Background The aggressive and heterogeneous nature of lung cancer has thwarted efforts to reduce mortality from this cancer through the use of screening. The advent of low-dose helical computed tomography (CT) altered the landscape of lung-cancer screening, with studies indicating that low-dose CT detects many tumors at early stages. The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce mortality from lung cancer. Methods From August 2002 through April 2004, we enrolled 53,454 persons at high risk for lung cancer at 33 U.S. medical centers. Participants were randomly assigned to undergo three annual screenings with either low-dose CT (26,722 participants) or single-view posteroanterior chest radiography (26,732). Data were collected on cases of lung cancer and deaths from lung cancer that occurred through December 31, 2009. Results The rate of adherence to screening was more than 90%. The rate of positive screening tests was 24.2% with low-dose CT and 6.9% with radiography over all three rounds. A total of 96.4% of the positive screening results in the low-dose CT group and 94.5% in the radiography group were false positive results. The incidence of lung cancer was 645 cases per 100,000 person-years (1060 cancers) in the low-dose CT group, as compared with 572 cases per 100,000 person-years (941 cancers) in the radiography group (rate ratio, 1.13; 95% confidence interval [CI], 1.03 to 1.23). There were 247 deaths from lung cancer per 100,000 person-years in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95% CI, 6.8 to 26.7; P=0.004). The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiography group, by 6.7% (95% CI, 1.2 to 13.6; P=0.02). Conclusions Screening with the use of low-dose CT reduces mortality from lung cancer. (Funded by the National Cancer Institute; National Lung Screening Trial ClinicalTrials.gov number, NCT00047385.).

/pdf/reduced-lung-cancer-mortality-with-low-dose-computed-315bk0rtxu.pdf

Reduced lung-cancer mortality with low-dose computed tomographic screening.

Background Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed. Methods Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients. Results Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy. Conclusions In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.

Hospital Volume and Surgical Mortality in the United States

The factors that cause large individual differences in professional achievement are only partially understood. Nobody becomes an outstanding professional without experience, but extensive experience does not invariably lead people to become experts. When individuals are first introduced to a professional domain after completing their education, they are often overwhelmed and rely on help from others to accomplish their responsibilities. After months or years of experience, they attain an acceptable level of proficiency and are able to work independently. Although everyone in a given domain tends to improve with experience initially, some develop faster than others and continue to improve during ensuing years. These individuals are eventually recognized as experts and masters. In contrast, most professionals reach a stable, average level of performance within a relatively short time frame and maintain this mediocre status for the rest of their careers. The nature of the individual differences that cause the large variability in attained performance is still debated. The most common explanation is that achievement in a given domain is limited by innate factors that cannot be changed through experience and training; hence, limits of attainable performance are determined by one’s basic endowments, such as abilities, mental capacities, and innate talents. Educators with this widely held view of professional development have focused on identifying and selecting students who possess the necessary innate talents that would allow them to reach expert levels with adequate experience. Therefore, the best schools and professional organizations nearly always rely on extensive testing and interviews to find the most talented applicants. This general view also explains age-related declines in professional achievement in terms of the inevitable reductions in general abilities and capacities believed to result from aging. In this article, I propose an alternative framework to account for individual differences in attained professional development, as well as many aspects of age-related decline. This framework is based on the assumption that acquisition of expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance. In order to contrast this alternative framework with the traditional view, I first describe the account based on innate talent. I then provide a brief review of the evidence on deliberate practice in the acquisition of expert performance in several performance domains, including music, chess, and sports. Finally, I review evidence from the acquisition and maintenance of expert performance in medicine and examine the role of deliberate practice in this domain.

http://edianas.com/portfolio/proj_EricssonInterview/articles/2004_Academic_Medicine_Vol_10,_S70-S81.pdf

Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.

http://incan-mexico.org/incan/pub/docencia/educacion-medica/articulos/esofago/GUIASBARRETAGA.pdf

Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines

Context.—Hospitals that treat a relatively high volume of patients for selected
surgical oncology procedures report lower surgical in-hospital mortality rates
than hospitals with a low volume of the procedures, but the reports do not
take into account length of stay or adjust for case mix.Objective.—To determine whether hospital volume was inversely associated with 30-day
operative mortality, after adjusting for case mix.Design and Setting.—Retrospective cohort study using the Surveillance, Epidemiology, and
End Results (SEER)–Medicare linked database in which the hypothesis
was prospectively specified. Surgeons determined in advance the surgical oncology
procedures for which the experience of treating a larger volume of patients
was most likely to lead to the knowledge or technical expertise that might
offset surgical fatalities.Patients.—All 5013 patients in the SEER registry aged 65 years or older at cancer
diagnosis who underwent pancreatectomy, esophagectomy, pneumonectomy, liver
resection, or pelvic exenteration, using incident cancers of the pancreas,
esophagus, lung, colon, and rectum, and various genitourinary cancers diagnosed
between 1984 and 1993.Main Outcome Measure.—Thirty-day mortality in relation to procedure volume, adjusted for comorbidity,
patient age, and cancer stage.Results.—Higher volume was linked with lower mortality for pancreatectomy (P=.004), esophagectomy (P<.001),
liver resection (P=.04), and pelvic exenteration
(P=.04), but not for pneumonectomy (P=.32). The most striking results were for esophagectomy, for which
the operative mortality rose to 17.3% in low-volume hospitals, compared with
3.4% in high-volume hospitals, and for pancreatectomy, for which the corresponding
rates were 12.9% vs 5.8%. Adjustments for case mix and other patient factors
did not change the finding that low volume was strongly associated with excess
mortality.Conclusions.—These data support the hypothesis that when complex surgical oncologic
procedures are provided by surgical teams in hospitals with specialty expertise,
mortality rates are lower.

https://jamanetwork.com/journals/jama/articlepdf/188202/JOC80665.pdf

Impact of hospital volume on operative mortality for major cancer surgery.

