Lung cancer patient follow-up: motivation of thoracic surgeons.

STUDY OBJECTIVES: To analyze variation in beliefs that potentially motivate thoracic surgeons in the design of posttreatment surveillance strategies for lung cancer patients and to examine the relationship between motivation and follow-up intensity. DESIGN: International survey. SETTING: Ambulatory care. PARTICIPANTS: All 3,700 members of the Society of Thoracic Surgeons were surveyed to measure their follow-up practices during the 5-year period after treatment, physician beliefs, and variation in these beliefs. The relationship between beliefs, as potentially motivating factors, and follow-up intensity was also analyzed. MEASUREMENTS AND RESULTS: Age, General Thoracic Surgery Club membership, percentage of practice that was noncardiac, South Central United States practice location, and overseas practice location were most frequently related to beliefs that potentially motivate physicians in the design of surveillance strategies. When viewed independently of follow-up practice patterns, thoracic surgeons appear to be motivated by the desire to please patients, avoid malpractice suits, and improve patient quality of life. When viewed in relation to self-reported follow-up, none of these motivating factors were consistently associated with follow-up intensity. Belief in curative treatment of recurrence and enhanced likelihood of immediate palliative treatment leading to improved survival were the factors most frequently associated with variation in follow-up. Although the ability of the logistic and stepwise regression models to predict test use and follow-up intensity was less than optimal for TNM stage I patients, predictive ability was substantially improved for TNM stage II and III patients by including earlier-stage practice patterns as an independent variable. CONCLUSIONS: Physician characteristics and beliefs predicted a less than expected amount of the variation in self-reported follow-up intensity by TNM stage when modelled without knowledge of follow-up practice for any other TNM stage. Discrepancies between self-reported and actual follow-up may be partially responsible, although lack of surveillance guidelines is more likely. The inclusion of barriers to follow-up may improve future models.

How tumor stage affects surgeons' surveillance strategies after lung cancer surgery.

The factors that influence decision making among surgeons are not well understood. We evaluated how tumor stage in patients subjected to potentially curative surgery for lung cancer affects the self-reported follow-up strategies employed by practicing surgeons. Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to the 3,700 members of the Society of Thoracic Surgeons. The effect of TNM stage on the surveillance strategies chosen by the respondents was analyzed. All of the ten most commonly employed surveillance modalities were ordered significantly more frequently with increasing TNM stage, although the differences are small. Only 23% of respondents modified their strategies according to the patient's TNM stage. This effect persisted through 5 years of follow-up. We conclude that most surgeons performing surveillance after potentially curative surgery for otherwise healthy patients with lung cancer use the same follow-up strategy irrespective of TNM stage. These data should help in the design of prospective trials of this topic.

Geographic variation in the conduct of patient surveillance after lung cancer surgery.

PURPOSE: Considerable variation among surgeons exists in the current practice of patient surveillance after lung cancer treatment. We evaluated whether geographic factors are responsible for this observed variation. METHODS: Profiles of hypothetical patients suitable for postoperative surveillance and a detailed questionnaire based on the profiles were mailed to the 3,700 members of the Society of Thoracic Surgery (STS). The influence of the geographic location of the respondents on practice patterns was assessed among eight large metropolitan statistical areas (MSAs) with sufficient numbers of respondents, among nine broad geographic areas (United States census regions), and by the population size of the MSA from which the respondents reported. RESULTS: There were 2,009 responses (54% return rate); 768 of those respondents both operate on and provide long-term follow-up care for lung cancer patients. There were sizeable effects of tumor-node-metastasis (TNM) stage and year postsurgery on practice patterns. Respondents from the Los Angeles/Long Beach MSA consistently had the highest frequency of follow-up test usage and those from the Tampa/St Petersburg MSA usually had the lowest. This held true for most testing modalities and was consistent across TNM stages I to III and years 1 to 5 postsurgery. Follow-up strategy was generally most intensive in the largest MSAs (population size, 2.5 to 10 million). The STS respondents from the Pacific US census region generally used the most intensive follow-up strategies and those from the East North Central and Mountain regions often used the least intensive. The differences disclosed in all three analyses were small. CONCLUSION: There is marked variation among STS members in surveillance strategy, and the determinants of testing intensity are complex and interrelated. TNM stage and year postsurgery clearly affect follow-up practice; this analysis provides the first evidence that geographic setting has rather little effect on the surveillance strategies of clinicians.

