Henry S. Park

Outcomes From 3144 Adrenalectomies in the United States Which Matters More, Surgeon Volume or Specialty?

OBJECTIVE To assess the effect of surgeon volume and specialty on clinical and economic outcomes after adrenalectomy. DESIGN Population-based retrospective cohort analysis. SETTING Healthcare Cost and Utilization Project Nationwide Inpatient Sample. PARTICIPANTS Adults (>or=18 years) undergoing adrenalectomy in the United States (1999-2005). Patient demographic and clinical characteristics, surgeon specialty (general vs urologist), surgeon adrenalectomy volume, and hospital factors were assessed. MAIN OUTCOME MEASURES The chi(2) test, analysis of variance, and multivariate linear and logistic regression were used to assess in-hospital complications, mean hospital length of stay (LOS), and total inpatient hospital costs. RESULTS A total of 3144 adrenalectomies were included. Mean patient age was 53.7 years; 58.8% were women and 77.4% white. A higher proportion of general surgeons were high-volume surgeons compared with urologists (34.1% vs 18.2%, P < .001). Low-volume surgeons had more complications (18.2% vs 11.3%, P < .001) and their patients had longer LOS (5.5 vs 3.9 days, P < .001) than did high-volume surgeons; urologists had more complications (18.4% vs 15.2%, P = .03) and higher costs (

Immortal time bias: a frequently unrecognized threat to validity in the evaluation of postoperative radiotherapy.

13,168 vs

Survival outcomes in atypical teratoid rhabdoid tumor for patients undergoing radiotherapy in a Surveillance, Epidemiology, and End Results analysis

11,732, P = .02) than did general surgeons. After adjustment for patient and provider characteristics in multivariate analyses, surgeon volume, but not specialty, was an independent predictor of complications (odds ratio = 1.5, P < .002) and LOS (1.0-day difference, P < .001). Hospital volume was associated only with LOS (0.8-day difference, P < .007). Surgeon volume, specialty, and hospital volume were not predictors of costs. CONCLUSION To optimize outcomes, patients with adrenal disease should be referred to surgeons based on adrenal volume and laparoscopic expertise irrespective of specialty practice.

Impact of Hospital Volume of Thoracoscopic Lobectomy on Primary Lung Cancer Outcomes

PURPOSE To evaluate the influence of immortal time bias on observational cohort studies of postoperative radiotherapy (PORT) and the effectiveness of sequential landmark analysis to account for this bias. METHODS AND MATERIALS First, we reviewed previous studies of the Surveillance, Epidemiology, and End Results (SEER) database to determine how frequently this bias was considered. Second, we used SEER to select three tumor types (glioblastoma multiforme, Stage IA-IVM0 gastric adenocarcinoma, and Stage II-III rectal carcinoma) for which prospective trials demonstrated an improvement in survival associated with PORT. For each tumor type, we calculated conditional survivals and adjusted hazard ratios of PORT vs. postoperative observation cohorts while restricting the sample at sequential monthly landmarks. RESULTS Sixty-two percent of previous SEER publications evaluating PORT failed to use a landmark analysis. As expected, delivery of PORT for all three tumor types was associated with improved survival, with the largest associated benefit favoring PORT when all patients were included regardless of survival. Preselecting a cohort with a longer minimum survival sequentially diminished the apparent benefit of PORT. CONCLUSIONS Although the majority of previous SEER articles do not correct for it, immortal time bias leads to altered estimates of PORT effectiveness, which are very sensitive to landmark selection. We suggest the routine use of sequential landmark analysis to account for this bias.

Postoperative Radiation Therapy Is Associated With Improved Overall Survival in Incompletely Resected Stage II and III Non–Small-Cell Lung Cancer

Atypical teratoid rhabdoid tumor (ATRT) is a rare central nervous system malignancy with a poor prognosis that affects mostly young children. Although radiotherapy (RT) historically has been delayed in patients aged <3 years, emerging evidence suggests a role for RT to achieve long‐term survivorship. Clinical features and age‐dependent trends of RT use were evaluated for patients with ATRT.

