ChestHealth

Periodically we highlight the research accomplishments of members of our Section of General Thoracic Surgery, as their data become available.  We will ask key simple but important questions including how they chose their research questions and most importantly how their work will impact patients.

Dr. Lisa Brown and co-authors’ paper Recurrence and Survival After Segmentectomy in Patients With Prior Lung Resection for Early-Stage Non-Small Cell Lung Cancer, was recently published first on line by the Annals of Thoracic Surgery.  The work was originally presented at the Sixty-second Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, November, 2015.

Dr. Brown is an Assistant Professor of Clinical Surgery, and the Clinical Director of the UC Davis Comprehensive Lung Cancer Screening Program.

Lisa M. Brown, MD, MAS

What is the question in this study?

Dr. Brown:

The goal of this study was to compare recurrence and survival in patients undergoing segmentectomy (or removal of a small part of the lung) for primary non-small cell lung cancer (NSCLC) versus those undergoing the same type of surgery for a second primary (completely new) NSCLC.

Why did you choose this research question?

Dr. Brown:

We chose this research question because we were seeing many patients who had a prior lung surgery for NSCLC presenting with a second primary (completely new) NSCLC and there is minimal data on the optimal extent of removal of lung tissue for these patients. We were interested in determining whether the long-term outcomes after segmentectomy for second primary NSCLC were as good as or at least equal to those with primary NSCLC.

What were your findings?

Dr. Brown:

In a series of 91 segmentectomies (23%) were undergoing segmentectomy for a second primary NSCLC and 70 (77%) were undergoing segmentectomy for a primary NSCLC (first lung cancer). The recurrence free survival was 61% in those undergoing segmentectomy for a second primary NSCLC and 84% in those undergoing segmentectomy for a first primary NSCLC (p=0.09). The 5-year survival was 55% in those with second primary NSCLC and 65% in those with primary NSCLC (p=0.4).

How might the findings help patients?

Dr. Brown:

We concluded that segmentectomy is a reasonable resection strategy for patients with a second primary NSCLC as the long term survival is similar to those with primary NSCLC and lung tissue is preserved when compared to lobectomy.

Learn more on how to support the research of the UC Davis Section of General Thoracic Surgery.

A Brief History of General Thoracic Surgery in Northern California, Sacramento and UC Davis

John R. Benfield, M.D.

Professor of Surgery Emeritus

UC Davis and the David Geffen School of Medicine at UCLA

(Prepared for the Department of Surgery Grand Rounds, June 2^nd 2015)

Paul C. Samson, an impressive 6’6” former football player and 1928 Olympic swimmer, was the first thoracic surgeon in the East Bay after completion of the University of Michigan’s first in the world residency that focused entirely upon Thoracic Surgery.  He became a Chairman of the American Board of Thoracic Surgery, and the first President of the Society of Thoracic Surgeons – now the world’s largest and most influential group in our specialty.  In the East Bay, Samson and his partner David Dugan, preached and implemented their conviction that it is in the best interest of patients if only certified thoracic surgeons do thoracic surgery.  In San Francisco, superb thoracic surgical leaders like Leo Eloesser, Victor Richards and others, believed thoracic surgery to be a component of general surgery.  I shall refer to them as The San Francisco School.

Paul C. Sampson, MD

In 1978, F. William Blaisdell, of The San Francisco School, became successful and deservedly much revered as chairman of the UC Davis (UCD) Department of Surgery.   There had been no accredited program in cardiothoracic surgery at UCD for nearly a decade, when Dr. Blaisdell sent Marvin Derrick, one of his excellent general surgery residency graduates to work with me for a year with the intent that Derrick would return to UC Davis to spearhead General Thoracic Surgery.  Derrick instead, elected to complete 2 more years and to become certified by the American Board of Thoracic Surgery, and not to return to UCD.   Dr. Blaisdell, a leader of the highest caliber,  recruited me in 1988.

F. William Blaisdell, MD

When I arrived, cardiac surgery in Sacramento was very strong, but regionally general thoracic surgery was mostly in the hands of general surgeons.  In Sacramento, the only general thoracic surgeons certified by the American Board of Surgery were the late Jack Baker, formerly at of Ohio State University, Donald Hopkins, formerly at the Mayo Clinic and M.B (Beau) O’Neill in the Kaiser Hospitals.   At UCD Medical Center, cardiac surgeons Herbert Berkoff, formerly the head of the University of Wisconsin’s Division of Cardiothoracic Surgery, and David M. Follette, formerly at UCLA, joined me at UCD Medical Center.  Baker, Hopkins, O’Neill, and cardiac surgeons like Paul Kelly, Steve Rossiter, Brad Harlan, and others welcomed us graciously.  We narrowed the gap between the community and the university.   Our newly approved residency in Thoracic Surgery attracted excellent people, including Hiran Fernando, the current professor and head of General Thoracic Surgery at Boston University, Andrea J. Carpenter the incoming president of the Southern Thoracic Surgical Association who is a professor at the University of Texas in San Antonio, and Capt. Peter Roberts the former head of the Navy’s largest and most successful program in cardiothoracic surgery who is now the Deputy Commander of the Tripler Army Hospital.

