Surgery to remove cancer might be an option for early-stage non-small cell lung cancer (NSCLC). It provides the best chance to cure the disease. But, lung cancer surgery is a complex operation that can have serious consequences, so it should be done by a surgeon who has a lot of experience operating on lung cancers.
Lung cancer is the most common form of cancer worldwide, and the most common cause of cancer death in western countries . Radical surgical resection, with or without adjuvant treatment, is still a prerequisite for the cure. Despite different additional modes of treatment, survival is still weak. In European countries, the proportion of patients with diagnosed lung cancer who undergo surgery for this disease varies between 10 and 20% . Advances in operative and postoperative care have led to a decline in complications and mortality rates during the last two decades . But since the proportion of older patients (≧70 years) has increased during this period, the incidence of associated co-morbidity has increased .
To be able to improve the quality of operative procedures and identify patients running the highest risk, and to optimise the patients’ condition, medication and respiratory status before surgery, it is essential to know peri- and postoperative mortality and morbidity, and also of risk factors before surgery. Furthermore, the operative risks must be considered concerning the long-term results to identify patients who will clearly benefit from surgery.
The present study aimed to examine the operative mortality and morbidity after lung cancer surgery and to identify factors associated with an adverse outcome. The study comprised 616 consecutive patients referred to Uppsala University Hospital, from a defined population, during 12 years.
For appropriately staged non-small cell lung cancer (NSCLC) surgery is generally accepted as the most effective treatment. Still, some people may not be offered surgery because of concerns about perioperative mortality. Hospitals with higher resection rates have better overall lung cancer survival, and it has been suggested that if all National Health Service (NHS) Trusts increased their resection rates the proportion of people surviving lung cancer would improve.
Several predictive models for early postoperative mortality have been developed, and the British Thoracic Society recommend the use of ‘a global risk score such as Thoracoscore to estimate the risk of death’ when assessing patients’ eligibility for lung cancer surgery.In developing Thoracoscore, Falcoz et al included 10 122 patients (57% of whom had cancer) who underwent any thoracic surgical procedure between 2002 and 2005. The score predicts the risk of in-hospital mortality and has recognised limitations, particularly with regard to lung cancer surgery.
Like Thoracoscore, almost all previous studies of early mortality in lung cancer surgery are based on 30-day or in-hospital mortality. These endpoints were used because they were felt to measure mortality directly attributable to the surgical procedure. For patients and their relatives, however, we believe an estimate of death within 90 days, which includes postoperative recovery time, maybe more appropriate.
The National Lung Cancer Audit (NLCA) has collected demographic, tumour and treatment data from English NHS Trusts since 2004. It has been shown to be representative of people with lung cancer in England.We used these data to estimate the proportion of patients who died within 30 and 90 days of potentially curative surgery for NSCLC and performed a multivariate analysis to quantify risk factors for death within 30 days and within 90 days. Our final aim was to see whether we could use the data in the NLCA to produce a predictive score for early death after thoracic surgery which was specifically for people with lung cancer, and looked beyond 30-day mortality.
Lung cancer is the rapid growth of abnormal cells in the lung tissue. Surgery to remove all or part of a lung may be done by making a cut on one side of your chest (thorax) during a procedure called a thoracotomy. Surgery that uses this approach avoids areas in the chest that contain the heart and the spinal cord.
After the cut is made between the ribs, all or part of the lung is removed depending on the location, size, and type of lung cancer that is present.
Risk of Lung Surgery Death
Patients cared for by hospitals with residents in training have a 17 percent less chance of dying after lung cancer surgery compared with patients undergoing surgery at non-teaching hospitals, according to results of a Johns Hopkins study published in the March issue of the Annals of Thoracic Surgery.
“There’s a public perception that teaching hospitals can be dangerous places because of training issues, and concerns are frequently voiced by patients and echoed in the press regarding fear of physicians-in-training practising on them,” says the lead author of the paper, Robert Meguid, M.D., a surgical resident at Johns Hopkins University School of Medicine. “The data from our study help refute these fears.”
