN EL MOMENTO DE LA COLECTOMÍA BENEFICIA A LAS MUJERES CON SÍNDROME DE LYNCH Y CÁNCER DE COLON: UN ANÁLISIS DE COSTO-EFECTIVIDAD DE MARKOV: Las mujeres con síndrome de Lynch que han completado la maternidad deberían recibir histerectomía profiláctica y salpingooforectomía bilateral para la prevención del cáncer ginecológico. El beneficio de la cirugía ginecológica profiláctica en el momento de la resección del cáncer de colon no está claro.Comparar el costo, la calidad de vida y la probabilidad de estar viva y libre de cáncer de colon, endometrio y ovario entre las opciones quirúrgicas para pacientes con síndrome de Lynch sometidos a cirugía por cáncer de colon.Se construyó un árbol de decisión de Markov que abarca cuarenta años para una cohorte hipotética de mujeres de 30 años con síndrome de Lynch diagnosticadas con cáncer de colon. Se compararon los resultados de seis estrategias quirúrgicas, incluida la colectomía abdominal segmentaria o total con o sin histerectomía sola o combinada con salpingooforectomía bilateral.Se realizó un análisis de costo-efectividad de Markov en un solo centro.se realizó una búsqueda bibliográfica para identificar estudios de pacientes con síndrome de Lynch con diagnóstico genético que describieron el costo, el riesgo de mortalidad y la calidad de vida después de la resección del cáncer de colon y la cirugía ginecológica profiláctica.años de vida ajustados por calidad y probabilidad de estar vivo y libre de cáncer de colon, endometrio y ovario 40 años después de la cirugía.Las mujeres con síndrome de Lynch que se sometieron a una colectomía e histerectomía abdominal total con salpingooforectomía bilateral tuvieron la mayor probabilidad de estar vivas y libres de cáncer. La colectomía abdominal total con histerectomía fue un segundo lugar cercano, pero produjo la mayor cantidad de años de vida ajustados por calidad y el costo más bajo.Este estudio está limitado por el método estadístico y la calidad de los estudios utilizados.La colectomía abdominal total con histerectomía profiláctica a los 30 años fue la opción quirúrgica más rentable en mujeres con síndrome de Lynch y cáncer de colon. La adición de salpingooforectomía bilateral ofreció la mayor supervivencia libre de eventos y la menor mortalidad. Sin embargo, la morbilidad adicional de la menopausia prematura de la salpingooforectomía profiláctica para las mujeres más jóvenes superó el beneficio de la prevención del cáncer de ovario. Consulte Video Resumen en http://links.lww.com/DCR/B287. (Traducción-Dr. Yesenia Rojas-Khalil).

Conventional Computed Tomographic Calcium Scoring vs full chest CTCS for lung cancer screening: a cost-effectiveness analysis.

BACKGROUND: Conventional CTCS images the mid/lower chest for coronary artery disease (CAD). Because many CAD patients are also at risk for lung malignancy, CTCS often discovers incidental pulmonary nodules (IPN). CTCS excludes the upper chest, where malignancy is common. Full-chest CTCS (FCT) may be a cost-effective screening tool for IPN. METHODS: A decision tree was created to compare a FCT to CTCS in a hypothetical patient cohort with suspected CAD. (Figure) The design compares the effects of missed cancers on CTCS with the cost of working up non-malignant nodules on FCT. The model was informed by results of the National Lung Screening Trial and literature review, including the rate of malignancy among patients receiving CTCS and the rate of malignancy in upper vs lower portions of the lung. The analysis outcomes are Quality-Adjusted Life Year (QALY) and incremental cost-effectiveness ratio (ICER), which is generally considered beneficial when <$50,000/QALY. RESULTS: Literature review suggests that rate of IPNs in the upper portion of the lung varied from 47 to 76%. Our model assumed that IPNs occur in upper and lower portions of the lung with equal frequency. The model also assumes an equal malignancy potential in upper lung IPNs despite data that malignancy occurs 61-66% in upper lung fields. In the base case analysis, a FCT will lead to an increase of 0.03 QALYs comparing to conventional CTCS (14.54 vs 14.51 QALY, respectively), which translates into an QALY increase of 16 days. The associated incremental cost for FCT is $278 ($1027 vs $748, FCT vs CTCS respectively. The incremental cost-effectiveness ratio (ICER) is $10,289/QALY, suggesting significant benefit. Sensitivity analysis shows this benefit increases proportional to the rate of malignancy in upper lung fields. CONCLUSION: Conventional CTCS may be a missed opportunity to screen for upper lung field cancers in high risk patients. The ICER of FCT is better than screening for breast cancer screening (mammograms $80 k/QALY) and colon cancer (colonoscopy $6 k/QALY). Prospective studies are appropriate to define protocols for FCT.