In 1964, the STS was founded to be inclusive – for cardiothoracic surgeons in the community as well as in academics.  The STS database was formed in 1989 in response to a misleading article in The New York Times about cardiac surgery results that was contrary to the interests of patients.   Paul Ebert, formerly the head of cardiothoracic surgery at UCSF, and eventually the Executive Director of the American College of Surgeons, took the initiative that led to the STS database.  The purpose was to provide patients and surgeons with accurate, risk-adjusted data about cardiac surgical outcomes.  It did not take long for Medicare, insurance companies and industry to acknowledge the STS database as exemplary in health care.  In my STS presidential address in 1996, I called for the expansion of the database to include general thoracic surgery.   I am pleased that this has become reality.

I am delighted that Dr. Cooke will discuss the STS database today.  Congratulations to him and the Division of Cardiothoracic Surgery and the Department of Surgery for their accomplishments and continuing insistence on excellence.

May 25, 2015

“Is there a cure for lung cancer?”  That is a very common question for me.  We all know the statistics.  Lung cancer has around a 15% five year survival rate.  But the truth is in the details.  The majority of patients diagnosed with lung cancer are diagnosed at an advance stage, i.e. stages III and IV (there are four stages).  Only 25% of people diagnosed with lung cancer are diagnosed at the earliest stages, stages I and II.  The standard of care treatment for the physically fit person with stage I and II lung cancer is surgery, or removal of part of the lung where the cancer is located.  The five year survival for someone treated with surgery for Stage I lung cancer is around 80%.  That means 80% of those individuals are effectively cured of their lung cancer.

This is great news right?  What’s the hesitation?  We all know that the information bin on lung cancer is a black box.  Public awareness about lung cancer and the treatment modalities to fight it is minimal…though improving.  Forums like #LCSM Chat, the American Lung Association and Addario Lung Cancer Foundation, are leading the charge to disseminate evidence-based information.  But the bottom line is: people are afraid of surgery.   Patients view thoracic surgery (surgery on the contents of the chest, in this case the lungs) as high risk, with potentially prohibitive complication rates.  “Are you going to crack my chest open?” another common question I receive.  I usually reply “You are not a walnut.”

Just as the treatment of advanced stage lung cancer has evolved (such as molecular testing, personalized therapy, immunotherapy, etc.) so has the surgical treatment for early stage lung cancer.  In most cases of stage I lung cancer, surgery can be performed minimally invasively with small incisions and a high definition camera.  If you had a friend who had their gall bladder removed in the past 10 years, most likely it was removed in a similar manner.  With the gall bladder, it is called laparoscopic surgery.  With lung cancer it is called thorascopic surgery (scopic meaning camera, thora or thorax meaning chest: chest surgery with a camera.  As I tell my students, 90% of surgery is common sense; the other 10% is finding a pair of scrubs that actually fit.)  Thorascopic surgery, also called video-assisted thoracic surgery or VATS, results in smaller incisions, shorter stay in the hospital, less need for pain medicine and faster return to work and activities of daily living.  Moreover, VATS has the same cancer survivor results as traditional open surgery, where we have to make a larger cut and spread the ribs (again, we’re not “crackin’” anything).

On March 19^th, around 10AM PT, At UC Davis we will be performing a Live Lung Cancer Surgery on Twitter (Don’t worry, we won’t be tweeting while operating, our public relations people will!).  One of our patients who has a keen interest in education was excited to volunteer and share her story.  She will undergo a right VATS lower lobectomy (removal of the bottom third of the right lung) for early stage lung cancer.  Now the focus of this Twitter project is not the surgery itself.  There are plenty of videos on YouTube that can show you how to do a VATS lobectomy (when I say “you” I mean your board certified thoracic surgeon…please leave your neighbors pets alone.).  The focus of this project is of course our patient, her story, her experiences on this important day, and the clinical care processes that will support her recovery.

Our patient’s case highlights some very important issues:

1)      Surgery for lung cancer has evolved.  Now with minimally invasive approaches, small incisions, and state of the art treatment during and after surgery, we are able to “stack the deck” in our patients favor to ensure their successful results.

2)      You only need lungs to get lung cancer.  She is a never smoker, and has no appreciable risk factors.

3)      Lung cancer is the number one cancer killer of women, yet only 1% of women when polled identify this fact (source: Lung Force Women’s Lung Health Barometer),

4)      Up to 80% of patients with stage I of lung cancer such as hers (early stage) are cured after treatment, and that is not the public perception.

The event will follow her day through the preoperative check in process, the operation, postoperative recovery, and follow her tumor through pathology processing, and whisking the tumor off to our research folks and tissue banking group.

The surgery is March 19th around 10am PT.  Please follow with the #LCSM hashtag or #UCDVATS.