Assessment of National Practice for Palliative Radiation Therapy for Bone Metastases Suggests Marked Underutilization of Single-Fraction Regimens in the United States

BACKGROUND This study evaluated hospital operative volume of video-assisted thoracoscopic surgery (VATS) lobectomy in primary lung cancer as a predictor of short-term outcomes after pulmonary lobectomy on a national scale. Some previous analyses comparing VATS vs open lobectomy outcomes have been limited by inaccuracies in patient cohort identification. METHODS The 2008 Healthcare Utilization Project-Nationwide Inpatient Sample database was culled using the International Classification of Diseases (9th Clinical Modification) procedure codes specifically distinguishing VATS vs open lobectomies (32.41 and 32.49, respectively) available only after October 2007. High hospital VATS volume was defined as 95th percentile or higher (>20 VATS/year). Univariable and multivariable analyses were used to identify independent predictors of the following outcome measures: 30-day in-hospital morbidity and mortality, hospital length of stay (LOS), and hospital costs. RESULTS We identified 6,292 primary lung cancer patients undergoing pulmonary lobectomy, including 1,523 undergoing VATS (24%). Compared with open, VATS patients had fewer complications (38% vs 44%, p<0.001) and median LOS (5 vs 7 days; p<0.001). In multivariable analysis, VATS was an independent predictor of fewer total complications (odds ratio, 0.83; p=0.004) and shorter LOS (2.3±0.3-day difference, p<0.001). Patients undergoing VATS at high-volume VATS hospitals had shorter median LOS (4 vs 6 days, p=0.001) compared with low-volume VATS hospitals. Multivariable analysis showed high hospital VATS volume independently predicted shorter LOS (0.9±0.4-day difference, p=0.001). CONCLUSIONS In a national database, VATS lobectomy was associated with fewer complications and shorter LOS than open lobectomy in primary lung cancer patients. Among patients undergoing VATS, high hospital volume was also associated with shorter LOS.

Central versus Peripheral Tumor Location: Influence on Survival, Local Control, and Toxicity Following Stereotactic Body Radiotherapy for Primary Non-Small-Cell Lung Cancer.

PURPOSE To review trends in the use of postoperative radiotherapy (PORT) for stage II and III incompletely resected non-small-cell lung cancer (NSCLC) and evaluate the association between PORT and survival in such patients. PATIENTS AND METHODS We identified patients with pathologic stage N0-2, overall American Joint Committee on Cancer stage II or III NSCLC within the National Cancer Data Base who had undergone a lobectomy or pneumonectomy with positive surgical margins. Only patients coded as receiving external-beam PORT at 50 to 74 Gy or observation were included. To account for perioperative mortality, we excluded patients who survived less than 4 months after diagnosis. Multivariable logistic regression was used to determine factors associated with PORT receipt. Cox proportional hazards regression was performed for multivariable analyses of overall survival. RESULTS Among 3,395 included patients, 1,207 (35.6%) received PORT. Predictors for the use of PORT among this patient population included age less than 60 years, treatment in a nonacademic facility, earlier year of diagnosis, decreased travel distance, lower nodal stage, and chemotherapy receipt. On multivariable analysis adjusting for demographic and clinicopathologic covariates, PORT (hazard ratio, 0.80; 95% CI, 0.70 to 092) was associated with improved survival. Subset analysis by nodal stage showed that PORT improved survival across all nodal stages. CONCLUSION PORT is associated with improved overall survival in patients with incompletely resected stage II or III N0-2 NSCLC. The use of PORT for this population in more recent years has been declining. In the absence of randomized trials evaluating PORT utilization for this patient population, our findings strongly support the delivery of PORT in patients with incompletely resected NSCLC.

