Portal de Periódicos da CAPES

Commentary: Invasive mediastinal staging for lung cancer—Quality gap, evidence gap, both?

2019; Elsevier BV; Volume: 158; Issue: 4 Linguagem: Inglês

10.1016/j.jtcvs.2019.05.016

1097-685X

Farhood Farjah, Gerard A. Silvestri, Douglas E. Wood,

Tracheal and airway disorders

Central MessageMounting evidence of suboptimal care delivery motivates efforts to increase guideline adherence in treating patients with lung cancer.See Article page 1220. Mounting evidence of suboptimal care delivery motivates efforts to increase guideline adherence in treating patients with lung cancer. See Article page 1220. Low and variable rates of invasive mediastinal staging form the basis of a perceived gap in the quality of lung cancer care.1Little A.G. Rusch V.W. Bonner J.A. Gaspar L.E. Green M.R. Webb W.R. et al.Patterns of surgical care of lung cancer patients.Ann Thorac Surg. 2005; 80 (discussion 2056): 2051-2056Abstract Full Text Full Text PDF PubMed Scopus (367) Google Scholar, 2Ost D.E. Niu J. Elting L.S. Buchholz T.A. Giordano S.H. Quality gaps and comparative effectiveness in lung cancer staging and diagnosis.Chest. 2014; 145: 331-345Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 3Krantz S.B. Howington J.A. Wood D.E. Kim K.W. Kosinski A.S. Cox M.L. et al.Invasive mediastinal staging for lung cancer by Society of Thoracic Surgeons database participants.Ann Thorac Surg. 2018; 106: 1055-1062Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar A recent prospective study of individuals with suspected or confirmed nonmetastatic lung cancer staged by computed tomography and positron emission tomography showed that 74% had at least one guideline-recommended indication for invasive mediastinal staging4Verdial F. Madtes D. Hwang B. Mulligan M.S. Odem-Davis K. Waworuntu R. et al.A prediction model for nodal disease among patients with non–small cell lung cancer.Ann Thorac Surg. 2019; 107: 1600-1606Abstract Full Text Full Text PDF Scopus (12) Google Scholar—suggesting that previously reported rates (21%-34%) are lower than they should be. What remains missing is high-level evidence linking process to outcome. The clinical basis for this link is that accurate mediastinal staging leads to more appropriate treatment selection, which in turn leads to better patient outcomes. A decade ago, researchers showed that the use of more staging tests was associated with better survival.5Farjah F. Flum D.R. Ramsey S.D. Heagerty P.J. Symons R.G. Wood D.E. Multi-modality mediastinal staging for lung cancer among Medicare beneficiaries.J Thorac Oncol. 2009; 4: 355-363Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar Use and appropriateness are not synonymous, however, and the process-outcome relationship was likely confounded by unmeasured factors related to treatment selection and provider characteristics. As a consequence, questions about a process-outcome link remain. In this month's Journal, Osarogiagbon and associates6Osarogiagbon R.U. Lee Y.S. Farris N.R. Ray M.A. Ojeabulu P.O. Smeltzer M.P. Invasive mediastinal staging for resected non–small cell lung cancer in a population-based cohort.J Thorac Cardiovasc Surg. 2019; 158: 1220-1229.e2Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar provide further evidence of a quality gap. First, they demonstrated a persistent underuse of invasive mediastinal staging nearly 2 decades after this finding was first reported. Second, they showed that dedicated thoracic surgeons perform invasive mediastinal staging more frequently than both general surgeons and board-certified cardiothoracic surgeons without a dedicated thoracic practice. This relationship has been observed in another regional study,7Thornblade L.W. Wood D.E. Mulligan M.S. Farivar A.S. Hubka M. Costas K.E. et al.SCOAP-CERTAIN CollaborativeVariability in invasive mediastinal staging for lung cancer: a multicenter regional study.J Thorac Cardiovasc Surg. 2018; 155: 2658-2671.e1Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar but it was not seen in a previous national study linked to the American Board of Thoracic Surgery Diplomates database.8Farjah F. Flum D.R. Varghese Jr., T.K. Symons R.G. Wood D.E. Surgeon specialty and long-term survival after pulmonary resection for lung cancer.Ann Thorac Surg. 2009; 87: 995-1004Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar On balance, these findings suggest that dedicated board-certified thoracic surgeons do a better job of staging lung cancer, but significant room for improvement remains for all types of surgeons. Finally, Osarogiagbon and colleagues6Osarogiagbon R.U. Lee Y.S. Farris N.R. Ray M.A. Ojeabulu P.O. Smeltzer M.P. Invasive mediastinal staging for resected non–small cell lung cancer in a population-based cohort.J Thorac Cardiovasc Surg. 2019; 158: 1220-1229.e2Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar showed—for the first time—a relationship between invasive mediastinal staging and better survival among patients with a guideline-recommended indication for invasive staging.9Silvestri G.A. Gonzalez A.V. Jantz M.A. Margolis M.L. Gould M.K. Tanoue L.T. et al.Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2013; 143: e211S-e250SAbstract Full Text Full Text PDF PubMed Scopus (1027) Google Scholar, 10Ettinger D.S. Wood D.E. Aisner D.L. Akerley W. Bauman J. Chirieac L.R. et al.Non–small cell lung cancer, version 5.2017, NCCN clinical practice guidelines in oncology.J Natl Compr Canc Netw. 2017; 15: 504-535Crossref PubMed Scopus (840) Google Scholar They were able to demonstrate this relationship independent of provider characteristics associated with better outcomes.8Farjah F. Flum D.R. Varghese Jr., T.K. Symons R.G. Wood D.E. Surgeon specialty and long-term survival after pulmonary resection for lung cancer.Ann Thorac Surg. 2009; 87: 995-1004Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 11Bach P.B. Cramer L.D. Schrag D. Downey R.J. Gelfand S.E. Begg C.B. The influence of hospital volume on survival after resection for lung cancer.N Engl J Med. 2001; 345: 181-188Crossref PubMed Scopus (582) Google Scholar, 12Meguid R.A. Brooke B.S. Chang D.C. Sherwood J.T. Brock M.V. Yang S.C. Are surgical outcomes for lung cancer resections improved at teaching hospitals?.Ann Thorac Surg. 2008; 85 (discussion 1024-5): 1015-1024Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 13National Lung Cancer Roundtable.https://nlcrt.org/Date accessed: April 26, 2019Google Scholar The most important limitation of their work is that their population was restricted to patients with resected lung cancer. As a consequence, there remains legitimate uncertainty about a causal relationship between guideline-concordant invasive mediastinal staging and better patient outcomes. Limitations notwithstanding, Osarogiagbon and colleagues6Osarogiagbon R.U. Lee Y.S. Farris N.R. Ray M.A. Ojeabulu P.O. Smeltzer M.P. Invasive mediastinal staging for resected non–small cell lung cancer in a population-based cohort.J Thorac Cardiovasc Surg. 2019; 158: 1220-1229.e2Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar have provided new information that bolsters concerns regarding the quality of lung cancer staging. This new body of evidence facilitates and further motivates several national efforts to improve the quality of lung cancer care. For instance, the American Cancer Society National Lung Cancer Roundtable has assembled a task group charged with finding ways to increase rates of guideline-concordant invasive mediastinal staging, and it is currently developing a national survey to understand facilitators of and barriers to invasive staging.14Mazzone P.J. Vachani A. Chang A. Detterbeck F. Cooke D. Howington J. et al.Quality indicators for the evaluation of patients with lung cancer.Chest. 2014; 146: 659-669Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The Thoracic Oncology Network and Quality Improvement Committee of the American College of Chest Physicians developed and validated a quality metric for invasive mediastinal staging on the basis of feasibility and relevance.12Meguid R.A. Brooke B.S. Chang D.C. Sherwood J.T. Brock M.V. Yang S.C. Are surgical outcomes for lung cancer resections improved at teaching hospitals?.Ann Thorac Surg. 2008; 85 (discussion 1024-5): 1015-1024Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Recently, the Society of Thoracic Surgeons General Thoracic Database modified its data collection form in a manner that would allow such quality measurement. These efforts represent opportunities to improve care delivery and survival for patients with lung cancer. Invasive mediastinal staging for resected non–small cell lung cancer in a population-based cohortThe Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 4PreviewInvasive mediastinal nodal staging is recommended before curative-intent resection in patients with non–small cell lung cancer deemed at risk for mediastinal lymph node involvement. We evaluated the use and survival effect of preoperative invasive mediastinal nodal staging in a population-based non–small cell lung cancer cohort. Full-Text PDF Open Archive