A patient’s perspective on lung cancer in never smokers

By Elizabeth A David, MD FACS

November is Lung Cancer Awareness Month, however, disappointingly few Americans are aware of many important truths about lung cancer.  Lung cancer is the #1 cause of cancer related deaths in the US, and it is estimated that 160,000 people will die of lung cancer in 2014.  Most of us are aware of the relationship between lung cancer and tobacco use.  However, new cases of lung cancer in people who have never smoked are on the rise. In 2007, approximately 10% of lung cancers were diagnosed in people who never smoked. That number has tripled to 30% of cases in 2014; roughly 66,000 Americans who have never smoked will be diagnosed with lung cancer this year.  “Never smokers” who are diagnosed with lung cancer tend to be younger and their disease is more serious when they are diagnosed.

John’s perspective

For Lung Cancer Awareness Month, our patient Mr. John Leung was willing to share his experience as a never smoker who was recently diagnosed with lung cancer and treated by our lung surgery team at UC Davis, in the hopes of, as John puts it, “breaking the mindset that lung cancer only happens in people who smoke.” 

John, only in his 50’s, experienced a cough for four years.  The cough would get better and worse and at times improved after he took medicine for post-nasal drip.  He had a chest x-ray when the cough began, and he had another this summer when the cough worsened.   John remembers feeling “apprehensive and worried” when his doctor told him that there was a mass on his chest x-ray.  “It wasn’t until my CT scan was abnormal, that I knew something had to be dealt with and I felt that it was highly likely to be cancer.” John said.  He felt like it was probably cancer because he knew it had not been present on his original x-ray four years earlier. John was diagnosed and treated with a minimally invasive (VATS) lobectomy for stage-1 non-small cell lung cancer in September.

How did he handle the diagnosis?

When John was told that his lung mass might be cancer, he immediately started “looking for a reason for why this would happen to me and looking for someone to blame.  I even tried to blame LA because I lived there in the smog.” John said.  “I wondered if it happened because of something I had done.”  He and his wife embarked on the journey of finding doctors and information that would help them. “I needed to have a doctor who could explain a process that I could understand and buy into.” He wanted to have something done quickly, but he needed to feel comfortable with the plan. So he sought several opinions.

Fear of the unknown has been a part of John’s lung cancer experience.  Initially, he was worried about how bad the cancer was, whether it was local or if it had spread to other organs.  Then he worried about surviving surgery. Now, he worries about whether it will recur soon, but he is learning to accept his fears just as he has accepted his diagnosis, knowing that he did nothing to cause it.

His family and friends have played an immense supporting role during the time of diagnosis, surgery and recovery.  His wife encouraged him to write questions down the night before his doctor visits, so they knew what they wanted to know before the visit was over. Everyone in his family is supportive, including his mom and siblings.

How does he feel about having Lung Cancer?

Some patients with lung cancer feel ashamed or embarrassed to be diagnosed with lung cancer, but not John. If anyone asks him he is honest with them and tells them about his diagnosis.  He sent his work colleagues an email every two weeks informing them of what was happening and how he was feeling.  He is a member of a Rotary club and he stood up and told his story at a meeting. He hopes that by telling his story it will help people understand that anyone can develop lung cancer, not just people who have smoked.  

In essence John has become an “ePatient”: educated, empowered and empathic.  “I have noticed that there is a lack of lung cancer awareness.” John points out.  “There seems to be pockets of people who are willing to drive the agenda because of personal experience, but there does not seem to be a general awareness of lung cancer like there is for other cancers.  People think that lung cancer is a penalty for the vice of smoking, but there doesn’t seem to be awareness that lung cancer occurs in people who never smoked.  The first question anyone asks me when I tell them I have lung cancer is – were you a smoker? And then they want to know why I have lung cancer.”

During the course of his diagnosis and treatment, John has learned that medicine and science have moved much further than he realized when it comes to lung cancer. He’s been “amazed at the progress.” He hopes that in the future, people won’t have preconceived notions about lung cancer and its treatment options. There are treatment options and hope for patients with lung cancer. “I didn’t think I would have it so easy if I had lung cancer.”  Of course, nothing is easy.  But it doesn’t have to be impossible either.

John has been very brave to share his experience to raise awareness about lung cancer in people who have never smoked. It is important to remember that chest pain, shortness of breath and cough are symptoms that should not be ignored. Unfortunately, most patients with lung cancer do not have symptoms until they have advanced disease. For patients with a long history of smoking, screening with a low-dose CT chest is currently recommended, please click here for more information. There are no screening recommendations for people who have never smoked at this time. Please remember that lung cancer can happen in anyone and treatment options are available.

For more information, please see these references:

1. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-041775.pdf
2. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-041776.pdf
3. Subramanian J, Govindan R. Lung cancer in never smokers: a review. J Clin Oncol. 2007 Feb 10;25(5):561-70.
4. Hasegawa Y, Ando M, Kubo A, Isa S, Yamamoto S, Tsujino K, Kurata T, Ou SH, Takada M, Kawaguchi T. Human papilloma virus in non-small cell lung cancer in never smokers: a systematic review of the literature. Lung Cancer. 2014 Jan;83(1):8-13. doi: 10.1016/j.lungcan.2013.10.002. Epub 2013 Oct 31.

