Practice makes perfect in cancer surgery

Researchers determine higher hospital and surgeon volume lead to better outcomes when treating bladder cancer patients

In a new, in-depth research project, Queen’s professors Rob Siemens (Urology) and Christopher Booth (Cancer Care and Epidemiology) investigated what affect higher volume hospitals and surgeons had on the outcomes of patients undergoing a radical cystectomy for bladder cancer in Ontario.

Using data provided by the Institute for Clinical Evaluative Sciences (ICES) the investigators studied 2,802 patients who underwent the procedure between 1994 and 2008 in Ontario and found that higher volume hospital and surgeons were associated with less post-operative complications and better overall survival.

These results are intriguing and will undoubtedly lead to some controversy in their interpretation,” says Dr. Siemens. “We wondered if the processes and interactions that lead to better outcomes for patients treated by higher volume providers can be studied and identified, perhaps leading to improved outcomes for all if adopted by lower volume hospitals and surgeons.

The recent study explored a number of different aspects of bladder cancer care to better understand how quality surgical care is delivered for patients with advanced bladder cancer. The explanations for this volume-outcome relationship still remain mostly unidentified which could be a research project in the future.

This research has only been able to illuminate a small fraction of the factors that explain the improved outcomes of higher volume providers,” says Dr. Siemens. “Some would interpret this as a call to more aggressively support a policy of centralizing care at higher volume hospitals for complex medical/surgical diseases.

Siemens et al., (2014). Processes of Care and the Impact of Surgical Volumes on Cancer-specific Survival: A Population-based Study in Bladder Cancer. Urology, 84: 1049–1057 [Abstract]

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Surgery associated with better survival for patients with advanced laryngeal cancer

Patients with advanced laryngeal cancer appear to have better survival if they are treated with surgery than nonsurgical chemoradiation.

Approximately 11,000 to 13,000 cases of laryngeal cancer are diagnosed each year and squamous cell carcinoma accounts for the vast majority of these tumors. Prior to 1991, total surgical removal of the larynx with postoperative radiation was the standard of care for advanced cancer. Since then, chemoradiation has become increasingly popular treatment because it can preserve the larynx.

The authors evaluated survival outcomes for surgical vs. nonsurgical treatment for advanced laryngeal cancer. The authors used data from the Surveillance, Epidemiology and End Results (SEER) database for their study of 5,394 patients diagnosed with stage III or IV laryngeal squamous cell carcinoma between 1992 and 2009.

Patients who had surgery had better 2-year and 5-year disease-specific survival (70 percent vs. 64 percent and 55 percent vs. 51 percent, respectively) and 2-year and 5-year overall survival (64 percent vs. 57 percent and 44 percent vs. 39 percent, respectively) than patients who did not under surgery. The use of nonsurgical treatment increased over time: 32 percent in the 1992 to 1997 patient group, 45 percent in the 1998 to 2003 group and 62 percent in the 2004 to 2009 group. The gap in survival between the two groups consistently narrowed over subsequent years. Patients who were diagnosed between 2004 and 2009 had better survival than those diagnosed earlier and this may be due to improvements in radiation and chemotherapy strategies.

The authors state that patients need to be made aware of the modest but significant survival disadvantage associated with nonsurgical therapy as part of the shared decision-making process during treatment selection.

Megwalu UC and Sikora AG (2014). Survival Outcomes in Advanced Laryngeal Cancer. JAMA Otolaryngol. Head Neck Surg., EPub Ahead of Print [Abstract]

Getting chemo first may help in rectal cancer

First things first. If cancer patients are having trouble tolerating chemotherapy after chemoradiation and surgery, then try administering it beforehand. Reordering the regimen that way enabled all but six of 39 patients to undergo a full course of standard treatment for rectal cancer, according to research to be presented at the American Society for Clinical Oncology annual meeting in Chicago.

Studies have shown that only about 60 percent of rectal cancer patients comply with postoperative chemotherapy, said lead researcher Dr. Kimberly Perez, assistant professor of medicine in the Warren Alpert Medical School of Brown University and a cancer physician at Rhode Island Hospital. In the phase II trial, “Complete Neoadjuvant Therapy in Rectal Cancer” (CONTRE), more than 90 percent of the patients were able to complete a regimen of mFOLFOX6 when it was moved to the front of the line.”The thought was, what can we do to make it more tolerable and get the benefit that we wanted,” said Perez, who will speak at 4 p.m. CDT on Saturday, May 31, 2014 at ASCO. “It’s encouraging because we were able to get the numbers up of patients who were able to get all the chemotherapy indicated.

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Only 60 percent of rectal cancer patients comply with chemotherapy after surgery. More patients complied and got the full benefit of chemotherapy when they received it first. For 13 patients in the study, the tumor (left) had disappeared when it was time for surgery. Credit: CONTRE Trial/Lifespan/Brown University

Almost all of the patients came into the study with rectal bleeding, but that symptom abated for all of them during treatment, Perez said.Regarding the cancer itself, a majority of patients, 32 of whom entered the trial at stage III and seven of whom were less advanced at stage II, responded at least to some degree to the induction chemotherapy and chemoradiation treatments. By the time they got to surgery, 13 patients had no tumor left (“pathologic complete response”), 10 got all they way back to stage I, seven were at stage II, and eight remained at stage III.

The study occurred too recently, however, to provide a measure of overall survival, Perez acknowledged. The last patient finished surgery in January 2014. The rate of side effects such as neutropenia, an adverse impact on the immune system, was not unusual.

