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Delay of NSCLC surgery can lead to worse prognosis
SAN DIEGO – Delaying
“There is significant upstaging with time from completion of clinical staging to surgical resection, with a 4% increase of upstaging per week for the overall study population,” said study coauthor Harmik J. Soukiasian, MD, FACS, of Cedars-Sinai Medical Center, Los Angeles, in an interview. “Upstaging impacts lung cancer prognosis as more advanced stages portend to a poorer prognosis.”
An estimated 80%-85% of lung cancer patients have NSCLC, according to the American Cancer Society, and Dr. Soukiasian said surgery offers a chance at a cure for those diagnosed at stage I.
“National Cancer Comprehensive Network (NCCN) Guidelines recommend surgery within 8 weeks of completed clinical staging for NSCLC to limit cancer progression or upstaging,” Dr. Soukiasian said. “Although these guidelines are well established and widely adopted, our study performs a more granular analysis, studying time as a predictor of upstaging for those patients diagnosed with stage I NSCLC.”
For the new study, Dr. Soukiasian and colleagues tracked 52,406 patients in a cancer database who had stage I NSCLC but had not undergone preoperative chemotherapy. The researchers tracked their clinical stages for up to 12 weeks from initial staging.
Researchers found that, while staging levels rose with each successive week, just 25% of patients underwent surgery by 1 week, and only 79% had surgery in accordance with NSCLC guidelines by week 8. At 12 weeks, 9% had still not undergone surgery.
Upstaging was common: 22% at 1 week, 32% after 8 weeks, and 33% after 12 weeks.
“We demonstrate that patients diagnosed with stage I NSCLC benefit from surgery sooner than the 8-week window recommended by the NCCN guidelines,” Dr. Soukiasian said. “Exclusive of the rate of progression and in addition to time to surgery, our study also demonstrated academic centers, higher lymph node yield during surgery, and left-sided tumors to be independent predictors of upstaging.”
The study design doesn’t provide insight into why surgery is often delayed. However, “we can theorize factors associated with delays to surgery may be due to patient factors (personal scheduling, availability of support systems, etc.), delays in follow up, operating room availability or scheduling, and issues with insurance approval,” Dr. Soukiasian said.
In his presentation, Dr. Soukiasian emphasized the role of the mediastinum. “Given the clinical impact of stage III disease, we analyzed upstaging rates of stage I NSCLC to stage IIIA and revealed a 1.3% increase per week of upstaging specifically to stage IIIA. Additionally, almost 5% of patients initially diagnosed with stage I NSCLC upstaged to IIIA disease. The significant rate of upstaging to IIIA disease makes the case for more accurate and aggressive mediastinal staging prior to surgical resection.”
No disclosures and no study funding are reported.
SOURCE: Soukiasian HJ et al. AATS 2018, Abstract 67.
SAN DIEGO – Delaying
“There is significant upstaging with time from completion of clinical staging to surgical resection, with a 4% increase of upstaging per week for the overall study population,” said study coauthor Harmik J. Soukiasian, MD, FACS, of Cedars-Sinai Medical Center, Los Angeles, in an interview. “Upstaging impacts lung cancer prognosis as more advanced stages portend to a poorer prognosis.”
An estimated 80%-85% of lung cancer patients have NSCLC, according to the American Cancer Society, and Dr. Soukiasian said surgery offers a chance at a cure for those diagnosed at stage I.
“National Cancer Comprehensive Network (NCCN) Guidelines recommend surgery within 8 weeks of completed clinical staging for NSCLC to limit cancer progression or upstaging,” Dr. Soukiasian said. “Although these guidelines are well established and widely adopted, our study performs a more granular analysis, studying time as a predictor of upstaging for those patients diagnosed with stage I NSCLC.”
For the new study, Dr. Soukiasian and colleagues tracked 52,406 patients in a cancer database who had stage I NSCLC but had not undergone preoperative chemotherapy. The researchers tracked their clinical stages for up to 12 weeks from initial staging.
Researchers found that, while staging levels rose with each successive week, just 25% of patients underwent surgery by 1 week, and only 79% had surgery in accordance with NSCLC guidelines by week 8. At 12 weeks, 9% had still not undergone surgery.
Upstaging was common: 22% at 1 week, 32% after 8 weeks, and 33% after 12 weeks.