UC Davis thoracic surgery providers are helping to evolve healthcare to emphasize patient value.  Patient value not only includes traditional outcomes such as  cure of cancer and amelioration of pain, but also by the effects on quality of life, function after surgery, and most importantly, what immediate outcomes are important to patients and their families.

Transparency in outcomes is important for patients and their families, referring physicians and other stakeholders to make informed decisions on which health systems provide optimal care.  The clinical outcomes of the UC Davis Section of General Thoracic Surgery are tracked by several validated national quality databases and evaluation organizations including the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP^®), The ACS Committee on Cancer Quality Improvement Program (CQIP^®), the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database and the LeapFrog Group.  These bodies compare medical institutions outcomes to national benchmarks and determine how individual institutions rank.

• The ACS NSQIP^® comparisons determine if an institution’s results are in line with its national peers (As Expected), underperform its peers (Needs Improvement) or out perform its peers (Exemplary).
• The CQIP^® compares cancer specific results between the Commission on Cancer accredited medical centers.  Medical centers listed in the comparisons are only national health systems with established quality cancer care infrastructure.
• The STS Database measures the outcomes of American Board of Thoracic Surgery eligible or certified physicians, and therefore measures the thoracic surgery outcomes of the “best of the best” surgeons in the nation.
• The LeapFrog Group determines the Highest Quality of Care Rating by surveying participating hospitals and measuring their outcomes.  A hospital can achieve a Highest Quality of Care Rating by:

–         Participating in the Leapfrog Survey

–         Performing ≥ 13 esophagectomies during the survey year

–         All of the esophagectomies performed by high-volume surgeon (≥ 2 esophagectomies/year)

Below are our UC Davis Section of General Thoracic Surgery Outcomes as measured by the most recent national quality assurance measures:

2013 ACS NSQIP^® All Procedures

Where Mortality is the rate of surviving the hospital experience after an operation; pneumonia is a lung infection acquired during the hospitalization; ventilator > 48hrs refers to the time on a breathing machine after an operation; morbidity is the accumulative complications after an operation; unplanned intubation is the need for a breathing tube to be put back in after an operation; deep venous thrombosis is a blood clot in the arms or legs that may develop after an operation; urinary tract infection is an infection often from a bladder catheter that is placed for an operation; return to the operating room is an unplanned re-operation after the intended or index operation.

2009-2011 CQIP^® Lung Cancer Resection

30-Day Mortality is the rate of not surviving 30 days after an operation, even after having gone home.  Lung Resection is the surgical removal of part of the lung such as a lobectomy or the entire lung on one side such as a pneumonectomy.  The most recent available data for CQIP^® is for the years 2009-2011.

STS General Thoracic Surgery Database (2011-2013)

Where Discharge Mortality is the rate of not leaving the hospital alive after the operation, and 30-Day Mortality is the rate of not surviving 30 days after an operation, even after having gone home.

LeapFrog Group Ratings for Esophageal Resection (2013)

 4-Bar, Best Odds for Survival Ranking or Highest Quality of Care Rating: Top in the Sacramento region.

Where 4-Bars (Highest Quality of Care Rating) means the patient has the best chances of surviving an esophageal resection.  An esophageal resection or Esophagectomy is a surgery to remove the esophagus and replace it with the stomach or colon and is most commonly performed for cancer, though sometimes it needs to be performed for very extreme non-cancer disease.

The LeapFrog Highest Quality of Care Rating determines quality or value based on the volume, or the number of procedures performed.  The thinking is that having experience with a procedure refines quality outcomes and promotes value.  This volume-outcome relationship has been demonstrated in the scientific literature (Birkmeyer et al, New Engl J of Med, 2002) for both esophageal cancer surgery (Esophagectomy) as well as lung cancer surgery otherwise called lung  resection, such as lobectomy and pneumonectomy.

Since 2008 our UC Davis Section of General Thoracic Surgery has performed over 100 esophagectomies and over 250 lobectomy and pneumonectomies.  Seventy percent of our lung resections are performed minimally invasively either by Video-Assisted Thoracic Surgery (VATS) or by Robot.

Patient-centered value outcomes, as mentioned above, have a lot to do with the skill of the surgeon and the surgeon’s volume based experience.  However the central driver of quality outcomes is careful planning, attention to detail, and scientific evidence based best-practice treatment algorithms that are followed in consensus by the entire care team.  Care processes or pathways that are patient/family-focused, foster coordination and communication amongst all providers can promote efficiency and improve results that are important to patients (Vanhaecht et al, Health Serv Mange Res, 2007).

At UC Davis, we have developed novel evidence based post-operative care pathways for esophagectomy (Cooke et al, Society of Thoracic Surgeons 49^th Annual Meeting, 2013) and lung resection as well as Respiratory Therapy pathways that are designed to prevent pneumonia, need for replacement of a breathing tube and pronged need for a breathing tube (Tanner-Corbett…Cooke et al, 14^th World Conference on Lung Cancer, 2011), and in effect, “stack the deck” in the patients favor to achieve important top clinical outcomes.

