ST. LOUIS – The VHA appears to fall short in providing equitable access to pre-operative care, which is associated with worse short- and long-term outcomes in clinical stage I non-small-cell lung cancer (NSCLC), according to a recent report.
The authors of a new study in Annals of Thoracic Surgery call for future VHA policy measures that provide more guideline-concordant care to veterans and assure equal access to care.1
“Equitable access to care is a critical component of comprehensive surgical lung cancer management,” explained authors from the VA St. Louis Healthcare System and Washington University School of Medicine. “Despite this, quality measures (QMs) assessing pre-operative access to care are lacking. We determined several pre-operative QMs based on contemporary treatment guidelines and hypothesized that poor access to care was associated with worse outcomes.”
To do that, the study team conducted a retrospective cohort study using a uniquely compiled VHA dataset of 9,749 patients with clinical stage I NSCLC receiving surgical treatment from 2006 to 2016.
Researchers defined four QMs that patients with clinical stage I NSCLC should routinely meet in the pre-operative period:
- timely surgery,
- positron emission tomography imaging,
- appropriate smoking management, and
- pulmonary function testing.
They then assessed the relationship between meeting these QMs and various short- and long-term outcomes.
Among veterans undergoing surgery for clinical stage I NSCLC, 3,371 (34.6%) met all QMs. The study determined that factors associated with a lower likelihood of meeting all QMs included black race (adjusted odds ratio [aOR] 0.744, 95% CI 0.652-0.848), higher area deprivation index score (e.g., quartile 5 vs. 1, aOR 0.747, 0.647-0.863), and increased distance to the hospital (e.g., quartile 5 vs. 1, aOR 0.700, 0.605-0.811).
On the other hand, “adherence to all QMs was associated with significantly lower likelihood of postoperative mortality (aOR 0.623, 0.433-0.896) and improved overall survival (adjusted hazard ratio [aHR] 0.897, 0.844-0.954),” the authors wrote.
In terms of smoking management and cessation, some of the same researchers published a study earlier this year pointing out that continuing to smoke after surgical treatment for lung cancer has a strong detrimental effect on overall survival.
The report in the journal Chest advised that smoking at the time of surgical treatment for lung cancer is known to increase the risk for perioperative morbidity and mortality. What has been unclear is the prevalence of persistent smoking in the post-operative period and how that affects long-term oncologic outcomes. The retrospective cohort study involved a similar VHA dataset as the more recent study. Persistent smoking was defined as continuing to smoke one year after surgery, and that information was used to describe the relationship between persistent smoking and disease-free survival and overall survival.2
Of the 7,489 patients undergoing surgical treatment for clinical stage I NSCLC, 60.9% were smoking at the time of surgery and 58.0% continued to smoke at one year after surgery, according to the authors. Among the 39.1% of patients who were not smoking at the time of surgical treatment, 19.6% relapsed and were smoking at one year after surgery, they added.
Results indicated that persistent smoking at one year after surgery was associated with significantly shorter overall survival (adjusted hazard ration [aHR], 1.291; 95% CI, 1.197-1.392; p<0.001) but was not associated with inferior disease-free survival (aHR, 0.989; 95% CI, 0.884-1.106; P=0.84).
“Persistent smoking following surgery for stage I NSCLC is common and is associated with inferior overall survival,” the researchers concluded. “Providers should continue to assess smoking habits in the post-operative period, given its disproportionate impact on long-term outcomes after potentially curative treatment for early-stage lung cancer.”
- Heiden BT, Eaton DB Jr, Chang SH, Yan Y, Schoen MW, Patel MR, Kreisel D, Nava RG, Samson P, Meyers BF, Kozower BD, Puri V. Access to Care Metrics in Stage I Lung Cancer: Improved Access Is Associated with Improved Survival. Ann Thorac Surg. 2022 Jun 17:S0003-4975(22)00832-3. doi: 10.1016/j.athoracsur.2022.05.047. Epub ahead of print. PMID: 35724700.
- Heiden BT, Eaton DB Jr, Chang SH, Yan Y, et. al. The impact of persistent smoking after surgery on long-term outcomes following stage I non-small cell lung cancer resection. Chest. 2021 Dec 14:S0012-3692(21)05082-0. doi: 10.1016/j.chest.2021.12.634. Epub ahead of print. PMID: 34919892