How practice patterns in colon cancer patient follow-up are affected by surgeon age.

BACKGROUND: Strategies for the follow-up of colon cancer patients after potentially curative treatment are known to vary widely. The optimal regimen remains unknown. We investigated whether the date of completion of formal surgical training affects choice of surveillance strategy. METHODS: The 1070 members of the Society of Surgical Oncology (SSO) and the 1663 members of the American Society of Colon and Rectal Surgeons (ASCRS) were surveyed using a detailed questionnaire to measure how these surgical experts deal with colon cancer follow-up. Subjects were asked how they use nine specific follow-up modalities during years 1-5 following primary treatment for patients with colon cancer (TNM Stages I-III). Repeated-measures analysis of variance was used to compare practice patterns by TNM stage and year post-surgery, as well as by the year in which the surgeon's formal surgery training was completed. RESULTS: Evaluable responses were received from 349 SSO members (33%) and 646 ASCRS members (39%). Few significant differences in follow-up practices were noted by training period, but follow-up for most of the nine modalities was highly correlated with TNM stage and year post-surgery, as expected. CONCLUSIONS: This analysis indicates that the post-treatment surveillance practice patterns of surgeons caring for patients with colon cancer do not vary substantially with practitioner age. The data provide credible evidence that postgraduate education is effective in homogenizing practitioner behaviour.

Geographic variation in patient surveillance after colon cancer surgery.

PURPOSE: Considerable variation among surgeons exists in the current practice of patient surveillance after colon cancer treatment. We evaluated whether geographic factors are responsible for this observed variation. METHODS: Profiles of hypothetical patients and a detailed questionnaire based on the profiles were mailed to 2,733 members of two national surgical societies. The influence of the geographic location of the respondents on practice patterns were assessed in two ways. Repeated-measures analysis of variance was used to compare the practice patterns among 19 large metropolitan statistical areas (MSAs) and chi 2 analysis was used to determine whether these patterns differed by MSA population size. RESULTS: Seven of nine commonly used surveillance modalities were ordered significantly more frequently with increasing tumor-node-metastasis (TNM) stage and significantly less frequently with year postsurgery among the 995 respondents with assessable responses, but MSA population size and geographic location of physicians generally had no effect on documented practice variability. The remaining two modalities (bone scan and computed tomography [CT]) were used so infrequently as to preclude meaningful analysis. CONCLUSION: Surveillance after potentially curative colon cancer surgery for otherwise healthy patients is not significantly affected by the geographic location of the surgeon who performs the surveillance testing and only modestly affected by the population size of the MSA in which he/she practices. These data should help in the design of prospective trials of this topic.

Clinical surveillance testing after lung cancer operations.

BACKGROUND: Although routine clinical surveillance testing after lung cancer operation has important clinical implications for patients and financial implications for society, the ideal surveillance strategy is unknown. METHODS: We surveyed The Society of Thoracic Surgeons membership by questionnaire to characterize the current practice of follow-up among experts in lung cancer treatment. There were 2,009 responses (54% return) from the 3,700 members; 768 of those responding both operate on and provide long-term follow-up for lung cancer patients. These responses form the basis of this study. RESULTS: The follow-up methods most frequently used during a 5-year follow-up include clinic visit, chest roentgenography, complete blood cell count, liver function testing, and chest computed tomography. Sputum cytology, head computed tomography, bone scanning, chest magnetic resonance imaging, and bronchoscopy are used infrequently. Although there is wide variation in the frequency of use of these ten methods, there is significant (p < 0.05) decrease in the frequency of testing over time for all tests except sputum cytology and chest magnetic resonance imaging. The survey also requested information regarding motivation behind routine clinical surveillance testing. Although the presumed rationale for such follow-up includes probable clinical benefit for the patient, fewer than half of respondents believe that such surveillance testing would yield a survival benefit for either stage I (44% of respondents) or advanced-stage patients (17% of respondents) after lung cancer resection. Only 1 of 4 respondents believe that the current literature documents any survival benefit. Other reasons for follow-up include maintenance of rapport with colleagues or patients and medicolegal liability concerns. CONCLUSIONS: This survey provides direct evidence regarding current surveillance practice among thoracic surgeons. There appears to be marked variation among members of The Society of Thoracic Surgeons in frequency of and rationale for routine clinical surveillance testing.