“We demonstrate that patients diagnosed with stage I NSCLC benefit from surgery sooner than the 8-week window recommended by the NCCN guidelines,” Dr. Soukiasian said. “Exclusive of the rate of progression and in addition to time to surgery, our study also demonstrated academic centers, higher lymph node yield during surgery, and left-sided tumors to be independent predictors of upstaging.”
The study design doesn’t provide insight into why surgery is often delayed. However, “we can theorize factors associated with delays to surgery may be due to patient factors (personal scheduling, availability of support systems, etc.), delays in follow up, operating room availability or scheduling, and issues with insurance approval,” Dr. Soukiasian said.
In his presentation, Dr. Soukiasian emphasized the role of the mediastinum. “Given the clinical impact of stage III disease, we analyzed upstaging rates of stage I NSCLC to stage IIIA and revealed a 1.3% increase per week of upstaging specifically to stage IIIA. Additionally, almost 5% of patients initially diagnosed with stage I NSCLC upstaged to IIIA disease. The significant rate of upstaging to IIIA disease makes the case for more accurate and aggressive mediastinal staging prior to surgical resection.”
No disclosures and no study funding are reported.
SOURCE: Soukiasian HJ et al. AATS 2018, Abstract 67.
SAN DIEGO – Delaying
“There is significant upstaging with time from completion of clinical staging to surgical resection, with a 4% increase of upstaging per week for the overall study population,” said study coauthor Harmik J. Soukiasian, MD, FACS, of Cedars-Sinai Medical Center, Los Angeles, in an interview. “Upstaging impacts lung cancer prognosis as more advanced stages portend to a poorer prognosis.”
An estimated 80%-85% of lung cancer patients have NSCLC, according to the American Cancer Society, and Dr. Soukiasian said surgery offers a chance at a cure for those diagnosed at stage I.
“National Cancer Comprehensive Network (NCCN) Guidelines recommend surgery within 8 weeks of completed clinical staging for NSCLC to limit cancer progression or upstaging,” Dr. Soukiasian said. “Although these guidelines are well established and widely adopted, our study performs a more granular analysis, studying time as a predictor of upstaging for those patients diagnosed with stage I NSCLC.”
For the new study, Dr. Soukiasian and colleagues tracked 52,406 patients in a cancer database who had stage I NSCLC but had not undergone preoperative chemotherapy. The researchers tracked their clinical stages for up to 12 weeks from initial staging.
Researchers found that, while staging levels rose with each successive week, just 25% of patients underwent surgery by 1 week, and only 79% had surgery in accordance with NSCLC guidelines by week 8. At 12 weeks, 9% had still not undergone surgery.
Upstaging was common: 22% at 1 week, 32% after 8 weeks, and 33% after 12 weeks.
“We demonstrate that patients diagnosed with stage I NSCLC benefit from surgery sooner than the 8-week window recommended by the NCCN guidelines,” Dr. Soukiasian said. “Exclusive of the rate of progression and in addition to time to surgery, our study also demonstrated academic centers, higher lymph node yield during surgery, and left-sided tumors to be independent predictors of upstaging.”
The study design doesn’t provide insight into why surgery is often delayed. However, “we can theorize factors associated with delays to surgery may be due to patient factors (personal scheduling, availability of support systems, etc.), delays in follow up, operating room availability or scheduling, and issues with insurance approval,” Dr. Soukiasian said.
In his presentation, Dr. Soukiasian emphasized the role of the mediastinum. “Given the clinical impact of stage III disease, we analyzed upstaging rates of stage I NSCLC to stage IIIA and revealed a 1.3% increase per week of upstaging specifically to stage IIIA. Additionally, almost 5% of patients initially diagnosed with stage I NSCLC upstaged to IIIA disease. The significant rate of upstaging to IIIA disease makes the case for more accurate and aggressive mediastinal staging prior to surgical resection.”
No disclosures and no study funding are reported.
SOURCE: Soukiasian HJ et al. AATS 2018, Abstract 67.
AT THE AATS ANNUAL MEETING
Key clinical point: Clinical staging levels worsen in each successive surgery-free week after initial staging in certain NSCLC patients.
Major finding: There was a 1.3% increase per week of upstaging to stage IIIA.
Study details: Analysis of 52,406 patients with stage I NSCLC who were tracked for up to 12 weeks.
Disclosures: No disclosures and no funding were reported.
Source: Soukiasian HJ et al. AATS 2018, Abstract 67.
