Thoracic – Original Submission
Impact of Surgeon Volume on Outcomes of Older Stage I Lung Cancer Patients Treated via Video-assisted Thoracoscopic Surgery

https://doi.org/10.1053/j.semtcvs.2017.01.013Get rights and content

Surgeon procedure volume influences outcomes of patients undergoing cancer operations. Limited data are available, however, on the volume-outcome relationship for video-assisted thoracoscopic surgery (VATS) in the treatment of non–small cell lung cancer (NSCLC). In this study, we used population-based data to evaluate the extent to which surgeon volume is associated with postoperative and long-term oncological outcomes following VATS resection for older patients with early-stage NSCLC. Stage I NSCLC patients >65 years treated with VATS wedge, segmentectomy, or lobectomy between 2000 and 2010 were identified from the Surveillance, Epidemiology, and End Results registry linked to Medicare. Surgeon volume was grouped into tertiles (low, intermediate, and high). Outcomes included perioperative complications, intensive care unit admission, extended length of stay, perioperative (30-day) mortality, and long-term overall and lung cancer-specific survival. We used propensity score methods to compare adjusted survival of patients by surgical volume group. A total of 2295 study patients were identified. Patients treated by high-volume surgeons had decreased intensive care unit admissions (hazard ratio [HR]: 0.46, 95% CI: 0.41-0.51) and postoperative length of stay (HR: 0.75, 95% CI: 0.61-0.92). Adjusted analyses showed that overall (HR: 0.73, 95% CI: 0.62-0.87) and lung cancer-specific (HR: 0.76, 95% CI: 0.58-0.99) survival was better for patients treated by high-volume surgeons. Elderly stage I NSCLC patients undergoing VATS by high-volume surgeons have reduced postoperative complications and improved survival. Organization of care favoring referrals of VATS candidates to high-volume providers may help improve the outcomes of patients with early-stage lung cancer.

Introduction

Patients with early-stage non–small cell lung cancer (NSCLC) are usually treated with lobectomy. Segmentectomy or wedge resections are also frequently used to treat patients with borderline lung function. Although the traditional technique to conduct these surgeries is via open thoracotomy, more recently, video-assisted thoracoscopic surgery (VATS) has been rapidly adopted as an approach for performing resections for early-stage lung cancer (Supplementary material). Current data suggest that VATS is associated with better perioperative outcomes and may be equivalent to open resection in terms of long-term oncological results.1, 2, 3

Several studies have shown that cancer patients whose surgical treatments are performed by surgeons with high case volumes have improved outcomes.4, 5, 6, 7 These studies, however, have not routinely included patients with lung cancer. The majority of studies focused on lung cancer have evaluated the association between hospital volume and patients' outcomes.4, 8 The few studies that have examined the importance of surgeon volume have primarily focused on postoperative mortality and reported mixed results.9, 10, 11 Lack of data regarding the relationship between surgeon volume and VATS is a challenge for generating recommendations for training certifications as well as national policy regarding organization of surgical care and referral patterns.

In this study, we used population-based data from a national cancer registry to evaluate the effect of surgeon volume on perioperative outcomes and long-term survival of older stage I NSCLC patients treated with VATS lobectomy, segmentectomy, or wedge resection.

Section snippets

Methods

Study subjects were identified from the Surveillance, Epidemiology, and End Results (SEER) database, a registry maintained by the National Cancer Institute that contains information on all new cases of cancer from several geographic areas of the United States.12 For patients ≥65 years of age in SEER, their cancer information has been linked to Medicare claims to create the SEER-Medicare database.12 The study cohort consisted of primary cases of pathologically confirmed, stage I NSCLC diagnosed

Results

We identified 2295 stage I NSCLC patients from SEER-Medicare databases who were treated with VATS resection between 2000 and 2010. Among the entire cohort, 67% underwent VATS lobectomy, 5% VATS segmentectomy, and 28% VATS wedge resection. The numbers of patients in each volume category were 774 (34%), 776 (34%), and 745 (32%) in the low-, intermediate-, and high-volume category, respectively. Baseline patient and physician characteristics of patients treated by low-, intermediate-, and

Discussion

VATS has been increasingly adopted as an approach for the treatment of early-stage lung cancers. To date, limited data exist regarding the surgeon volume-outcome relationship for lung cancer patients undergoing VATS. Using population-based data, we found that patients treated by surgeons with high volume of VATS resections had significantly improved perioperative outcomes and long-term survival. These data provide strong evidence that has the potential to impact training, accreditation, and

Acknowledgments

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

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    Dr Wisnivesky is a member of the research board of EHE International, and has received consultant honorarium from BMS, Quintiles, and Merck, and a research grant from Aventis Pharmaceutical. Drs Smith and Wolf, and author Mhango have no commercial interests to disclose.

    Funding source: This study was supported by the Agency for Health Care Research and Quality (R01HS019670-01). Dr Smith was supported by the Clinical Translational and Science Award (KL2TR000069).

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