Background: Despite curative intent resection in patients with non-small cell lung cancer (NSCLC), recurrence leading to mortality remains too common. Melatonin has shown promise for the treatment of patients with lung cancer; however, its effect following cancer resection has not been studied. We evaluated if melatonin taken after complete resection reduces lung cancer recurrence and mortality, or impacts quality of life (QOL), symptomatology or immune function. Methods: Participants received melatonin (20 mg) or placebo nightly for one year following surgical resection of primary NSCLC. The primary outcome was two-year disease-free survival (DFS). Secondary outcomes included five-year DFS, adverse events, QOL, fatigue, sleep, depression, anxiety, pain, and biomarkers assessing for immune function/inflammation. This study is registered at https://clinicaltrials.gov NCT00668707. Findings: 709 patients across eight centres were randomized to melatonin (n = 356) versus placebo (n = 353). At two years, melatonin showed a relative risk of 1¢01 (95% CI 0¢83À1¢22), p = 0¢94 for DFS. At five years, melatonin showed a hazard ratio of 0¢97 (95% CI 0¢86À1¢09), p = 0¢84 for DFS. When stratified by cancer stage (I/II and III/IV), a hazard reduction of 25% (HR 0¢75, 95% CI 0¢61À0¢92, p = 0¢005) in five-year DFS was seen for participants in the treatment arm with advanced cancer (stage III/IV). No meaningful differences were seen in any other outcomes. Interpretation: Adjuvant melatonin following resection of NSCLC does not affect DFS for patients with resected early stage NSCLC, yet may increase DFS in patients with late stage disease. Further study is needed to confirm this positive result. No beneficial effects were seen in QOL, symptoms, or immune function.
As an innovative approach to improve quality of surgical care, we combined surgeon self-assessment and anonymized peer comparison with continuous quality improvement seminars using positive deviance (CQI/PD) to identify surgeon(s) with the lowest rates of adverse events (AEs) to guide group practice recommendations. Our objective was to quantify the impact these interventions on postoperative AEs rates after major non-cardiac chest operations. All postoperative AEs after all thoracic operations (n = 1,084, March, 2013 to February, 2016, single-center) were prospectively collected using the thoracic morbidity and mortality system, based on Clavien-Dindo schema. Online software provided surgeons (n = 6) with self-evaluation and peer comparison at all times. In addition, quarterly CQI/PD seminars (n = 8, September, 2013 to December, 2015) focused on common impactful AEs: atrial fibrillation (AFIB), prolonged alveolar air leak (PAAL), and anastomotic leak (AL). Impact was analyzed using univariate statistics 6, 9, and 12 months before and after implementation. We observed reductions of postoperative AEs after CQI/PD: a decrease (all time periods) in AFIB, greatest at 6 months (10.1% vs. 6.7%; p = .36); a decrease (all time periods) in PAAL, greatest at 12 months (18.9% vs. 11.7%; p < .05); and decrease (6 and 9 months) in AL, greatest at 6 months (11.1% vs. 8.3%; p = .82). Improvements in AE rates after individual surgeon self-evaluation and CQI/PD seminars provide encouraging results that merit further investigation.
In this cohort, postoperative AEs were minimally associated with negative patient experience. However, patients who experienced PLOS demonstrated a marked reduction in experience after thoracic surgical procedures.
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