Presidential address focused on learning and teams
Thoralf M. Sundt III, MD, titled his AATS Presidential Address, “Ancora Imparo: Always Learning,” to emphasize the fact that learning is at the core of team development and of dealing with a complex world.
The world once seemed simple, deterministic – a Newtonian world of individual performance, he said. But in fact, it is a complex, unpredictable world, where the solutions of a previous generation of leaders that relied on individual knowledge and authority no longer apply.
“Complex is not the same as complicated,” said Dr. Sundt. “A watch is complicated, but it is entirely predictable. Complexity is different.” Complex systems are composed of many diverse autonomous parts. They are independent, they are linked as a system, and most important – they adapt. They change in response to the environment and to their own component parts.
How they change depends critically on the nature of the interactions among those components, allowing them to demonstrate emergent properties. And they are unpredictable too, said Dr. Sundt.
This unpredictability poses problems, he added, pointing to the inevitability of systems failures in truly complex endeavors from nuclear power to petrochemical plants.
“The implication of this is that we must think beyond error prevention because we simply cannot prevent them all,” said Dr. Sundt. “That is why checklists alone will not solve our problems.” The focus, instead, he suggested, needs to be on “error management” in order to include detection and recovery.
This is all relevant to surgeons because “our world, our patients, the procedures we perform, and the institutions in which we performed them – are increasingly complex.” Therefore, “no matter how much we care, and no matter how much we try, accidents, mistakes and mishaps will occur – individual effort is not enough.”
But complexity is only half the problem, he said. “The other half is us.”
Dr. Sundt discussed two ways of thinking – fast and slow – with fast thinking grabbing on to patterns and making quick, seemingly intuitive decisions, such as those made by “experts,” and the slow following a deliberative and logical path.
Both types of thinking have their benefits and lacks, which points to how important it is to have access to each type in order to maximize success. Thus, he pointed out, there must be a focus on teams and on a diversity of views, because diversity increases the chances of finding the best good solution.
So diversity is necessary, but is it sufficient? Two other things are necessary, according to Dr. Sundt.
The first is synergy, which is the difference between another useless administrative meeting and an exciting, generative one during which everyone shares opinions, changes their views a bit, and collectively comes up with an entirely original idea.
“But the key to transforming a workgroup to a high-performing team is learning,” he said. “It is an active process that requires both cognitive, and - unfortunately for us task-oriented personalities – affective skills. The aim is to create a ‘learning organization’ – a culture that encourages learning through open interactions in a psychologically safe space.
“It is entirely within our power to change the nature of the interactions we have within our teams, and we can do it today. No hospital committee or departmental approval is required. You cannot solve all of the problems, but you do have an enormous impact on those individuals around you.”
As the leader of a team, “everyone is watching you.” he added.
Dr. Sundt concluded by pointing out that it is also extremely important to confront inevitable failure as a learning experience. “You must wring every drop of learning out of it,” he counseled. And ultimately, “trust your team - you need them. The patient needs them,” he concluded.
Thoralf M. Sundt III, MD, titled his AATS Presidential Address, “Ancora Imparo: Always Learning,” to emphasize the fact that learning is at the core of team development and of dealing with a complex world.
The world once seemed simple, deterministic – a Newtonian world of individual performance, he said. But in fact, it is a complex, unpredictable world, where the solutions of a previous generation of leaders that relied on individual knowledge and authority no longer apply.
“Complex is not the same as complicated,” said Dr. Sundt. “A watch is complicated, but it is entirely predictable. Complexity is different.” Complex systems are composed of many diverse autonomous parts. They are independent, they are linked as a system, and most important – they adapt. They change in response to the environment and to their own component parts.
How they change depends critically on the nature of the interactions among those components, allowing them to demonstrate emergent properties. And they are unpredictable too, said Dr. Sundt.
This unpredictability poses problems, he added, pointing to the inevitability of systems failures in truly complex endeavors from nuclear power to petrochemical plants.
“The implication of this is that we must think beyond error prevention because we simply cannot prevent them all,” said Dr. Sundt. “That is why checklists alone will not solve our problems.” The focus, instead, he suggested, needs to be on “error management” in order to include detection and recovery.
This is all relevant to surgeons because “our world, our patients, the procedures we perform, and the institutions in which we performed them – are increasingly complex.” Therefore, “no matter how much we care, and no matter how much we try, accidents, mistakes and mishaps will occur – individual effort is not enough.”
But complexity is only half the problem, he said. “The other half is us.”