We are now creating patient-centered pathways to foster patient engagement and activation, so that patients and their families are more participatory in their care, and help make the outcomes that are most important to them a reality.  These research endeavors are supported by a grant from the Patient-Centered Outcomes Research Institute.  To learn more click here.

With our evolving health care system, the definition of quality has matured from not only advanced technology that is available, but also the value in outcomes that the patient experiences, and maximization of the outcomes that are most important to patients and their families.  At UC Davis we are proud to be innovators and leaders in quality healthcare.

On Thursday, June 19^th at 5 PM Pacific/ 8 PM Eastern, Dr. David Tom Cooke (Twitter@UCD_ChestHealth) will moderate the #LCSM Tweet Chat. The topic: “What are clinical and functional outcomes after lung cancer surgery that are most important to patients & their families?” 

We will partner with #LCSM (#Lung Cancer Social Media; Twitter@LCSMchat), a TweetChat patient education platform, to engage the lung cancer community.  On Twitter, stakeholders tweet using the hashtag #LCSM to flag microblogging discussions of lung cancer treatment, research, and numerous other lung cancer patient focused issues.  The #LCSM TweetChat is a set time when people interested in lung cancer gather virtually via Twitter, and with guidance from a moderator, chat about specific patient-centered topics in lung cancer.  The bimonthly #LCSM TweetChats are an hour long. Hundreds of #LCSM tweets are sent during the chat. Participants in the TweetChat are international, and include patients, family members, researchers, multidisciplinary medical professionals and advocates.  All tweets that include the #LCSM hashtag during the specified hour are recorded in a TweetChat transcript and made available online.

The June 19^th #LCSM Tweet Chat moderated by Dr. Cooke is part of his Patient Centered Outcomes Research Institute funded project entitled “Empowering Patients and Their Families to Improve Outcomes That Are Most Important to Them after Lung Cancer Surgery”.

Patient-centered outcomes research (PCOR) seeks to assist stakeholders (patients, their family members , friends and care providers) communicate and make informed healthcare decisions, allowing multiple voices to be heard in assessing the value and efficacy of healthcare options.  PCOR answers patient-centered questions such as: “What can I do to improve the outcomes that are most important to me?” and “How can clinicians and the care delivery systems they work in help me make the best decisions about my health?” (http://www.pcori.org/). Dr. Cooke is seeking to bring the concept of PCOR to thoracic surgery research and improve outcomes for patients undergoing lung cancer surgery.

Lung cancer surgery, specifically lobectomy (removing 1/5 of the lung) and pneumonectomy (removing the entire lung on one side), are the gold-standard therapies for early and locally advanced lung cancer.  However, lung cancer surgery is high-risk and associated and can be associated with an elevated risk of death (mortality), complications, and prolonged hospital length-of-stay and hospital readmissions.  In U.S. hospitals, national 30-day mortality after lobectomy ranges between 4-6% and 11-17% after pneumonectomy (Birkmeyer et al, N Engl J Med. 2002).  Dr. Cooke is investigating if patient and family participation can drive improvements in lung cancer surgery outcomes, leading to the creation of successful after-surgery patient care protocols that will translate the good results of high performing medical centers to all types of institutions performing lung cancer surgery.  Active engagement of patients and their families in the after-surgery clinical care process may improve the quality of life and overall survival of patients surgically treated for lung cancer.

By having a conversation with the #LCSM community, #LCSM will put to light what after-surgery clinical and functional outcomes are most important to patients and family and friends after surgery for lung cancer.  Talk about the communication between the patient, family/friends & healthcare providers after their operation and during their hospital stay. Were there any problems and if so how can surgeons, patients and all stakeholders improve the communication?  And finally, what changes in the lung cancer surgery care process are needed to achieve the clinical and functional goals that are important to patients and their family/friends?

With the above goals, here are the 3 questions that will be discussed during the June 19^th Tweet Chat:

What are clinical and functional outcomes after #lungcancer surgery that are most important to patients & families? #LCSM

T1 What post-op clinical and functional outcomes are most important to you (patients & family) after #surgery for #lungcancer. #lcsm

T2 Talk about communication between the patient, family & HCPs after operation and during hospital stay. Problems/how to improve? #lcsm

T3 ? changes in #lungcancer surgery care process are needed to achieve clinical/functional goals important to patients & family. #lcsm

Here is more info on how to participate in the #LCSM Chat.  To learn more about how to support the Section of General Thoracic Surgery’s innovative research, click here.

Ending Lung Cancer in Women – Turning the Country Turquoise

What We Should Know During National Women’s Health Week

By Elizabeth A David, MD

General Thoracic Surgeon

UC Davis Section of General Thoracic Surgery

Each October, the US turns pink to raise awareness for breast cancer.  Football fields are painted pink, women are reminded to do breast self-exams, and have their annual screening mammograms.   Approximately, 40,000 women will die of breast cancer in 2014 and 232,670 new cases of breast cancer will be diagnosed (^1,2).    Breast cancer advocates are to be congratulated on their successes with raising awareness and lung cancer advocates, physicians, and patients should take note of their strategies.

