Functional Outcomes After Lung Cancer Resection
2009; Elsevier BV; Volume: 135; Issue: 2 Linguagem: Inglês
10.1378/chest.08-2131
ISSN1931-3543
Autores Tópico(s)Genetic factors in colorectal cancer
ResumoWho cares about functional outcomes as long as you are cured? The patient, it turns out. Clearly, the patient does not want complications or death from lung cancer surgery but would not forgo surgery because of these possibilities. However, surgery would be declined in the face of predictable, persistent, and significant postoperative physical disability,1Cykert S Kissling G Hansen CJ Patient preferences regarding possible outcomes after lung resection: what outcomes should preoperative evaluation target?.Chest. 2000; 117: 1551-1559Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar in other words a poor functional outcome.Functional outcomes after curative lung cancer surgery are poorly characterized. The sparse existing outcomes data are not pretty.2Handy JR Asaph JW Skokan L et al.What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery.Chest. 2002; 122: 21-30Abstract Full Text Full Text PDF PubMed Scopus (243) Google ScholarDeath from lung cancer, of course, is not pretty, and death is the usual clinical outcome of this terribly aggressive disease.3American Cancer Society Lung cancer.Available at: http://www.cancer.org/downloads/PRO/LungCancer.pdfGoogle Scholar Lung cancer is typically diagnosed at advanced stage, with many treatment possibilities but little chance of cure. Localized lung cancer has the best chance of cure by resection; thus, characterization of surgery outcomes is vitally important. Indeed, the literature surrounding lung cancer surgery is focused on characterization and potential prediction of perioperative morbidity and mortality risk, not functional outcomes.The important study from Germany in this issue of CHEST (see page 322) by Schulte et al4Schulte T Schniewind B Dohrmann P et al.The extent of lung parenchyma resection significantly impacts long-term quality of life in patients with non-small cell lung cancer.Chest. 2009; 135: 322-329Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar characterizes functional outcomes up to 2 years after pulmonary resection with curative intent. They demonstrate persistent physical function impairment, pain, and dyspnea after lobectomy and bilobectomy. Outcomes are even worse after pneumonectomy.Such data highlight the fundamental difference between restorative and extirpative surgery. Any patient and almost all physicians, when asked, would characterize cardiac surgery as a much riskier endeavor than pulmonary resection. Yet the operative mortality for lobectomy is at least double that of coronary artery bypass or aortic valve replacement.5Goodney PP Lucas FL Stukel TA et al.Surgeon speciality and operative mortality with lung resection.Ann Surg. 2005; 241: 179-184PubMed Google Scholar, 6Society of Thoracic Surgeons STS adult cardiac surgery database: executive summary.Available at: www.sts.org/documents/pdf/ndb/2008_Harvest2_ExecutiveSummary.pdfGoogle Scholar Only very complex cardiac surgery, such as concomitant mitral valve replacement and coronary artery bypass or double valve replacement, approaches the mortality of pneumonectomy. However, when anatomic pulmonary resection is performed in dedicated centers, the results are far superior.7Society of Thoracic Surgeons STS general thoracic surgery executive summary.Available at: www.sts.org/documents/pdf/ndb/Spring_2008_STSTHOR-ExecutiveSUMMARY.pdfGoogle Scholar Is it possible these operative results are reflected in longer-term functional outcomes? Are functional results better in dedicated centers? We do not know.If these German data are confirmed in larger study populations, they verify the possibility that pulmonary resection is similar to extensive enterectomy, extremity amputation, or oncologic neurosurgery, in that all these procedures typically leave the patient with significant functional impairment negatively impacting quality of life. When does the negative impact exceed the beneficial effects necessitating the procedure in the first place? We do not know.With lung cancer killing more men and women than any other malignancy and the astounding persistence of cigarette smoking, the time is ripe for large longitudinal studies of lung cancer surgery functional outcomes with accurate functional prediction formulae as one of the desired goals. Such prediction formulae would importantly inform the discussion between thoracic oncologists and patients, each struggling with this terrible disease. The Schulte study highlights that the time for such studies is now. Who cares about functional outcomes as long as you are cured? The patient, it turns out. Clearly, the patient does not want complications or death from lung cancer surgery but would not forgo surgery because of these possibilities. However, surgery would be declined in the face of predictable, persistent, and significant postoperative physical disability,1Cykert S Kissling G Hansen CJ Patient preferences regarding possible outcomes after lung resection: what outcomes should preoperative evaluation target?.Chest. 