Ely Sora, Jiang Sheng-Fang, Dominguez Dana A, Patel Ashish R, Ashiku Simon K, Velotta Jeffrey B
Department of Surgery, UCSF East Bay, Highland Hospital, Oakland, Calif; Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, Calif.
Division of Research, Kaiser Permanente Northern California, Oakland, Calif.
J Thorac Cardiovasc Surg. 2022 Mar;163(3):769-777. doi: 10.1016/j.jtcvs.2021.03.050. Epub 2021 Mar 20.
Existing evidence demonstrates some benefit of regionalization on early postoperative outcomes following lung cancer resection, but data regarding the persistence of this effect in long-term mortality are lacking. We investigated whether previously reported improvements in short-term outcomes translated to long-term survival benefit.
We retrospectively reviewed patients undergoing major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) for cancer within our integrated health care system before (2011-2013; n = 782) and after (2015-2017; n = 845) thoracic surgery regionalization. Overall survival was compared by Kaplan-Meier analysis, and 1- and 3-year mortality was compared by the by χ or Fisher exact test. Multivariable Cox regression models evaluated the effect of regionalization on mortality adjusted for relevant factors.
Kaplan-Meier curves showed that overall survival was better among patients undergoing surgery postregionalization (log-rank test, P < .0001). Both 1- and 3-year mortality were decreased after regionalization: to 5.7% from 11.1% (P < .0001) for 1 year and to 17.0% from 25.5% (P = .0002) for 3 years. The multivariable adjusted Cox regression analysis revealed that only regionalization (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.42-0.76), age (HR, 1.03; 95% CI, 1.02-1.04), cancer stage (HR, 1.72, 1.83, and 2.56 for stages II, III, and IV, respectively), and Charlson comorbidity index (HR, 1.80 for 1-2; 2.05 for ≥3) were independent predictors of mortality.
We found that overall mortality as well as 1- and 3-year mortality for lung cancer resection were lower after thoracic surgery regionalization. The association between regionalization and reduced mortality was significant even after adjusting for other related factors in a multivariable Cox analysis. Notably, surgeon volume, facility volume, surgeon specialty, neoadjuvant treatment, and video-assisted thoracoscopic surgery approach did not significantly affect mortality in the adjusted model.
现有证据表明区域化对肺癌切除术后早期预后有一定益处，但缺乏关于这种影响在长期死亡率方面持续性的数据。我们调查了先前报道的短期预后改善是否转化为长期生存获益。
我们回顾性分析了在我们综合医疗保健系统中，在胸外科区域化之前（2011 - 2013年；n = 782）和之后（2015 - 2017年；n = 845）接受主要肺切除术（肺叶切除术、双肺叶切除术或全肺切除术）治疗癌症的患者。通过Kaplan - Meier分析比较总生存率，通过χ²检验或Fisher精确检验比较1年和3年死亡率。多变量Cox回归模型评估区域化对经相关因素调整后的死亡率的影响。
Kaplan - Meier曲线显示，区域化后接受手术的患者总生存率更高（对数秩检验，P <.0001）。区域化后1年和3年死亡率均降低：1年死亡率从11.1%降至5.7%（P <.0001），3年死亡率从25.5%降至17.0%（P =.0002）。多变量调整后的Cox回归分析显示，只有区域化（风险比[HR]，0.57；95%置信区间[CI]，0.42 - 0.76）、年龄（HR，1.03；95% CI，1.02 - 1.04）、癌症分期（II期、III期和IV期的HR分别为1.72、1.83和2.56）以及Charlson合并症指数（1 - 2分的HR为1.80；≥3分的HR为2.05）是死亡率的独立预测因素。
我们发现胸外科区域化后肺癌切除术的总死亡率以及1年和3年死亡率均较低。即使在多变量Cox分析中对其他相关因素进行调整后，区域化与死亡率降低之间的关联仍然显著。值得注意的是，在调整模型中，外科医生手术量、机构手术量、外科医生专业、新辅助治疗以及电视辅助胸腔镜手术方式对死亡率没有显著影响。
