Cancer – Thoracic Surgery

HITHOC: the Indian experience

This 2019 article from the Indian Journal of Surgical Oncology covers a very tiny group of patients undergoing HITHOC during an 8 1/2 year period has serious limitations (with a total of only seven patients having HITHOC) but it’s still worth a few minutes of our readers time, particularly if the reader’s interest in HITHOC hasn’t translated into practice yet.

Patel et. al. do a very nice job of describing their inclusion criteria, as well as the surgical techniques utilized in this study, where patients underwent either pleurectomy/ decortication (P/D) or extrapleural pneumonectomy (EPP) with/ without HITHOC.

In fact, it’s one of the better overviews of the procedure that’s been published in recent years. This praise must be tempered by the fact that HITHOC is paired with two very high morbidity/ mortality procedures in this study. P/D and EPP alone are difficult-to-tolerate procedures, and for that reason, are limited to a small subset of eligible patients. Multiple studies by the leaders in the area of HITHOC such as Reid, Isik etc. have already demonstrated that HITHOC can be effective without EPP.

For readers, there are some other serious limitations in their study. Despite having a tiny sample size, the HITHOC and non-HITHOC groups are not comparable. It is figuratively; apples to oranges.

The non-HITHOC group was primarily made up of pleural mesothelioma patients, and based on that diagnosis alone – would have been expected to do worse post-operatively. Yet, we don’t know if they did (do worse or not).

One of the reasons that we don’t know if the pleural mesothelioma patients outlived the HITHOC treatment group is that measurements were discordant as well. The authors talk about 24 month and 36 month survival in the non-HITHOC group, but apparently, didn’t even follow the HITHOC group after 9 months. (Or chose not to present their data after nine months, which is, worse. )

The authors do acknowledge this, in their discussion, but also point out that two of the HITHOC patients (one a 40 year old female*) had extensive, infiltrating disease processes and poor pre-operative functional statuses.

It’s an interesting read for the most part, but it begs for follow-up so we will reach out to Patel etl. al. and update readers with any response.

Reference article

Patel MD, Damodaran D, Rangole A, et al. (2019). Hyperthermic Intrathoracic Chemotherapy (HITHOC) for Pleural Malignancies-Experience from Indian Centers. Indian J Surg Oncol. 2019;10(Suppl 1):91–98. doi:10.1007/s13193-018-0859-y [link to free full text].

*There are two charts that nicely display all the characteristics of patients in both groups. Interestingly, in this HITHOC group, both of the female patients presented with more advanced disease many, many months after initial diagnosis. The 40F patient is clearly a last ditch ‘salvage’ patient, so her six month survival time after surgery would be better measured against more palliative procedures.

Advances in Thoracic Surgical Oncology

an upcoming conference on thoracic oncology in New York, New York

Mark your calendars and clear your schedules for the first weekend in October! The Advances in Thoracic Surgical Oncology course is October 3rd – 4th, 2014.

Unlike many of the association conferences – this conference is not geared at the thoracic surgery specialty or cardiothoracic surgery crowd in its entirety.

This course, offered by the internationally famous Memorial Sloan Kettering Cancer Center in New York, New York is focused on the use of thoracic surgery in modern cancer treatment, particularly in the treatment of lung and esophageal cancers*.

As a world-famous academic and cancer research center, Sloan Kettering has hundreds of educational offerings for practicing physicians, nurses and other health care professionals as well as Fellowships and doctoral programs in specialty focus areas.

The event is hosted by Dr. David R. Jones, a thoracic surgeon and recent transplant from the University of Virginia in Charlottesville, Virginia. Dr. Jones is the Chief of Thoracic Surgery, and the Surgical Director of the Thoracic Oncology Program at Memorial Sloan Kettering Cancer Center.

To register for this event, click here

*More information on the lectures and presenters was not available at this time. (I hope to add more details as we get closer to the event).

Lung Resection in the Elderly – the Harvard/ Keating experience

a new article published in Cancer, and summarized at Medscape talks about the importance of Lung Resection for long-term survival in Lung Cancer.

Re-posting an article on the benefits of early surgical intervention on elderly patients with early stage lung cancers from Medscape.com. This is a nice article summarizing the research study conducted by Dr. Nancy Keating at Harvard Medical School in Boston, MA. A link to the original research abstract is here, but no free full-text available.

This article that highlights the importance of surgery – even for patients that primary care physicians and others may not immediately think of as great surgical candidates (frail elderly, COPD, other illnesses.)

Unfortunately, they didn’t address WHO was doing the surgeries – was it thoracic surgeons in high resection geographic areas (on the higher risk patients) as is often the case? Were surgeries in the areas with lower resection rates more likely to be done by general surgeons who are less experienced in operating on more frail thoracic patients? [all thoracic patients are frail to some decrease given the nature of the condition – so specialty trained thoracic surgeons are usually much more experienced in caring for these patients]. It would have been nice to know.

Surgery Rates tied to Lung Cancer Outcomes in the Elderly

David Douglas (Medscape)

NEW YORK (Reuters Health) Aug 24 – People with early non-small cell lung cancer (NSCLC) live longer if they’re in regions of the U.S. where doctors perform more surgeries for that indication, according to a new study.

The link between higher surgery rates and better survival held true even for frailer patients.

“We found that areas with high rates of surgery tended to operate on older and sicker patients, yet still had better outcomes for early-stage lung cancer than areas with lower use of surgery,” said senior investigator Dr. Nancy L. Keating in an email to Reuters Health.

“These data suggest that areas with lower surgery rates may benefit from higher rates of surgery,” she said.

Dr. Keating, from Harvard Medical School in Boston, said, “Resection has by far the highest chance of cure.”

But, she noted, “It may be that fear of harm (surgeons being concerned about causing poor outcomes) may be leading to relative underuse of this effective treatment.”

“While there are some patients for whom the risks certainly outweigh the benefits,” she added, “those patients may be fewer than some physicians recognize.”

Dr. Keating and colleagues studied a population-based cohort of more than 17,000 Medicare beneficiaries at least 66 years old who were diagnosed with stage I or II NSCLC during 2001 to 2005.

Using Surveillance, Epidemiology, and End Results (SEER) data, they compared areas with high and low rates of curative surgery for early stage lung cancer.

Fewer than 63% of patients had operations in low-surgery areas, whereas more than 79% did in high-surgery areas, according to a July 28th online paper in Cancer.

The high-surgery areas saw more operations on older patients and in those with chronic obstructive pulmonary disease (COPD).

The one-year lung-cancer-specific mortality rate was 12% in the high-surgery regions and 17% in low-surgery. The adjusted odds ratio for each 10% increase in the surgery rate was 0.86. There were similar findings for all-cause mortality.

Original article reference information:

Cancer. 2011 Jul 28. doi: 10.1002/cncr.26363. [Epub ahead of print]. Improved outcomes associated with higher surgery rates for older patients with early stage nonsmall cell lung cancer. Gray SW, Landrum MB, Lamont EB, McNeil BJ, Jaklitsch MT, Keating NL.