Lung cancer remains the number one cause of cancer-related deaths in the US.  It is estimated in 2014, that 72,330 women will die of lung cancer and 108,210 women will be diagnosed with lung cancer (^1,2).  As many of us know, a large number of lung cancer cases are related to tobacco use and for this reason carries a stigma in society which can interfere with patients seeking treatment.  What many people don’t know is that lung cancer in women who have never smoked is on the rise.  Dana Reeve, widow of Christopher Reeve, was one example.  Mrs. Reeve was diagnosed at age 44 and died within a year of her diagnosis; she had never smoked.  Although the stigma of lung cancer discouraged her, Mrs. Reeve became an advocate for other lung cancer patients and a strong supporter of the American Cancer Society. 

Unfortunately for all patients with lung cancer, symptoms are rare for early-stage disease when a cure is possible.  Generally by the time patients have symptoms, their disease is advanced and more difficult to treat and or cure.   Lung cancer screening has been shown to provide a 20% reduction in lung cancer specific death rates when high-risk patients were screened with annual low-dose CT scans of the chest (³).    High-risk individuals have been defined as those 55-74 years old, with a smoking history of 30 years or more and former smokers who had quit within the last 15 years.   These statistics do not help our female patients who have never smoked though.   Research is continuing to look at blood tests and other tests that can be used as screening exams for asymptomatic patients. 

What can you do to help yourself or someone you love?  If you are an individual who is high-risk for lung cancer (i.e. you are currently smoking and have a 30 pack-year history or you quit within the last 15 years), ask your doctor about lung cancer screening with a low dose CT scan.  For information on our UC Davis Comprehensive Lung Cancer Screening Program please call 916 734-0655 to schedule a low dose CT for lung cancer screening.  Our lung cancer screening program is a Lung Cancer Alliance Screening Center of Excellence.  If you have a first degree-relative with lung cancer, talk to your doctor about your risk and whether or not screening is appropriate.  Please do not ignore symptoms of cough, chest pain or unexplained weight loss – talk to your doctor. 

If you would like more information about women’s lung health, go to www.lungforce.org.  We are proud to partner witht the American Lung Association in California, especially during this National Women’s Health Week.  The American Lung Association is launching a national campaign to raise awareness for women’s lung health, decrease the stigma of lung cancer and COPD and to promote research.  Join the effort by wearing Turquoise, the signature color for the Lung Force lung cancer and COPD campaign, and telling people why you are doing so.  Remember, when your doctor mentions your annual mammogram to ask about your risk of lung cancer and whether or not screening is appropriate. 

References:

1. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-041775.pdf
2. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-041776.pdf
3. http://www.nejm.org/doi/full/10.1056/NEJMoa1102873

On December 30^th , via a publication in the Annals of Internal Medicine found here, the United States Preventive Services Task Force (USPSTF) announced they recommend annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55-80 years who have a 30 pack-year smoking history (the number of years smoking x number of packs per day, for example 2 pack/day smoking habit for 15 years equals 30 pack-years, or 1 pack/day smoking habit for 30 years also equals 30 pack-years) and currently smoke or have quit within the past 15 years.  The USPSTF also recommended that screening should discontinue once a person has stopped smoking for 15 or more years, or has developed a medical condition that would preclude curative surgery if a lung cancer was to be found.

These ground breaking recommendations are a follow-up to the USPSTF recommendations released July 29^th, 2013.  Since their July 29^th announcement, the USPSTF reviewed multiple data including US and European randomized clinical trials, and employed population modeling studies commissioned from the Cancer Intervention and Surveillance Modeling Network (CISNET).  The USPSTF’s support of lung cancer screening by LDCT is a departure from their last report in 2004, where they found no evidence in support of lung cancer screening by LDCT or chest x-ray or sputum analysis.

So what is the USPSTF?  The USPSTF is an “independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services.” (http://www.ahrq.gov/clinic/uspstfix.htm Agency for Healthcare Research Quality).  The USPSTF offers graded recommendations from A (high certainty that the net benefit [of an intervention] is beneficial) to D (recommendation against [the intervention]).  There is an alternative grade called “I” or insufficient evidence.  The USPSTF provides a grade “B” recommendation for lung cancer screening with LDCT; randomized clinical trials looking at LDCT for lung cancer screening provides “moderate certainty” of the benefit to a high-risk population.

So why are the USPSTF recommendations on lung cancer screening important?  Currently very few insurance plans, including Medicare or Medicaid, cover the costs of lung cancer screening.  Most asymptomatic patients who fit the high risk group defined above must pay out of pocket expenses if they want a LDCT specifically for the purposes of lung cancer screening.  Lesser et al demonstrated (Lesser et al, Ann Fam Med. 2011) that from 2007 to 2009 the USPSTF recommended 15 preventative interventions for adults aged 65 years and older.  Medicare partially covered 93% of the recommended services.  In the same time frame, USPSTF recommended against 16 preventive services, and Medicare partially covered only 44% of those services.  So although the USPSTF recommendations, per their own disclaimer, “are independent of the US Government”, the Centers for Medicare and Medicaid Services (CMS) take their recommendations seriously when determining clinical services coverage.

