Quality Improvement

STS 2023, SAN DIEGO — Patients who undergo lobectomy for primary incidence of lung cancer often die from the same cancer recurrence, prompting researchers from Massachusetts General Hospital in Boston to advocate for adjuvant therapies at the time of surgery or following procedures. Research coordinator Alexandra Potter, BSE, presented “Incidence, Timing and Causes of Death Among Patients Who Underwent Lobectomy for Stage IA Lung Cancer in the National Lung Screening Trial (NLST),” an analysis of long-term survival of patients from the National Lung Screening Trial.  The randomized NLST included 53,454 patients. The team at Massachusetts General delved into the NLST data and developed a cohort of 433 patients whose cancers were identified by low-dose computed tomography or Xray and met other study inclusion criteria. They found that: ·       Five-year cancer-specific survival was 80%, 10-year was 70%. ·       Five-year overall survival was 72%, 10-year overall survival was 55%. ·       Five-year overall survival for patients under age 65 at time of diagnosis was 79% and 10-year overall survival was 62%. ·       Five-year overall survival for patients 65 and older at time of diagnosis was 62% and 10-year overall survival was 48% . ·       The leading cause of death for all patients in the cohort was lung cancer, either primary or at recurrence, accounting for 59% of all deaths. The longer patients lived following resection surgery, the more likely they were to die from other causes—the top ones being heart disease, COPD, and other types of cancers. “These findings highlight the importance of developing strategies to reduce the risk of lung cancer death among early-stage lung cancer patients undergoing surgery,” Potter said. This includes patients at high risk for lung cancer recurrence. Potter offered several suggestions: identifying remaining tumor cells in the blood post-surgery, which may indicate increased risk for cancer recurrence. These patients may benefit from adjuvant therapies.

STS 2023 Day 1 — General thoracic surgeons should not miss this presentation that challenges lobectomy as the gold standard treatment for patients with smaller lung tumors. Surgical segmentectomy, as opposed to lobectomy, should be considered for patients whose lung cancer has been downstaged following neoadjuvant chemoimmunotherapy, STS 2023 presenters say. On Saturday, January 21 at 9:45 a.m. PT, Charles Logan, MD, from Northwestern University Feinberg School of Medicine in Chicago, will present “Pathologic Downstaging Following Neoadjuvant Chemoimmunotherapy for Locally Advanced Lung Cancer is Associated with Survival Comparable to Early Stage-Matched Disease.” The study is part of the STS 2023 session “Is the Hype Real? Targeted and Immunotherapy in Resectable Non-Small Cell Lung Cancer.” Recent randomized clinical trials suggest that a lung resection accomplished by segmentectomy may be the best approach for treating small tumors in early-stage, non-small cell lung cancer (NSCLC). This study takes the investigation further by suggesting that patients with stage IIIA cN2 lung cancer downstaged after neoadjuvant chemoimmunotherapy and lobectomy have similar survival to patients with small tumors who undergo segmentectomy. Those who receive segmentectomy may benefit from improved quality of life and greater ability to tolerate toxic adjuvant suppressive immunotherapies—compared to patients with small tumors who undergo lobectomy. “We hope to spark a discussion among those who care for lung cancer patients whether patients whose malignancies have been downstaged after neoadjuvant therapy should be candidates for segmentectomy. We think the available data point toward ‘yes,’ but a randomized clinical trial may be needed to answer this definitively,” Dr. Logan says. Segmentectomy potentially offers other advantages over lobectomy for these patients because a smaller resection minimizes the amount of functional lung tissue removed. Research into targeted therapies for NSCLC has also escalated, offering the possibility that more patients will be downstaged after neoadjuvant treatment and may not need to have an entire lobe removed. Dr. Logan is a postdoctoral research fellow and surgery resident at Northwestern, and senior study co-authors Samuel Kim, MD, Ankit Bharat, MD, and David Odell, MD, MMSc, are also from Northwestern.

Investigators will discuss the real—yet easily identified—risk that living in a food desert may have on patients recovering from esophagectomy on Day 1 of STS 2023. Mortality risks for patients with colon and breast cancers who live in food deserts have been reported in recent years as part of a large administrative database review. On Saturday, January 21 at 1:25 p.m. PT, surgeons from six high-volume medical centers will present the first multi-institutional research that identifies patients who undergo tri-modality therapy for esophageal cancer have increased risk of readmission following surgery. Joseph Phillips, MD, from Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, will present the study exploring the association between food deserts and patient re-hospitalizations after esophagectomy.  In this retrospective research, surgeons reviewed records from a diverse US patient population that underwent neoadjuvant chemoradiation followed by esophagectomy. Of 425 patients included, 73 lived in a food desert, which are areas where access to nutritious foods is inadequate. The study found that patients from food deserts were twice as likely to be readmitted to the hospital for any reason within 30 days post-surgery. The study also found that these patients had significantly lower median household incomes, although this was not a factor when patients were stratified by readmission status. No differences were found in length of stay, complications, or 30-day mortality between patients who lived or did not live in food deserts. “Living in a food desert is an easily identifiable risk factor that should alert surgeons that pre- and post-surgical interventions may be needed to improve outcomes,” Dr. Phillips says. Food deserts, as defined by the United States Department of Agriculture (USDA), are low-income census tracts where a substantial number of residents have low access to grocery stores. The USDA identifies about 6,500 tracts in urban and rural areas as food deserts, where 13.5 million people don’t have a supermarket nearby. Aside from scarcity of nutritious food, residing in a food desert is also often an indicator of low incomes and inadequate healthcare access. The study authors also postulate that patients receiving tri-modality therapy for esophageal cancer may benefit from early referral to resources such as social workers and dieticians for intervention prior to and during treatment. Furthermore, these patients may benefit from more directed post-discharge care to avoid unnecessary readmissions to the hospital.