The Johns Hopkins investigators looked at data from 46,951 patients, ages 18 to 85, who underwent surgery for lung cancer at hospitals across the United States between 1998 and 2004. Operations ranged from small lung-segment removal to total lung removal.
The researchers tracked discharges and deaths, and compared patient outcomes at three different types of hospitals – those with any kind of physician specialty training program, those with general surgery training programs and those with thoracic surgery training programs. They took into account factors such as age, gender and other illnesses of each patient, and they also took into consideration the number of each of the different types of lung cancer surgeries that each hospital performed.
“It has been well studied and reported that for complex procedures for high-risk patients, the more surgeries a hospital performs; the more likely the patient will survive the operation and hospitalisation. This is the first study we know of which shows that teaching hospitals are factors associated with good patient outcomes, independent of volume,” says Meguid.
Lung cancer is the leading cause of cancer death among both males and females in the United States. In 2007, there were an estimated 213,380 new cases of lung cancer in the United States and 160,390 deaths related to the disease.
Management of lung cancer has dramatically improved over the past several decades. As a result, an increasing number of patients become eligible for lung resection procedures every year.
“Considerable efforts have been made to identify factors that may improve the quality of surgical care and associated outcomes for these high-risk patients,” says Meguid. “Surgery for lung cancer at teaching hospitals may provide one source of quality improvement.”
Additional researchers in the study from the Department of Surgery, Johns Hopkins University School of Medicine, include Stephen Yang, M.D., chief of the Division of Thoracic Surgery; Malcolm Brock, M.D.; Benjamin Brooke, M.D., David Chang, Ph.D., and Timothy Sherwood, M.D. Sherwood has since left Johns Hopkins and is currently at Mary Washington Hospital in Fredericksburg, Va.
Among patients undergoing resection for lung cancer, 50% of deaths occur within 90 days after hospital discharge. And, strikingly, 90-day mortality rates in these patients are twice that of 30-day mortality rates, according to results from a study published in Surgical Oncology.
In patients undergoing pulmonary resection for lung cancer, 90-day mortality rates are twice that of 30-day mortality rates.
“Evidence has been consistently provided that 90-day mortality after pulmonary resection for lung cancer can exceed the double of 30-day mortality, with similar mortality rates reported for the first 30 postoperative days and the postoperative period from 31 to 90 days,” noted study researchers, led by Florencio Quero-Valenzuela, MD, Servicio de Cirugía Torácica, Hospital Universitario Virgen de las Nieves de Granada, Granada, Spain.
“An explanation is that deaths that occur beyond 30 postoperative days may not be recorded. Some patients may die more than a month after surgery, as a result of severe postoperative complications that required prolonged hospitalisation. On the other hand, death beyond 31 postoperative days may occur during readmission, or suddenly at home from complications. Thus, surgery-related deaths may be underreported when only 30-day mortality is recorded,” they added.
Thus, they conducted this prospective, follow-up study to take a closer look at 90-day mortality rates in 378 patients (83.3% male) who underwent pulmonary resection for lung cancer. Dr. Quero-Valenzuela and colleagues found that the overall 30-day mortality rate was 1.6% compared with 3.2% for overall 90-day mortality. Both 30- and 90-day mortality rates were highest in patients who underwent pneumonectomy (3.7% and 7.4%, respectively), followed by lobectomy (1.6% and 3.6%).
The mean number of postoperative days until death was 39 days, and the mean age of those who died within the first 90 days after surgery was 67.91 years compared with a mean age of 65.21 years in those who survived (P=0.371). Mean length of hospital stay was more significant in patients who died within the first 90 days compared with those who survived (14.7 vs 7.2 days; P=0.002).
Upon univariate analysis, researchers also found significant differences in 30-day mortality in patients with a history of peripheral vascular disease (P=0.033), postoperative pneumonia (P=0.029), postoperative pulmonary/lobar collapse (P=0.031), postoperative arrhythmia (P < 0.001), reintubation (P < 0.001), and in those who underwent a pneumonectomy (P=0.027).