Total abdominal colectomy is cost-effective in treating colorectal cancer in patients with genetically diagnosed Lynch Syndrome.

BACKGROUND: Lynch syndrome (LS) has a 80% lifetime risk of developing colorectal cancer and metachronous cancer. No studies have examined the quality adjusted life expectancy after SEG or TAC for LS patients, which this study was aiming for. If TAC offers a higher quality adjusted life year (QALY) to SEG in LS patients, preoperative diagnosis of LS is critical as it alters the recommended surgical procedure. METHODS: A Markov decision tree was constructed using Treeage software to compare QALY of LS patients following SEG or TAC. Probabilities, cost, and utility were obtained from literature. Cost-effectiveness analyses were performed. RESULTS: TAC dominates SEG as both the life-saving and cost-saving strategy. TAC dominated SEG on QALY (17.80 vs 17.13 QALY) for a cohort of LS patients diagnosed at an average of 30 year old and followed every 2 years after initial surgery. CONCLUSIONS: We conclude that TAC as the primary surgical option for LS patients diagnosed with Stage I-III colon cancer is cost-effective. Further cost-effectiveness study is recommended to include extra-colonic malignancies in LS patients.

Vessel Ligation Fundamentals: A Comparison of Technical Evaluations by Crowdsourced Nonclinical Personnel and Surgical Faculty.

BACKGROUND: Evaluation of fundamental surgical skills is invaluable to the training of medical students and junior residents. This study assessed the effectiveness of crowdsourcing nonmedical personnel to evaluate technical proficiency at simulated vessel ligation. STUDY DESIGN: Fifteen videos were captured of participants performing vessel ligation using a low-fidelity model (5 attending surgeons and 5 medical students before and after training). These videos were evaluated by nonmedical personnel recruited through Amazon Mechanical Turk, as well as by 3 experienced surgical faculty. Evaluation criteria were based on Objective Structured Assessment of Technical Skills (scale: 5-25). Results were compared using Wilcoxon signed rank-sum and Cronbach's alpha (α). RESULTS: Thirty-two crowd workers evaluated all 15 videos. Crowd workers scored attending surgeon videos significantly higher than pretraining medical student videos (20.5 vs 14.9, p < 0.001), demonstrating construct validity. Across all videos, crowd evaluations were more lenient than expert evaluations (19.1 vs 14.5, p < 0.001). However, average volunteer evaluations correlated more strongly with average expert evaluations (α = 0.95) than the strength of correlation between any 2 individual expert evaluators (α = 0.72-0.88). Combined reimbursement for all workers was $80.00. CONCLUSION: After adjustments for score inflation, crowdsourced can evaluate surgical fundamentals with excellent validity. This resource is considerably less costly and potentially more reliable than individual expert evaluations.

Screening individuals with intracranial aneurysms for abdominal aortic aneurysms is cost-effective based on estimated coprevalence.

OBJECTIVE: Aneurysm rupture is a major cause of morbidity and mortality, and evidence suggests shared risk for both abdominal aortic aneurysms (AAAs) and intracranial aneurysms (IAs). We hypothesized that screening for AAA in patients with known IA is cost-effective. METHODS: We used a decision tree model to compare costs and outcomes of AAA screening vs no screening in a hypothetical cohort of patients with IA. We measured expected outcomes using quality-adjusted life-years (QALYs) and the incremental cost-effectiveness ratio (ICER). We performed a Monte Carlo simulation and additional sensitivity analyses to assess the effects of ranging base case variables on model outcomes and identified thresholds where a decision alternative dominated the model (both less expensive and more effective than the alternative). RESULTS: In our base case analysis, screening for AAA provided an additional 0.17 QALY (2.5-97.5 percentile: 0.11-0.27 QALY) at a saving of $201 (2.5-97.5 percentile: $-127 to $896). This yielded an ICER of $-1150/QALY (2.5-97.5 percentile: $-4299 to $6374/QALY), that is, screening saves $1150 per QALY gained. CONCLUSIONS: Based on this model, screening for AAA in individuals with IA is cost-effective at an ICER of $1150/QALY, well below accepted societal thresholds estimated at $60,000/QALY. Cost-effectiveness of cross-screening in these populations is sensitive to aneurysm coprevalence and risk of rupture. Further prospective study is warranted to validate this finding.