Comparison Between Veteran and Non-Veteran Populations With Clinical Stage I Non-small Cell Lung Cancer Undergoing Surgery

Abstract

Objective: The aim of this study was to compare quality of care and outcomes between Veteran and non-Veteran patients undergoing surgery for clinical stage I non-small cell lung cancer (NSCLC). Background: Prior studies and the lay media have questioned the quality of care that Veterans with lung cancer receive through the VHA. We hypothesized Veterans undergoing surgery for early-stage NSCLC receive high quality care and have similar outcomes compared to the general population. Methods: We performed a retrospective cohort study of patients with clinical stage I NSCLC undergoing resection from 2006 to 2016 using a VHA dataset. Propensity score matching for baseline patient- and tumor-related variables was used to compare operative characteristics and outcomes between the VHA and the National Cancer Database (NCDB). Results: The unmatched cohorts included 9981 VHA and 176,304 NCDB patients. The VHA had more male, non-White patients with lower education levels, higher incomes, and higher Charlson/Deyo scores. VHA patients had inferior unadjusted 30-day mortality (VHA 2.1% vs NCDB 1.7%, P = 0.011) and median overall survival (69.0 vs 88.7 months, P < 0.001). In the propensity matched cohort of 6792 pairs, VHA patients were more likely to have minimally invasive operations (60.0% vs 39.6%, P < 0.001) and only slightly less likely to receive lobectomies (70.1% vs 70.7%, P = 0.023). VHA patients had longer lengths of stay (8.1 vs 7.1 days, P < 0.001) but similar readmission rates (7.7% vs 7.0%, P = 0.132). VHA patients had significantly better 30-day mortality (1.9% vs 2.8%, P < 0.001) and median overall survival (71.4 vs 65.2 months, P < 0.001). Conclusions: Despite having more comorbidities, Veterans receive exceptional care through the VHA with favorable outcomes, including significantly longer overall survival, compared to the general population.

Assessment of Duration of Smoking Cessation Prior to Surgical Treatment of Non-small Cell Lung Cancer

“…17 Our study shows that more frequent medical visits (including appointments with primary care providers) and new prescriptions for cessation pharmacotherapy can promote smoking cessation in the preoperative period. Our group has previously studied objective quality measures for the surgical management of stage I lung cancer in Veteran 26 , 39 and civilian populations. 30 , 40 Based on our work and this study, we believe that appropriate peri-operative smoking management should become a quality metric for the surgical treatment of early-stage lung cancer.…”

Association Between Surgical Quality Metric Adherence and Overall Survival Among US Veterans With Early-Stage Non–Small Cell Lung Cancer

“…Based on contemporary treatment guidelines and previously validated literature, including some of our prior work, we defined 5 process-based QMs that should be met in all patients diagnosed with early-stage NSCLC: timely surgery (defined as surgery within 12 weeks of radiographic suspicion, as previously described by our group), [7][8][9] anatomic resection (via lobectomy or segmentectomy), 10,11,29 minimally invasive approach, 12,13 negative margin, 14 and adequate lymph node sampling. 15,16 Timely surgery has been previously associated with worse cancer-specific outcomes.…”

“…An integer-based score (termed the Veterans Affairs Lung Cancer Operative quality [VALCAN-O] score) from 0 (no QMs met) to 13 (all QMs met) was constructed, with higher scores reflecting progressively better risk-adjusted OS. The median (IQR) OS differed substantially between the score categories (score of 0-5 points, 2.6 [1.0-5.7] years of OS;[6][7][8][9][10][11]] years; and 12-13 points, 7.0 [3.0-12.5] years; P < .001). In addition, risk-adjusted RFS improved in a stepwise manner between the score categories (6-8 vs 0-5 points, multivariable-adjusted hazard ratio [aHR], 0.62; 95% CI, 0.48-0.79; P < .001; 12-13 vs 0-5 points, aHR, 0.39; 95% CI, 0.31-0.49; P < .001).…”

“…3 Specifically in the setting of surgical resection, most contemporary lung cancer treatment guidelines recommend several modifiable, process-based surgical quality metrics (QMs) that should be met for all patients diagnosed with early-stage non-small cell lung cancer (NSCLC). [4][5][6] These metrics include timely surgery, [7][8][9] receipt of anatomic resection, 10,11 a minimally invasive approach, 12,13 negative surgical margin, 14 and adequate lymph node sampling. [15][16][17] Prior work from our group has demonstrated that adherence to these surgical QMs is associated with improved outcomes among patients diagnosed with NSCLC who received definitive surgical treatment.…”

Keeping a Safe Distance From Surgical Volume Standards

“…Although undoubtedly important, it raises the question of why this metric is used. For example, operative mortality is an increasingly rare event for most cancer surgeries (eg, < 2% for patients with lung cancer receiving surgery in the United States die 11 ); does that mean that all patients who escape this fate (eg, > 98% of patients with lung cancer) have received a high-quality surgery? Similarly, how does one control for the reliability of hospital performance metrics in low-volume centers, where infrequent outcomes (like mortality) may not occur for years 7 ?…”