Surveillance after curative colon cancer resection: practice patterns of surgical subspecialists.

BACKGROUND: In the literature, suggested strategies for the follow-up of colon cancer patients after potentially curative resections vary widely. The optimal regimen to monitor for recurrences and new primary tumors remains unknown. The nationwide cost impact of wide practice variation is also unknown. METHODS: The 1,070 members of The Society of Surgical Oncology (SSO) were surveyed using a detailed questionnaire to measure the practice patterns of surgical experts nationwide. Respondents were asked how often they use nine separate methodologies in follow-up during years 1-5 postsurgery for TNM stage I, II, and III patients. Costs were estimated for representative less and more intensive strategies. RESULTS: Evaluable responses were received from 349 members (33%). Office visit and carcinoembryonic antigen analysis were performed most frequently. SSO members generally see patients every 3 months in years 1-2, every 6 months in years 3-4, and annually thereafter. There was wide variability in test ordering patterns and moderate variation between SSO and previously surveyed American Society of Colon and Rectal Surgeons members. The charge differential between representative less and more intensive follow-up strategies for each annual U.S. patient cohort is approximately $800 million. CONCLUSIONS: Actual practice patterns vary widely, indicating lack of consensus regarding optimal follow-up. The enormous cost differential associated with such variation is difficult to justify because there is no proven benefit of more intensive follow-up.

How tumor stage affects surgeons' surveillance strategies after colon cancer surgery.

BACKGROUND: The factors that influence decision making among surgeons are not well understood. This study sought to evaluate how the tumor stage of patients subjected to potentially curative surgery for colon cancer affects the follow-up strategies used by practicing surgeons. METHODS: Hypothetical patient profiles and a detailed questionnaire based on these profiles were mailed to 2733 members of two major surgical societies. The effect of TNM Stage on the surveillance strategies chosen by the respondents was analyzed. RESULTS: Seven of the nine most commonly used surveillance modalities all were performed significantly more frequently with increasing TNM Stage. This effect persisted through 5 years of follow-up. The other two modalities (computed tomography and bone scan) were performed too infrequently for meaningful analysis. CONCLUSIONS: Surgeons performing surveillance after potentially curative surgery for otherwise healthy patients with colon cancer modify their strategies according to the patient's TNM Stage. These data should help in the design of prospective trials related to this topic.

Rare anal canal cancers in the U.S. veteran: patterns of disease and results of treatment.

Nationwide treatment results among U.S. veterans with rare anal cancers (AC) have not been previously reported. We sought to evaluate the demographics and treatment outcome of patients with rare AC in Veterans Affairs Medical Centers (VAMCs). Using national VA computer data sets, we identified all patients with the ICD-9 diagnostic code (154.2) for anal cancer from 1987-1991. Patient demographics, histopathology, tumor size, results of treatment, and survival data were sought from local tumor registrars. A total of 405 patients with AC were identified by computer search; 204 (51%) were evaluable. 164 (80%) had squamous cell carcinomas, 25 (13%) had basaloid carcinomas, 8 (4%) had melanomas and 7 (3%) had anal gland adenocarcinomas. Patients were treated either by local excision, abdominoperineal resection (APR), or primary chemoradiation. Mean follow-up was 5.1 years. Among 25 patients with basaloid tumors, 19/25 were treated with chemoradiation; 13/19 (68%) are alive, and 3/5 treated with radical surgery are living. Among the seven patients with adenocarcinoma, those treated with CR fared better than those who underwent APR. Among the 8 patients with melanoma, 3/7 (38%) underwent primary APR, and 5 (62%) were treated by local excision; 7/8 died. Rare anal tumors account for 20 per cent of all anal canal cancers in the VA population. Patients with basaloid tumors respond well to chemoradiation. Patients with anal melanoma continue to have a poor prognosis.

Evaluation of alternate messages on an electronic message strip to recruit subjects to a smoking-cessation program.

