Surgery News - February 2008 - (Page 10)

ONCOLOGY SURGERY NEWS • F E B R U A RY 2 0 0 8 Data Find Low Lymph Node Staging for GI Cancers BY BRUCE JANCIN Else vier Global Medical Ne ws C O L O R A D O S P R I N G S — Fewer than one in four patients undergoing surgery for gastric cancer and one in six with pancreatic cancer have an adequate number of regional lymph nodes evaluated for staging purposes, according to data gathered for an American College of Surgeons quality improvement program. The likelihood of receiving an adequate pathologic lymph node (LN) evaluation varies by hospital type and procedural volume. Rates are highest at National Comprehensive Cancer Network/National Cancer Institute–designated hospitals, followed by other academic medical centers and trailed by community hospitals. But even at high-volume NCCN/NCI centers, a minority of patients undergoing surgery for these GI malignancies have 15 or more LNs examined as recommended in national guidelines, Dr. Karl Y. Bilimoria reported at the annual meeting of the Western Surgical Association.“The emphasis on nodal counts has led to significant improvement over time for colon cancer. Similarly, we need quality surveillance measures for pancreatic and gastric cancers to help improve nodal evalua- tion,” said Dr. Bilimoria, an ACS Fellow with Northwestern University, Chicago. Adequate LN examination is critical for accurate cancer staging as well as for decision making about adjuvant therapy and clinical trial design. It is also a powerful predictor of outcome in early-stage cancer; recent studies have shown a link between pathologic examination of an increasing number of LNs and better survival. To learn how patients with GI malignancies fare with regard to LN evaluation, Dr. Bilimoria turned to the National Cancer Data Base, a joint project of the American College of Surgeons’ (ACS) National Commission on Cancer and the American Cancer Society. It contains prospectively gathered data on more than 20 million U.S. cancer patients at 1,430 participating hospitals required to report all their cancer cases. This amounts to more than 70% of all cancers occurring in the United States. He documented a slow increase over time in the proportion of gastric and pancreatic cancer patients with at least 15 regional LNs examined: from 17% in 1995 to 23% in 2004 for gastric cancer, and from 10% in 1995 to 17% in 2004 for pancreatic cancer. Among the 3,088 patients who underwent resection of clinically node-negative gastric cancer during 2003-2004, 12% had their surgery at NCCN/NCI centers, 34% at other academic centers, and the rest at community hospitals. The proportion of patients with 15 or more LNs examined was 42% at NCCN/NCI centers, 26% at other academic centers, and 17% at community hospitals. The median number of LNs examined was 12, 8, and 6, respectively. Thirty-five percent of patients treated at hospitals in the top quartile nationally in terms of gastric cancer resection volume had an adequate LN evaluation, compared with 17% in the lowest quartile. In a multivariate logistic regression analysis adjusted for patient demographic and tumor characteristics, gastric cancer patients treated at other academic and community hospitals were, respectively, 60% and 73% less likely to get an adequate LN exam than those at NCCN/NCI centers, Dr. Bilimoria continued. Among the 1,130 pancreaticoduodenectomy patients, the median number of LNs removed and examined was 9 in NCCN/NCI centers, 7 in other academic centers, and 6 in community hospitals. How might this information be used? “Not only is the National Cancer Data Base a data repository, but we can feed it back to hospitals such that at the end of the year the hospital can receive a report card showing what proportion of their cases had 15 or more nodes examined. We can also show them a curve benchmarking them against the other 1,400 hospitals so they can understand whether they’re a low or high outlier—and if they are an outlier they can spark a quality improvement initiative at their own hospital,” Dr. Bilimoria explained. Discussant Dr. Anton J. Bilchik lauded the ACS for leading the way in establishing benchmarks for cancer care but expressed reservations about this “provocative” study. “This information is in the hands of third-party payers and is already threatening reimbursement,” cautioned Dr. Bilchik, an ACS Fellow and director of the gastroenterology program at the John Wayne Cancer Institute, Santa Monica, Calif. “Without fully understanding the mechanisms behind the large variations in node sampling, some would argue that benchmarks are premature.” The fact that an insufficient number of LNs are examined in the pathology lab doesn’t necessarily mean surgeons removed too few. “Most surgeons would say they do the same operation every time,” he noted. Audience members were quick to agree. “When I get a pathology report that has fewer lymph nodes than I wanted, I just call up the pathologist and order more lymph nodes—and they always find more. So before we start getting paid less for removing fewer lymph nodes than is standard, I think we need to look more extensively at the role of the pathologic evaluation,” argued Dr. Kelly M. McMasters, an ACS Fellow who is professor and chief of the division of surgical oncology at the University of Louisville (Ky.). Dr. John H. Donohue an ACS Fellow and professor of surgery at the Mayo Clinic, Rochester, Minn., said that when he and his colleagues analyzed 100 gastrectomies at two local hospitals in terms of factors related to the adequacy of LN staging, they found that the one important variable in multivariate analysis was who the pathology technician was. Dr. David J. Bentrem, Dr. Bilimoria’s coinvestigator, agreed “the pathology technician is the linchpin.” But he stressed that this quality improvement project is not an exercise in blame-the-surgeon. “It’s most important to look at this from a hospital-wide perspective, not individual physicians,” said Dr. Bentrem, a surgical oncologist at Northwestern. ■ Tumor Size Helps Stratify Risk For Hürthle Cell Malignancy M O N T R E A L — A threshold measurement of 4 cm in Hürthle cell neoplasms can stratify patients into high or low risk for malignancy, and help determine the need for total thyroidectomy, according to findings presented at a meeting sponsored by the International Society of Surgery. While many studies have associated larger tumor size with greater malignancy risk, more specific measurement can individualize a patient’s risk, said Dr. Rebecca Sippel, of the University of Wisconsin, Madison. “When we looked at tumors below 4 cm in size, they had only a 13% risk of malignancy in comparison to those tumors that were greater than 4 cm in size, which had a 55% risk of malignancy,” she said in an interview. She recommended that an initial total thyroidectomy be considered for patients with tumors larger than 4 cm. Dr. Sippel’s study, conducted when she was with the University of California, San Francisco, reviewed 57 thyroidectomy patients whose Hürthle cell neoplasms had been diagnosed preoperatively with fine needle aspiration cytology. A total of 12 patients (21%) had malignant disease, most of which was Hürthle cell cancer. Among the remaining 45 patients (79%) with benign disease, the most common diagnoses were Hürthle cell adenomas and follicular adenomas that had Hürthle cell changes, she said. While most surgeons accept that a Hürthle cell neoplasm is associated with around a 20% risk of malignancy, Dr. Sippel said physicians can be more specific, based on the size of the tumor. “In our series, no tumor under 2 cm was malignant, and all tumors greater than 6 cm were malignant,” she said. The study found no difference between patients with benign or malignant disease in terms of age, gender, history of radiation exposure, or family history of thyroid cancer. But malignant tumors averaged 5.1 cm in comparison to 2.7 cm in the benign patients, she said. —Kate Johnson http://www.ce-university.org/surgery http://www.ce-university.org/surgery

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Surgery News - February 2008 Contents IOM Committee Looks Into Safety Of Work Schedules Expertise Can Extend Liver Resectability Report Faults Specialty Hospitals' EDs Meeting Expectations Silver Lining HOD on Health Longer Liver Life?

Surgery News - February 2008

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