Importance of tumour volume and histology in trimodality treatment of patients with Stage IIIA non-small cell lung cancer-results from a retrospective analysis.

OBJECTIVES: Chemoradiotherapy (CRT) has been the backbone of guideline-recommended treatment for Stage IIIA non-small cell lung cancer (NSCLC). However, in selected operable patients with a resectable tumour, good results have been achieved with trimodality treatment (TT). The objective of this bi-institutional analysis of outcomes in patients treated for Stage IIIA NSCLC was to identify particular factors supporting the role of surgery after CRT. METHODS: In a 2-centre retrospective cohort study, patients with Stage III NSCLC (seventh edition TNM) were identified and those patients with Stage IIIA who were treated with CRT or TT between January 2007 and December 2013 were selected. Patient characteristics as well as tumour parameters were evaluated in relation to outcome and whether or not these variables were predictive for the influence of treatment (TT or CRT) on outcome [overall survival (OS) or progression-free survival (PFS)]. Estimation of treatment effect on PFS and OS was performed using propensity-weighted cox regression analysis based on inverse probability weighting. RESULTS: From a database of 725 Stage III NSCLC patients, 257 Stage IIIA NSCLC patients, treated with curative intent, were analysed; 186 (72%) with cIIIA-N2 and 71 (28%) with cT3N1/cT4N0 disease. One hundred and ninety-six (76.3%) patients were treated by CRT alone (high-dose radiation with daily low-dose cisplatin) and 61 (23.7%) by TT. The unweighted data showed that TT resulted in better PFS and OS. After weighting for factors predictive of treatment assignment, patients with a large gross tumour volume (>120 cc) had better PFS when treated with TT, and patients with an adenocarcinoma treated with TT had better OS, regardless of tumour volume. CONCLUSIONS: Patients with Stage IIIA NSCLC and large tumour volume, as well as patients with adenocarcinoma, who were selected for TT, had favourable outcome compared to patients receiving CRT. This information can be used to assist multidisciplinary team decision-making and for stratifying patients in studies comparing TT and definitive CRT.

Pre- and postoperative care for stage I-III NSCLC: Which quality of care indicators are evidence-based?

Identification of evidenced-based Quality of Care (QoC) indicators for lung cancer care is essential to quality improvement. The aim of this review was to identify evidence-based quality indicators for the pre- and postoperative care of stage I-III Non Small Cell Lung Cancer (NSCLC) provided by the lung physician. To obtain these indicators, a search in PubMed, Embase and the Cochrane library database was performed. English literature published between 1980 and 2012 was included and search terms regarding 'lung neoplasms', 'quality of care', 'pathology', 'diagnostic methods', 'preoperative and postoperative treatment' were used. The potential indicators were categorized as structure, process or outcome measures and the indicators supported by literature with high evidence level were selected. Five QoC indicators were identified. The use of the positron emission tomography-computed tomography (PET-CT) results in more accurate mediastinal staging compared to the CT scan. Endoscopic Ultrasound-Fine Needle Aspiration and Endobronchial Ultrasound-Fine Needle Aspiration are sensitive diagnostic tools for mediastinal staging and reduce futile thoracotomies. Pathological conformation of lung cancer can best be obtained by a combination of cytological and histological diagnostics used during bronchoscopy. For patients with clinical stage III NSCLC, preoperative multimodality treatment (i.e. preoperative chemoradiation) results in superior survival and increased mediastinal downstaging compared to single modality treatment (i.e. preoperative chemotherapy or radiotherapy). After surgery, the addition of chemotherapy results in a significant survival benefit for patients with pathological stage II and III NSCLC. These five QoC indicators can be used for benchmarking and ultimately quality improvement of lung cancer care.

Peri- and postoperative management of stage I-III Non Small Cell Lung Cancer: Which quality of care indicators are evidence-based?

Quality of care (QoC) has a central role in our health care system. The aim of this review is to present a set of evidence-based quality indicators for the surgical treatment and postoperative management of lung cancer. A search was performed through PubMed, Embase and the Cochrane library database, including English literature, published between 1980 and 2012. Search terms regarding 'lung neoplasms', 'surgical treatment' and 'quality of care' were used. Potential QoC indicators were divided into structure, process or outcome measures and a final selection was made based upon the level of evidence. High hospital volume and surgery performed by a thoracic surgeon, were identified as important structure indicators. Sleeve resection instead of pneumonectomy and the importance of treatment within a clinical care path setting were identified as evidence-based process indicators. A symptom-based follow-up regime was identified as a new QoC indicator. These indicators can be used for registration, benchmarking and ultimately quality improvement in lung cancer surgery.

Optimal surgical management of pulmonary metastases: VATS versus thoracotomy.

Survival benefit after pulmonary metastasectomy is under question and knowledge of functional recovery after pulmonary metastasectomy by thoracotomy and video-assisted thoracoscopic surgery (VATS) is of great importance. We analysed prospective data of 100 patients operated for pulmonary metastasis by either VATS or thoracotomy. VATS yielded a better physical performance 1 month postoperative, shorter hospital stay, a shorter duration of chest tube drainage and epidural analgesia. We concluded that VATS is the preferable approach due to superior functional outcome.

A clinical audit in a multidisciplinary care path for thoracic surgery: an instrument for continuous quality improvement.

BACKGROUND: Although it is advocated that (major) surgical procedures should be embedded in clinical pathways, the efficacy of such pathways is hardly ever systematically evaluated. The objective of our study was to assess the results of a multidisciplinary care path for patients undergoing thoracic cancer surgery, using a concurrent integrated prospective database. METHODS: From April 2006 to December 2008, 169 eligible patients, admitted for thoracic cancer surgery in our institute, gave informed consent to participate in this prospective study. Detailed clinical data concerning patient-, tumour-, treatment- and outcome characteristics were collected. For evaluation of pain and quality of life (QoL), visual analogue scale (VAS) and SF-36 were used respectively. Information retrieved on 94 patients operated in the baseline period (until November 2007) was used in multidisciplinary consensus meetings to develop a new care path. After the introduction of this care path (January 2008) data-collection continued to evaluate outcome using the data of 75 patients operated in the evaluation period (until December 2008). RESULTS: Data from the baseline period showed age (p=0.001), indication (p=0.03), postoperative pain (p<0.001) and complications (p<0.001) to be independently related to length of stay (LOS). Subsequently, the package of measures taken in the multidisciplinary care path were evaluated, showing significantly less postoperative pain (p=0.026) and a reduced length of hospital stay (p=0.014). In addition, a (trend towards) improvement in physical quality of life was observed 1 month (p=0.03) and 6 months (p=0.07) postoperatively. CONCLUSION: The use of a prospective database integrated in a clinical care path for thoracic cancer patients revealed important improvements of the care process determining short- and long-term outcome. There was a significant reduction in length of hospital stay, postoperative pain and loss of quality of life. Ongoing and multicentre collection of such data can provide surgeons with instruments to further improve quality of care.