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Greater surgeon experience linked to better long-term survival in NSCLC

Key clinical point:Insufficient lymph-node sampling by less-experienced surgeons may be a reason why patients with stage I NSCLC had better long-term survival if operated on by moderate- and high-experience surgeons.

Major finding: Short-term outcomes in pathologic stage I NSCLC were not affected by surgeon experience, but 5-year survival was significantly lower for the low-experience compared to the moderate-experience surgeons (76.9% vs. 67.5%).

Data source: An institutional database analysis was conducted of 800 operations on stage I NSCLC patients performed from 2000 to 2012.

Disclosures: The authors reported having no conflicts of interest.

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Experience or training?

How do you measure surgeon experience? “What is more important, the surgeon maturity, the volume of surgeries, or a reference oncologic hospital? I believe that experience in surgery is not mathematics, but is an art that any one can be trained to do,” Dr. Daniele Cristina Cataneo wrote in her invited editorial commentary [doi: 10.1016/j.jtcvs.2014.12.073].

This is borne out by this study, she added. The authors have answered the question – surgeon experience has no impact on perioperative outcomes, but can affect long-term survival based upon N2 resection. This means that the pertinent component of experience can be trained, i.e., sampling more nodes. She concluded that with appropriate training, a surgeon could be rendered “experienced” to operate in early stage lung cancer – not only without complications, but also, by increasing N2 resection, with improved survival.

Dr. Cataneo is an associate professor of thoracic surgery at the Botucatu School of Medicine, Sao Paulo State University, Brazil.


 

FROM THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY

References

Surgeon experience may be a factor in long-term survival of patients after lung resection for non–small cell lung cancer (NSCLC) but the correlation between the two is not straightforward.

Postfellowship surgeon experience did not influence perioperative outcomes in pathologic stage I NSCLC. However, a moderate level of experience was associated with greater utilization of video-assisted thoracic surgery, higher mediastinal lymph noted yield, and improved 5-year survival, according to the results of a single center, retrospective review of a lung cancer database.

©Sergey Nivens/thinkstockphotos.com

Between January 2000 and December 2012, 800 patients underwent resection for pathologic stage I NSCLC by eight surgeons – comprising 638 lobectomies (79.8%) and 162 sublobar resections (20.2%).

Experience was based on the number of years at the time of surgery beyond the individual’s completion of a cardiothoracic surgery fellowship. The low-experience (LE) group was defined as operations conducted within the first 5 years of practice after specialty training. The moderate-experience (ME) group comprised surgeons with experience of 5-15 years. The high-experience (HE) group comprised surgeons with more than 15 years post fellowship, according to Paul J. Scheel III and colleagues in the division of cardiothoracic surgery, Washington University, St. Louis.

Over the complete time period, operations were performed by six different surgeons in the LE group, five surgeons in the ME group, and two surgeons in the HE group. By multiple criteria in previous publications, “all the operators involved in our study are specialty trained in thoracic surgery, and are high-volume surgeons,” which eliminates some potential confounders, according to the report, which was published online and in the April issue of The Journal of Thoracic and Cardiovascular Surgery. [doi:10.1016/j.jtcvs.2014.12.032].

The number of mediastinal (N2) lymph node stations sampled per operation was highest for the ME group and lowest for the HE group: LE = 2.8, ME = 3.5, and HE = 2.3, all of which were significantly different across all groups.

The risk of perioperative morbidity defined by STS criteria was not significantly different: with LE = 30.3%, ME = 22.8%, and HE = 28.9%, all similar (P = .163). There were no differences seen in length of hospital stay or perioperative mortality between the groups.

Unadjusted 5-year survival, however, was significantly higher in the ME group (76.9%) compared to the LE group (67.5%, P < .001) and the HE group (71.4%, P = .006). In addition, the ME group surgeons were significantly more likely to have used video-assisted thoracic surgery (VATS) than were the other two groups.

In their discussion, the researchers pointed out a possible reason for the difference seen in mortality: “We noted that the ME group tended to have a higher yield of lymph nodes and this also correlated with survival. It is plausible that surgeons who are in the early stage of their career may be completely focused on ‘getting the specimen out’ with less attention being paid to nodal sampling with its added operative time and perceived additional morbidity.” HE surgeons may have lower yields because “the importance of nodal sampling has been predominately realized over the last 2 decades,” they pointed out.

“Patients operated on by moderately experienced surgeons may have better long-term survival after resection for pathologic stage I lung cancer. Expanding this study to a larger patient and surgeon population would be needed to validate the results and identify the underlying causes for these differences in order to provide the best patient care,” the researchers concluded.

The authors reported having no conflicts of interest.

mlesney@frontlinemedcom.com

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