2000; 117: 1551-1559Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar in other words a poor functional outcome. Functional outcomes after curative lung cancer surgery are poorly characterized. The sparse existing outcomes data are not pretty.2Handy JR Asaph JW Skokan L et al.What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery.Chest. 2002; 122: 21-30Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar Death from lung cancer, of course, is not pretty, and death is the usual clinical outcome of this terribly aggressive disease.3American Cancer Society Lung cancer.Available at: http://www.cancer.org/downloads/PRO/LungCancer.pdfGoogle Scholar Lung cancer is typically diagnosed at advanced stage, with many treatment possibilities but little chance of cure. Localized lung cancer has the best chance of cure by resection; thus, characterization of surgery outcomes is vitally important. Indeed, the literature surrounding lung cancer surgery is focused on characterization and potential prediction of perioperative morbidity and mortality risk, not functional outcomes. The important study from Germany in this issue of CHEST (see page 322) by Schulte et al4Schulte T Schniewind B Dohrmann P et al.The extent of lung parenchyma resection significantly impacts long-term quality of life in patients with non-small cell lung cancer.Chest. 2009; 135: 322-329Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar characterizes functional outcomes up to 2 years after pulmonary resection with curative intent. They demonstrate persistent physical function impairment, pain, and dyspnea after lobectomy and bilobectomy. Outcomes are even worse after pneumonectomy. Such data highlight the fundamental difference between restorative and extirpative surgery. Any patient and almost all physicians, when asked, would characterize cardiac surgery as a much riskier endeavor than pulmonary resection. Yet the operative mortality for lobectomy is at least double that of coronary artery bypass or aortic valve replacement.5Goodney PP Lucas FL Stukel TA et al.Surgeon speciality and operative mortality with lung resection.Ann Surg. 2005; 241: 179-184PubMed Google Scholar, 6Society of Thoracic Surgeons STS adult cardiac surgery database: executive summary.Available at: www.sts.org/documents/pdf/ndb/2008_Harvest2_ExecutiveSummary.pdfGoogle Scholar Only very complex cardiac surgery, such as concomitant mitral valve replacement and coronary artery bypass or double valve replacement, approaches the mortality of pneumonectomy. However, when anatomic pulmonary resection is performed in dedicated centers, the results are far superior.7Society of Thoracic Surgeons STS general thoracic surgery executive summary.Available at: www.sts.org/documents/pdf/ndb/Spring_2008_STSTHOR-ExecutiveSUMMARY.pdfGoogle Scholar Is it possible these operative results are reflected in longer-term functional outcomes? Are functional results better in dedicated centers? We do not know. If these German data are confirmed in larger study populations, they verify the possibility that pulmonary resection is similar to extensive enterectomy, extremity amputation, or oncologic neurosurgery, in that all these procedures typically leave the patient with significant functional impairment negatively impacting quality of life. When does the negative impact exceed the beneficial effects necessitating the procedure in the first place? We do not know. With lung cancer killing more men and women than any other malignancy and the astounding persistence of cigarette smoking, the time is ripe for large longitudinal studies of lung cancer surgery functional outcomes with accurate functional prediction formulae as one of the desired goals. Such prediction formulae would importantly inform the discussion between thoracic oncologists and patients, each struggling with this terrible disease. The Schulte study highlights that the time for such studies is now.
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