What information is the USPSTF using for their recommendations?  Although the USPSTF reviewed multiple studies and randomized clinical trials, the largest study they looked at is the National Lung Screening Trial (NLST).  The NLST was a US, academic, multi-hospital randomized clinical trial comparing chest X-ray to LDCT for screening in patients considered high risk (aged 55-74, 30 pack-year smoking history, current smoker or quit within 15 years at point of eligibility).  Patients underwent three annual screening exams.  The results demonstrated that LDCT reduced death from lung cancer by 20% compared to chest X-ray, and overall death from all causes by 6.7% compared to chest X-ray.  70% of the lungs cancers found by LDCT were stage I or II, or the earliest most curable stage.

Why is lung cancer screening important?  Currently 75% of patients who are diagnosed with lung cancer are diagnosed at stage III or IV, or locally advanced or metastatic stages.  Although there have been improvements in targeted molecular therapy as illustrated here, long term survival for patients with advanced stage lung cancer is difficult.  As mentioned above, 70% of the lung cancers found by screening LDCT were early stage tumors, where 5 year survival is 75-80%.  This is an incredible “stage-shift” which will have marked benefits on society.

What else did the USPSTF say?  The USPSTF highly recommended that smoking cessation be incorporated into any screening program.  This brings up the important point; any lung cancer screening program should be a comprehensive screening program.  What does that mean?  It means that a patient should enter the appointment with a referral from a primary-care provider.  This allows for communication of results, and continuity of care.  All active smokers should undergo smoking cessation counseling.  Patients with abnormal lung findings should have the opportunity to receive counseling and guidance form a lung cancer screening program clinician.  In addition the screening program should be multidisciplinary, and have frequent continuous quality improvement meetings to oversee the efficacy and results of the program.  Our UC Davis Comprehensive Lung Cancer Screening Program fits theses criteria, and is comprehensive in its design and implementation.

Is there any controversy to the USPSTF recommendations?  Not controversy, but the USPSTF recommendations focus on a group that is defined as high risk (aged 55-80, 30 pack-year smoking history, current smoker or quit within 15 years), but what about patients that do not fit the smoking criteria but are also at risk for lung cancer?  Those patients include, but not limited to those individuals who have been exposed to asbestos, have COPD, high levels of radon exposure, history of interstitial lung disease and a family history of lung cancer.  The National Comprehensive Cancer Network recommends LDCT screening in patients who are aged 50-74, 20 pack-year smoking history and have one additional risk factor.  Risk factors include the following:  personal lung cancer history (>5 years), family history of lung cancer (first degree relative), chronic lung disease, and carcinogen exposure (excluding second hand smoke exposure).  We have also incorporated the NCCN guidelines into our UC Davis Comprehensive Lung Cancer Screening Program.

How can I learn more about lung cancer screening LDCT?  There are a number of patient-centered resources.  The National Cancer Institute has a NLST Patient and Physician Guide.  The American Lung Association offers an online patient-centered tool found here, that helps patients determine if they are candidates for LDCT lung cancer screening.  A great social media community is #LCSM, which regularly has Twitter chats that discuss lung cancer issues, and has an associated blog.  Finally our representatives from our UC Davis Comprehensive Lung Cancer Screening Program are available to answer questions at 916-734-0655.

Medicine is evolving where the focus expands to not just state of the art technology and procedures to care for our patients, but also what value can medicine provide to patients.  That value is defined by not just the overarching goals of therapy, i.e. cure of cancer, resolution of infection, amelioration of pain, but also by the effects on quality of life, function after surgery, and most importantly, what immediate outcomes are important to patients and their families.

For a potential patient and their family, transparency in provider outcomes is key.  The patient-centered outcomes of the UC Davis General Thoracic Surgery Program are tracked by several quality databases and evaluation organizations including the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP^®), the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database and the LeapFrog Group.  These bodies compare medical institutions outcomes to national benchmarks and determine how individual institutions rank.  For example, in the case of ACS NSQIP, comparisons determine if an institution’s results in eight measured outcomes are in line with its national peers (As Expected), underperform its peers (Needs Improvement) or out perform its peers (Exemplary).

Below are our UC Davis Thoracic Surgery Program Outcomes as measured by the most recent national quality assurance measures:

2012 ACS NSQIP^®

Where Mortality is the rate of surviving the hospital experience after an operation; pneumonia is a lung infection acquired during the hospitalization; ventilator > 48hrs refers to the time on a breathing machine after an operation; morbidity is the accumulative complications after an operation; unplanned intubation is the need for a breathing tube to be put back in after an operation; deep venous thrombosis is a blood clot in the arms or legs that may develop after an operation; urinary tract infection is an infection often from a bladder catheter that is placed for an operation; return to the operating room is an unplanned re-operation after the intended or index operation.