Dr. Sundt discussed two ways of thinking – fast and slow – with fast thinking grabbing on to patterns and making quick, seemingly intuitive decisions, such as those made by “experts,” and the slow following a deliberative and logical path.
Both types of thinking have their benefits and lacks, which points to how important it is to have access to each type in order to maximize success. Thus, he pointed out, there must be a focus on teams and on a diversity of views, because diversity increases the chances of finding the best good solution.
So diversity is necessary, but is it sufficient? Two other things are necessary, according to Dr. Sundt.
The first is synergy, which is the difference between another useless administrative meeting and an exciting, generative one during which everyone shares opinions, changes their views a bit, and collectively comes up with an entirely original idea.
“But the key to transforming a workgroup to a high-performing team is learning,” he said. “It is an active process that requires both cognitive, and - unfortunately for us task-oriented personalities – affective skills. The aim is to create a ‘learning organization’ – a culture that encourages learning through open interactions in a psychologically safe space.
“It is entirely within our power to change the nature of the interactions we have within our teams, and we can do it today. No hospital committee or departmental approval is required. You cannot solve all of the problems, but you do have an enormous impact on those individuals around you.”
As the leader of a team, “everyone is watching you.” he added.
Dr. Sundt concluded by pointing out that it is also extremely important to confront inevitable failure as a learning experience. “You must wring every drop of learning out of it,” he counseled. And ultimately, “trust your team - you need them. The patient needs them,” he concluded.
Thoralf M. Sundt III, MD, titled his AATS Presidential Address, “Ancora Imparo: Always Learning,” to emphasize the fact that learning is at the core of team development and of dealing with a complex world.
The world once seemed simple, deterministic – a Newtonian world of individual performance, he said. But in fact, it is a complex, unpredictable world, where the solutions of a previous generation of leaders that relied on individual knowledge and authority no longer apply.
“Complex is not the same as complicated,” said Dr. Sundt. “A watch is complicated, but it is entirely predictable. Complexity is different.” Complex systems are composed of many diverse autonomous parts. They are independent, they are linked as a system, and most important – they adapt. They change in response to the environment and to their own component parts.
How they change depends critically on the nature of the interactions among those components, allowing them to demonstrate emergent properties. And they are unpredictable too, said Dr. Sundt.
This unpredictability poses problems, he added, pointing to the inevitability of systems failures in truly complex endeavors from nuclear power to petrochemical plants.
“The implication of this is that we must think beyond error prevention because we simply cannot prevent them all,” said Dr. Sundt. “That is why checklists alone will not solve our problems.” The focus, instead, he suggested, needs to be on “error management” in order to include detection and recovery.
This is all relevant to surgeons because “our world, our patients, the procedures we perform, and the institutions in which we performed them – are increasingly complex.” Therefore, “no matter how much we care, and no matter how much we try, accidents, mistakes and mishaps will occur – individual effort is not enough.”
But complexity is only half the problem, he said. “The other half is us.”
Dr. Sundt discussed two ways of thinking – fast and slow – with fast thinking grabbing on to patterns and making quick, seemingly intuitive decisions, such as those made by “experts,” and the slow following a deliberative and logical path.
Both types of thinking have their benefits and lacks, which points to how important it is to have access to each type in order to maximize success. Thus, he pointed out, there must be a focus on teams and on a diversity of views, because diversity increases the chances of finding the best good solution.
So diversity is necessary, but is it sufficient? Two other things are necessary, according to Dr. Sundt.
The first is synergy, which is the difference between another useless administrative meeting and an exciting, generative one during which everyone shares opinions, changes their views a bit, and collectively comes up with an entirely original idea.
“But the key to transforming a workgroup to a high-performing team is learning,” he said. “It is an active process that requires both cognitive, and - unfortunately for us task-oriented personalities – affective skills. The aim is to create a ‘learning organization’ – a culture that encourages learning through open interactions in a psychologically safe space.
“It is entirely within our power to change the nature of the interactions we have within our teams, and we can do it today. No hospital committee or departmental approval is required. You cannot solve all of the problems, but you do have an enormous impact on those individuals around you.”
As the leader of a team, “everyone is watching you.” he added.
Dr. Sundt concluded by pointing out that it is also extremely important to confront inevitable failure as a learning experience. “You must wring every drop of learning out of it,” he counseled. And ultimately, “trust your team - you need them. The patient needs them,” he concluded.