The authors previously published details of a method to evaluate the effectiveness of electronic message strips in recruiting subjects to a smoking-cessation program. They now report data suggesting that a shorter, more negative message yields better results than a longer, more positive message. The data also show that this approach increases the number of subjects who enroll in a smoking-cessation program and the number of subjects who actually quit smoking.

Periampullary cancer treatment in U.S. Department of Veterans Affairs hospitals: 1987-1991.

BACKGROUND: Reported treatment outcomes for painless jaundice caused by ampullary, distal biliary, or duodenal (ABD) cancer are better than those caused by pancreatic cancer. METHODS: Outcomes after resection, bypass, or biliary intubation were compared in 432 patients with ABD cancer and 1753 with periampullary pancreatic cancer from U.S. Veterans Affairs hospitals. Computer and tumor registrar records from 1987 to 1991 were compiled; follow-up to death was complete in more than 93%. RESULTS: Operative mortality and complication rates were similar for each diagnosis. Adenocarcinomas staged from registrar reports (179 ABD, 571 pancreatic) exhibited significantly longer mean survival time (analysis of variance; p < or = 0.03) in patients with ABD for all stage groupings (localized, node involvement, metastatic) when stratified by treatment. After localized cancer resection, projected 5-year survival rate was 30% in 58 patients with ABD and 6% in 64 with pancreatic cancer. However, mean survival rates were similar with or without resection when nodes were involved. No 5-year survivors were projected after resection with nodal or distant metastases. CONCLUSIONS: Patients with ABD had a longer mean survival time than those with pancreatic adenocarcinoma, and this difference persisted when studied by TNM stage. The curative potential of resection was confined to patients without nodal involvement.

Recurrent squamous cell carcinoma of the anal canal. Predictors of initial treatment failure and results of salvage therapy.

OBJECTIVE: The outcomes of patients with squamous cell carcinoma of the anal canal treated by either sphincter-preserving procedures or radical surgery were evaluated, with the goals of identifying factors predicting treatment failure and quantifying results of salvage therapy in patients with recurrent disease. BASIC PROCEDURES: A population-based study on all patients in all 159 hospitals of the Department of Veterans Affairs (VA) from 1987 to 1991 was carried out. Data were compiled from several national computerized VA data sets. Supplementary information from local tumor registrars also was obtained, including demographic information, discharge summaries, operative reports, pathology reports, and medical oncology and radiation oncology summaries. From these sources, information on tumor histology, tumor stage, tumor grade, presence of regional or distant metastases, surgical procedures, use of chemotherapy and radiation therapy (RT), toxicity of chemotherapy and RT, development of recurrent disease, treatment of recurrence, survival, and cause of death were obtained. MAIN FINDINGS: Four hundred five patients with anal cancer were identified by computer search, and 204 (51%) were evaluable; 164 of 204 (80%) had squamous cell carcinoma, 137 of whom (84%) were treated with sphincter-preserving procedures, and 27 of whom (16%) were treated by by radical surgery. One hundred fourteen of 138 (83%) were treated by multimodality therapy, which we defined as local excision followed by chemotherapy and RT. The mean dose of RT among patients treated by multimodality therapy was 4200 +/- 540 cGy and 82% of those treated with multimodality therapy received 5-FU/mitomycin C. Recurrent disease was diagnosed in 43 of all 149 patients (29%) with potentially curable disease. (stages I-III) Multivariate analysis revealed that stage at diagnosis (p = 0.04) and method of treatment (p = 0.03) were the sole predictors of recurrence. Fifty-three percent of patients who underwent salvage abdominoperineal resection (APR) are alive, whereas only 19% who underwent salvage chemotherapy with or without RT are alive. PRINCIPAL CONCLUSIONS: These data indicate that multimodality therapy currently is being employed in the majority of patients with squamous cell carcinoma of the anal canal in the VA system. Tumor stage and method of treatment appear to affect the likelihood of development of recurrent disease. Salvage APR has curative potential. Results with salvage chemotherapy and RT are disappointing.

Current follow-up strategies after resection of colon cancer. Results of a survey of members of the American Society of Colon and Rectal Surgeons.

UNLABELLED: The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown. PURPOSE: The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts. METHODS: The 1,663 members of The American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five posttreatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy. RESULTS: Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (> 75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1, 2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III. CONCLUSION: The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.