STS General Thoracic Surgery Database (2010-2012)

Where Discharge Survival is the rate of leaving the hospital alive after the operation, and 30-Day Survival is the rate of surviving 30 days after an operation, even after having gone home.

LeapFrog Group Ratings for Esophageal Resection (2013)

 4-Bar, Best Odds for Survival Ranking or Highest Quality of Care Rating: Top in the Sacramento region.

Where 4-Bars (Highest Quality of Care Rating) means the patient has the best chances of surviving an esophageal resection.  An esophageal resection or Esophagectomy is a surgery to remove the esophagus and replace it with the stomach or colon and is most commonly performed for cancer, though sometimes it needs to be performed for very extreme non-cancer disease.

The LeapFrog Group determines the Highest Quality of Care Rating by surveying participating hospitals and measuring their outcomes.  A hospital can achieve a Highest Quality of Care Rating by:

–       Participating in the Leapfrog Survey

–       Performing ≥ 13 esophagectomies during the survey year

–       All of the esophagectomies performed by high-volume surgeon (≥ 2 esophagectomies/year)

The LeapFrog Highest Quality of Care Rating determines quality or value based on the volume, or the number of procedures performed.  The thinking is that having experience with a procedure refines quality outcomes and promotes value.  This volume-outcome relationship has been demonstrated in the scientific literature (Birkmeyer et al, New Engl J of Med, 2002) for both esophageal cancer surgery (Esophagectomy) as well as lung cancer surgery otherwise called pulmonary resection, such as lobectomy and pneumonectomy.

Since 2008 our UC Davis General Thoracic Surgery Program has performed 100 esophagectomies and over 200 lobectomy and pneumonectomies.

Patient-centered value outcomes, as mentioned above, have a lot to do with the skill of the surgeon and the surgeon’s volume based experience.  However the central driver of quality outcomes is careful planning, attention to detail, and scientific evidence based best-practice treatment algorithms that are followed in consensus by the entire care team.  Care processes or pathways that are patient/family-focused, foster coordination and communication amongst all providers can promote efficiency and improve results that are important to patients (Vanhaecht et al, Health Serv Mange Res, 2007).

At UC Davis, we have developed novel evidence based post-operative care pathways for esophagectomy (Cooke et al, Society of Thoracic Surgeons 49^th Annual Meeting, 2013) and lung resection as well as Respiratory Therapy pathways that are designed to prevent pneumonia, need for replacement of a breathing tube and pronged need for a breathing tube (Tanner-Corbett…Cooke et al, 14^th World Conference on Lung Cancer, 2011), and in effect, “stack the deck” in the patients favor to achieve important top clinical outcomes.

With our evolving health care system, the definition of quality has matured from not only advanced technology that is available, but also the value in outcomes that the patient experiences, and maximization of the outcomes that are most important to patients and their families.  Transparency in provider outcomes helps patients make informed decisions on how their care should be directed.

The section of General Thoracic Surgery at UC Davis is offering Robotic Thoracic Surgery to further enhance our top regional minimally invasive thoracic surgery program. 

 What is robotic surgery? 

Robotic surgery is performed in much the same way that minimally invasive thoracic surgery (VATS) is performed.  It involves the use of small incisions, a video camera and a surgical robot.  The surgical robot is under the control of your surgeon at all times.  One of the many advantages of the surgical robot is the ability to have wristed articulation inside the chest, almost like having a surgeon’s hand inside your chest (without having a large incision).  The robot also provides exceptional optics, surgeon control of all instruments and is ideal for visualization in tight spaces like the middle of the chest¹.  Additionally, robotic lung resection is associated with a shorter need for narcotic pain medication after surgery and an earlier return to usual activities when it is compared to traditional VATS lung resections².  When compared to VATS, robotic surgery has been found to have similar complication and death rates, as well as similar long-term survival for cancer patients undergoing cancer resections³. 

For what surgeries is the robot being used? 

We are currently using the surgical robot for:

• mediastinal tumors (tumor in the middle of the chest)
• lung biopsy
• lung lobectomy (removal of parts of the lung)
• removal of masses from the chest
• procedures of the diaphragm

The UC Davis Robotic Thoracic Surgery Program offers unprecedented new value and quality to our patients

UC Davis Robotic Thoracic Surgery Team:

Dr. Elizabeth A. David

Dr. David Tom Cooke

Robin Kelly, PA-C

References

1. Cerfolio EJ, Bryan AS, Minnich DJ.  Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology.  . J Thor and CV Surgery 2012; 143 (5) 1138-43.
2. Louie BE, FarivarAS, Aye RW et al. Early Experience with Robotic Lung Resection Results in Similar Operative Outcomes and Morbiditiy When Compared with Matched Video-Assisted Thoracoscopic Surgery Cases.  Ann Thor Surg 2012 May Vol 93 (5) 1598-1605.
3. Park BJ, Melfi F, Mussi A et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): Long-term oncologic results. J Thor and CV Surgery 2012; 143 (2) 383-9.