Background If discovered at an early stage, non–small-cell lung cancer is potentially curable by surgical resection. However, two disparities have been noted between black patients and white patients with this disease. Blacks are less likely to receive surgical treatment than whites, and they are likely to die sooner than whites. We undertook a population-based study to estimate the disparity in the rates of surgical treatment and to evaluate the extent to which this disparity is associated with differences in overall survival. Methods We studied all black patients and white patients 65 years of age or older who were given a diagnosis of resectable non–small-cell lung cancer (stage I or II) between 1985 and 1993 and who resided in 1 of the 10 study areas of the Surveillance, Epidemiology, and End Results (SEER) program (10,984 patients). Data on the diagnosis, stage of disease, treatment, and demographic characteristics of the patients were obtained from the SEER data base. Information on coexisting illne...

Racial differences in the treatment of early-stage lung cancer.

Background Among patients who have undergone high-risk operations for cancer, postoperative mortality rates are often lower at hospitals where more of these procedures are performed. We undertook a population-based study to estimate the extent to which the number of procedures performed at a hospital (hospital volume) is associated with survival after resection for lung cancer. Methods We studied patients 65 years old or older who received a diagnosis of stage I, II, or IIIA non–small-cell lung cancer between 1985 and 1996, resided in 1 of the 10 study areas covered by the Surveillance, Epidemiology, and End Results Program, and underwent surgery at a hospital that participates in the Nationwide Inpatient Sample (2118 patients and 76 hospitals). Results The volume of procedures at the hospital was positively associated with the survival of patients (P<0.001). Five years after surgery, 44 percent of patients who underwent operations at the hospitals with the highest volume were alive, as compared with 33 p...

The Influence of Hospital Volume on Survival after Resection for Lung Cancer

Background: Randomized trials have established that 5-fluorouracil-based adjuvant chemotherapy following resection of stage III colon cancer reduces subsequent mortality by as much as 30%. However, the extent to which adjuvant therapy is used outside the clinical trial setting, particularly among the elderly, is unknown. Methods: A retrospective cohort study utilizing the Surveillance, Epidemiology, and End Results/Medicare-linked database identified 6262 patients aged 65 years and older with resected stage III colon cancer. The primary outcome was chemotherapy use within 3 months of surgery, as ascertained from Medicare claims. We examined the extent to which age at diagnosis was associated with adjuvant chemotherapy usage, and we adjusted for potential confounding based on differences in other patient characteristics with the use of multiple logistic regression. All P values were two-sided. Results: Age at diagnosis was the strongest determinant of chemotherapy: 78% of patients aged 65-69 years, 74% of those aged 70-74 years, 58% of those aged 75-79 years, 34% of those aged 80-84 years, and 11% of those aged 85-89 years received postoperative chemotherapy. The age trend remained pronounced after adjustment for potential confounding based on variation in patients' demographic and clinical characteristics and after exclusion of patients with any evident comorbidity (all P values <.001). Conclusions: Adjuvant chemotherapy for stage III colon cancer is used extensively, especially for patients under the age of 75 years. However, treatment rates decline dramatically with chronologic age. Because patients in their 70s and even 80s have a reasonable life expectancy, further efforts are needed to ensure that elderly patients have the opportunity to make informed decisions regarding this potentially curative treatment.

Age and adjuvant chemotherapy use after surgery for stage III colon cancer.

ContextSurvival following high-risk cancer surgery, such as pancreatectomy
and esophagectomy, is superior at hospitals where high volumes of these procedures
are performed. Conflicting evidence exists as to whether the association between
hospital experience and favorable health outcomes also applies to more frequently
performed operations, such as those for colon cancer.ObjectiveTo determine whether hospital procedure volume predicts survival following
colon cancer surgery.Design, Setting, and ParticipantsRetrospective cohort study of data from the Surveillance, Epidemiology
and End Results–Medicare linked database on 27 986 colon cancer
patients aged 65 years and older who had surgical resection for primary adenocarcinoma
diagnosed between 1991 and 1996.Main Outcome MeasuresThirty-day postoperative mortality and overall and cancer-specific long-term
survival, by hospital procedure volume.ResultsWe found small differences in 30-day postoperative mortality for patients
treated at low- vs high-volume hospitals (3.5% at hospitals in the top-volume
quartile vs 5.5% at hospitals in the bottom-volume quartile). However, the
correlation was statistically significant and persisted after adjusting for
age at diagnosis, sex, race, cancer stage, comorbid illness, socioeconomic
status, and acuity of hospitalization (P<.001).
The association was evident for subgroups with stage I, II, and III disease.
Hospital volume directly correlated with survival beyond 30 days and also
was not attributable to differences in case mix (P<.001).
The association between hospital volume and long-term survival was concentrated
among patients with stage II and III disease (P<.001
for both). Among stage III patients, variation in use of adjuvant chemotherapy
did not explain this finding.ConclusionOur data suggest that hospital procedure volume predicts clinical outcomes
following surgery for colon cancer, although the absolute magnitudes of these
differences are modest in comparison with the variation observed for higher-risk
cancer surgeries.

https://jamanetwork.com/journals/jama/articlepdf/193380/joc00938.pdf

Laura D. Cramer

Papers

Impact of hospital volume on operative mortality for major cancer surgery.

Racial differences in the treatment of early-stage lung cancer.

The Influence of Hospital Volume on Survival after Resection for Lung Cancer

Age and adjuvant chemotherapy use after surgery for stage III colon cancer.

Influence of hospital procedure volume on outcomes following surgery for colon cancer.