Characteristics that were associated with 90-day mortality included a Charlson index of > 3 (P < 0.001) or a history of stroke (P=0.036). Associated postoperative complications included pneumonia (P=0.001), pulmonary/lobar collapse (P=0.001), reintubation (P < 0.001), and arrhythmia (P=0.002).
All deaths occurred in patients who underwent thoracotomy, which was also associated with 90-day mortality (P=0.011), as was hospital readmission (P < 0.001). Ninety-day mortality was not associated with pneumonectomy compared with lobar and sublobar resection (P=0.1). There were no differences based on gender, histology, age, respiratory functional FEV1, carbon monoxide diffusing capacity (DLCO), predicted postoperative FEV1, predicted postoperative DLCO, maximal oxygen uptake (VO2 max), tobacco use, induction or adjuvant cancer treatment, or the presence of diabetes, hypertension, ischemic heart disease, COPD, or obesity.
Pneumothorax and subcutaneous emphysema (30.4%) were the most common reasons for readmission, followed by pneumonia (13%) and pleural empyema (8.7%). Respiratory and cardiovascular complications were the most common causes of death (58.3% and 33.2%, respectively). Respiratory complications included postoperative pneumonia, bronchial fistula and pleural empyema, and acute pulmonary thromboembolism.
“The findings of this study have direct implications for clinical practice, as they provide more accurate data to healthcare professionals and patients on the risk of mortality following pulmonary resection for lung cancer beyond the first 30 days. The data obtained could be useful for the design of specific outpatient follow-up programs based on follow-up visits and the optimisation of postsurgical care for patients at a higher risk of mortality,” concluded Dr. Quero-Valenzuela et al.
What To Expect After Surgery
Lung surgery requires you to stay in the hospital after the procedure. How long you stay will depend on:
- Your remaining lung function.
- Your overall health before surgery.
- Which type of surgery was done.
Pain is a common concern after this surgery. Depending on the type of surgery you have, your chest area may be painful for several weeks to months after surgery. Your doctor will prescribe pain medicines you can use for pain after the surgery. You can also talk to your doctor about things you can do at home to help ease the pain.
One or more chest tubes are used after surgery to drain your chest cavity of fluid and blood, which are present after lung surgery. The chest tubes also help your lungs refill with air. Chest tubes are placed in your chest cavity and extend out through your chest wall and skin through small cuts between your ribs on the same side as the surgery. The tubes are connected to a machine that creates a gentle suction, which helps your chest fluid to drain. The liquid is collected in a container that measures the amount of fluid draining from your chest. The chest tubes will be removed when the drainage from your chest has stopped, and no air is leaking from your chest incision, which is usually after a few days.
A respiratory therapist will help you with breathing treatments to improve your lung function after surgery. Treatments usually involve deep breathing and the use of a spirometer. Medicines may also be used to help open your airway and help you breathe more easily.
There is a risk of problems or complications after any operation. You might have one or more of these problems. Let your doctor or nurse know if you feel unwell or are worried.
Feeling tired and weak.
Most people feel weak and lack strength for some time afterwards. How long this lasts varies.
Tell your doctor or nurse if the weakness continues for more than a few weeks. They can suggest things to help, such as physiotherapy.
It is possible, although not common, to develop an infection of the wound site or of the lung itself. Tell your doctor or nurse if you have any of the following symptoms. They can be a sign of infection:
- feeling generally unwell
- feeling hot and cold – with a temperature
- feeling sick
- swelling or redness around your wound
Some breathlessness is normal after lung surgery. This depends on the type of operation you have had and how to fit and well you usually are. If you had breathing problems before the procedure, you might still have some questions afterwards.
Once at home, you might still get breathless when you are getting dressed or going up the stairs, for example. But this generally settles down when you rest.
Many people worry that they won’t be able to breathe correctly if they have had part of a lung removed, or a whole lung removed. But the remaining lung usually adapts, and breathing should improve over time.
Long term problems
While some people find that their breathing improves as they recover, other people might have long term problems. Talk to your doctor about ways to manage this. You could ask to be referred to a breathlessness clinic.