A must-see session for pediatric surgeons will showcase the first study that analyzes multiple factors impacting survival of young patients with ventricular assist devices (VADs) over the last decade.  “Variables Affecting Survival in Pediatric Patients Supported with VADs: A Special Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report,” will be presented at 11:30 a.m. PT on Sunday, January 22, 2023, during the STS Annual Meeting. The presentation is part of the STS “Current Controversies in Congenital Transplantation and Mechanical Circulatory Support” session. Awais Ashfaq, MD, from Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, will report on findings. Although 10 leading children’s hospitals conducted the study, the analysis includes all 47 hospitals in the Pedimacs database of children and adolescents under age 19.  The group reviewed Pedimacs data back to the registry’s inception in 2012 through the end of December 2021, covering 1,109 patients, and identified that illness at time of VAD implantation, diagnosis, support strategy, and VAD device type all affected mortality. This study is the first step to create evidence-based guidance on VAD device choices and other decisions in care management. For instance, one finding indicates that infants and older pediatric patients with paracorporeal continuous device support, congenital heart disease, biventricular support, and Intermacs profile 1 (cardiogenic shock) had worse overall survival after six months. "For anyone in our field, and especially for those who have an interest in pediatric mechanical support, Pedimacs is invaluable,” Dr. Ashfaq says. “There is so much to learn from the data available in the database.” Pedimacs became part of The STS National Database™ in 2018 and is a joint effort among the National Heart, Lung, and Blood Institute, the Food and Drug Administration, the Centers for Medicare & Medicaid Services, and others. The North American clinic registry includes patients who receive an FDA-approved mechanical circulatory support device to treat advanced heart failure. Due to its exponential growth in terms of participation and stature, the STS National Database has become the gold standard for clinical outcomes registries among health care administrators, government officials, and payers. Dr. Ashfaq adds that the group will be taking their results and expanding them into a web-based tool to help physicians decide if patients will benefit from VADs and which device to choose.  

With too few donor hearts available for transplantation, surgeons will present a novel solution to heart allocation on Day 2 of STS 2023, with an aim at serving the growing population of eligible patients in their 70s. On Sunday, January 22, at 3:30 p.m. PT, “The Use of Donor Hearts 50 Years or Older to Septuagenarians in Heart Transplant: The Potential of Expanding the Donor Pool in Older Patients and Increasing the Availability of Younger Hearts” will uncover a potential new group of heart donors who have been previously overlooked. The presentation, part of the session “Expanding the Donor Pool in Heart Transplantation: Current Strategies and Future Perspectives,” will be thought-provoking for surgeons who want to open the door for organ donation to older recipients. Suguru Ohira, MD, PhD, from Westchester Medical Center Heart & Vascular Institute in Valhalla, New York, will present this study to consider donor patients in their 50s for an emerging segment of heart recipients ages 70-79.  Several key factors, including advances in cardiac transplantation and the 2018 modified guidelines from the Organ Procurement and Transplantation Network (OPTN), make more and more patients in their 70s eligible for cardiac transplantation. This study is the first to present a feasible solution to serve these patients without compromising the entire pool of heart recipients. In the United Network for Organ Sharing system, 1,036 heart transplants occurred between January 2011 to December 2021 in patients 70 years or older. Of these, 861 patients received hearts from donors under age 50 and 175 patients received hearts from donors ages 50 and older. Survival was comparable between both recipient groups: One-year and five-year survival rates for patients who received hearts from donors over age 50 were 89.4% and 76.6%, respectively. One- and five-year survival rates for patients who received hearts from donors ages 50 or under were 86.2% and 71.1%, respectively. “Although these hearts from advanced age donors might not be the best hearts for younger recipients who are in their 30s or early 40s, they could be a reasonable option for candidates in their 70s,” Dr. Ohira says. “Yet these hearts are often not recovered, just because of ‘donor age,’ even though their functions and structures are normal.”  Dr. Ohira says this study, conducted with six colleagues from Westchester Medical Center and New York Medical College, was undertaken following excellent outcomes at their institution with transplants for septuagenarians using hearts from donors in their 40s and 50s. STS 2023 is being held in person, and there is still time to register at sts.org/annualmeeting.