Patients Selected for Definitive Concurrent Chemoradiation at High-volume Facilities Achieve Improved Survival in Stage III Non–Small-Cell Lung Cancer

PURPOSE To characterize temporal trends in the application of various bone metastasis fractionations within the United States during the past decade, using the National Cancer Data Base; the primary aim was to determine whether clinical practice in the United States has changed over time to reflect the published randomized evidence and the growing movement for value-based treatment decisions. PATIENTS AND METHODS The National Cancer Data Base was used to identify patients treated to osseous metastases from breast, prostate, and lung cancer. Utilization of single-fraction versus multiple-fraction radiation therapy was compared according to demographic, disease-related, and health care system details. RESULTS We included 24,992 patients treated during the period 2005-2011 for bone metastases. Among patients treated to non-spinal/vertebral sites (n=9011), 4.7% received 8 Gy in 1 fraction, whereas 95.3% received multiple-fraction treatment. Over time the proportion of patients receiving a single fraction of 8 Gy increased (from 3.4% in 2005 to 7.5% in 2011). Numerous independent predictors of single-fraction treatment were identified, including older age, farther travel distance for treatment, academic treatment facility, and non-private health insurance (P<.05). CONCLUSIONS Single-fraction palliative radiation therapy regimens are significantly underutilized in current practice in the United States. Further efforts are needed to address this issue, such that evidence-based and cost-conscious care becomes more commonplace.

Treatment patterns of aging Americans with differentiated thyroid cancer

Introduction: Stereotactic body radiotherapy (SBRT) has been increasingly utilized for medically inoperable early stage non–small-cell lung cancer. However, a lower biological equivalent dose (BED) is often used for central tumors given toxicity concerns, potentially leading to decreased local control (LC). We compared survival, LC, and toxicity outcomes for SBRT patients with centrally versus peripherally located tumors. Methods: We included patients with primary cT1-2N0M0 non–small-cell lung cancer treated with SBRT at our institution from September 2007 to August 2013 with follow-up through August 2014. Central tumor location was defined as within 2 cm of the proximal bronchial tree, heart, great vessels, trachea, or other mediastinal structures. Kaplan–Meier analysis and multivariable Cox regression modeling were used for overall survival (OS) and LC, and the &khgr;2 test and multivariable logistic regression modeling were used for toxicity. Results: We included 251 patients (111 central, 140 peripheral) with median follow-up of 31.2 months. Patients with central tumors were more likely to be older (mean 75.8 versus 73.5 years; p = 0.04), have larger tumors (mean 2.5 cm versus 1.9 cm; p < 0.001), and be treated with a lower BED (mean 120.2 Gy versus 143.5 Gy; p < 0.001). Multivariable analysis revealed that tumor location was not associated with worse OS, LC, or toxicity. Patients with central tumors were less likely to have acute grade greater than or equal to three toxicity than those with peripheral tumors (odds ratio: 0.24; p = 0.02). Conclusions: Central tumor location did not predict for inferior OS, LC, or toxicity following SBRT when a lower mean BED was utilized.

Trends in stereotactic body radiation therapy for stage I small cell lung cancer

Background: The relationship between provider experience and clinical outcomes is poorly defined in radiation oncology. This study examined the impact of facility case volume on overall survival in patients with stage III non–small cell lung cancer (NSCLC) treated with definitive concurrent chemoradiation therapy (CCRT). Methods: Using the National Cancer Data Base, we identified clinical stage III NSCLC patients diagnosed in 2004 to 2006 who were treated with definitive CCRT to 59.4–74.0 Gy. High-volume facilities (HVF) were defined as those in the ninetieth percentile of annual CCRT volume (≥12 cases/year). Independent predictors of receiving CCRT at HVF were identified using multivariable logistic regression. Overall survival based on receiving CCRT at HVF was assessed using Kaplan–Meier analysis, Cox proportional hazards regression, and propensity score matching. Results: Among 10,072 included patients, 1207 (12.0%) were treated at HVF. Patients in HVF were more likely to have a higher Charlson–Deyo comorbidity score, more advanced nodal stage, higher doses, and 3D-conformal or intensity-modulated radiotherapy. When controlling for demographic and clinical covariates including academic affiliation, treatment at HVF was independently associated with a significantly decreased risk of death (hazards ratio = 0.93; 95% confidence interval: 0.87–0.99; p = 0.03). Propensity score matching showed that these findings were robust (hazards ratio = 0.91; 95% confidence interval: 0.84–0.99; p = 0.04). Conclusions: Our findings suggest that treatment at HVF is associated with improved overall survival among stage III NSCLC patients receiving definitive CCRT, independent of academic affiliation. Further research is needed to determine whether or not efforts supporting centralization of radiotherapy at HVF will improve population-based survival, toxicities, and costs.