The results of the CONTRE trial are now feeding into the development of a new national rectal cancer trial spearheaded by NRG Oncology, Perez said. That protocol will involve chemo first, then chemoradiation with biological anti-cancer agents, and finally surgery. Brown Univeristy Oncology Group and the Cancer Center of Rhode Island Hospital and associated satellites will be one of the study sites, Perez said.

 Presented at the American Society for Clinical Oncology annual meeting 2014 in Chicago.

Is growing MRI use leading to more invasive breast cancer surgery?

Heavy use of magnetic resonance imaging (MRI) may be leading to unnecessary breast removal in older women with breast cancer, according to a study by Yale School of Medicine researchers in the current issue of Breast Cancer Research and Treatment.

“These data are concerning because the long-term benefits associated with bilateral mastectomy for older women with breast cancer are unclear,” said the study’s lead author Cary Gross. M.D., associate professor of internal medicine at Yale School of Medicine and director of the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center at Yale Cancer Center.

“Patient concern about recurrence and survival must be balanced with the increased risk for complications associated with more aggressive cancer surgery, particularly when there is no proven benefit of the more aggressive option,” Gross added.

The research team tracked the use of breast MRI and surgical care of 72,461 female Medicare beneficiaries age 67-94 who were diagnosed with breast cancer during 2000 to 2009.

The team found a considerable increase in the use of preoperative breast MRI over the study period from 1% in 2000-2001 to 25% in 2008-2009. The researchers also found that women who received an MRI were more likely to subsequently undergo more aggressive surgical treatment. In women who received mastectomy, 12.5% of those who had MRI received bilateral mastectomy, while only 4.1% of those who did not have MRI had bilateral mastectomy.

The study also revealed that women undergoing MRI were more likely to have a contralateral prophylactic mastectomy (surgery to remove both breasts when cancer was only found in one breast). Among women who underwent mastectomy, 6.9% of women who had an MRI underwent contralateral prophylactic mastectomy, compared to 1.8% in women who did not have an MRI.

“There has been no randomized controlled clinical trial demonstrating improved outcomes for women who undergo preoperative breast MRI at any age,” said Brigid Killelea, M.D., assistant professor of surgery at Yale School of Medicine, and first author on the study. “Breast conserving therapy, when feasible, remains the preferred approach for women with early stage breast cancer.”

Killelea et al., (2013). Trends and clinical implications of preoperative breast MRI in Medicare beneficiaries with breast cancer. Breast Cancer Res. Treat., EPub Ahead of Print, doi:10.1007/s10549-013-2656-1 [Abstract]

Pattern in lung cancer pathology may predict cancer recurrence after surgery

Findings could help identify patients most likely to benefit from lung-sparing surgery

A new study by thoracic surgeons and pathologists at Memorial Sloan-Kettering Cancer Center shows that a specific pattern found in the tumor pathology of some lung cancer patients is a strong predictor of recurrence. Knowing that this feature exists in a tumor’s pathology could be an important factor doctors use to guide cancer treatment decisions.

According to the study’s authors, the findings offer the first scientific evidence that may not only help surgeons identify which patients are more likely to benefit from less radical lung-sparing surgery, but which patients will benefit from more extensive surgery, potentially reducing the risk of lung cancer recurrence by 75 percent. The study will be published in the August 20 issue of the Journal of the National Cancer Institute.

Researchers retrospectively evaluated the clinical characteristics and pathology information of 734 patients who had surgery for early-stage adenocarcinoma — the most common subtype of non-small cell lung cancer — and found that tumors in 40 percent of those patients exhibited an abnormal cell pattern strongly associated with cancer recurrence after surgery. No study to date has investigated the prognostic utility of this classification, called micropapillary (MIP) morphology, for patients with small, early-stage lung adenocarcinomas. Currently there are no evidence-based criteria for choosing the most effective surgical approach for this group.

The findings suggest that limited resection may not be appropriate for patients with the MIP pattern, as they were found to have a 34 percent risk of the cancer returning within five years after lung-sparing surgery, or limited resection, in which the tumor is removed by minimally invasive means and lung function is preserved. In contrast, patients with the MIP pattern who underwent lobectomy — the standard approach in which up to a third of the lung is removed along with the tumor — had only a 12 percent incidence of recurrence over a five-year period.

The study observations may play a key role in deciding whether to perform lung-sparing surgery or lobectomy for patients with small lung adenocarcinomas. It currently takes an expert lung pathologist to identify the MIP pattern during an operation. If the surgeon performs lung-sparing surgery in the presence of the MIP pattern, the chance of recurrence is high within the spared lobe of the lung. A lobectomy can reduce this chance of recurrence by 75 percent. If the MIP pattern is not found, the surgeon can confidently perform lung-sparing surgery.

Only a handful of cancer centers in the country have the expertise needed to identify the MIP pattern during surgery. Patients whose tumors are later found to have the MIP pattern after lung-sparing surgery may require another excision or a full lobectomy to reduce their risk of recurrence. Researchers at Memorial Sloan-Kettering are working to develop new technology that can be used to precisely identify which tumors have the MIP pattern before or during surgery. This will not only help doctors recommend the most effective surgical approach for each patient, but will result in fewer patients requiring additional treatment.

Nearly 250,000 patients are diagnosed with non-small cell lung cancer each year in the United States. The detection of small, early-stage lung adenocarcinomas is expected to increase as a result of advances in imaging technology, the widespread use of CT screening, and professional guidelines recommending screening long-time smokers for lung cancer. The findings of the new study will have immediate implications for the management of these patients.

Nitadori et al., (2013). Impact of micropapillary histologic subtype in selecting limited resection vs lobectomy for lung adenocarcinoma of 2cm or smaller. J. Natl. Cancer Inst., EPub Ahead of Print [Abstract]