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The Benefit of Expertise: Careful Pathologic Analysis from Lung Surgery Changes Treatments

http://blog.lungevity.org/2012/08/17/no ... -ut-study/

August 17th, 2012 - by Dr. Jack West

I suspect most surgeons are at least a little competitive: the lung surgeons I work with certainly are, both competing against each other and striving to improve their own outcomes. They track how many lymph nodes they are collect from their mediastinoscopies and lung cancer resections, knowing that there’s evidence that patients who have had more nodes removed at surgery tend to have better outcomes. Why? It may be that the better surgeons are the ones who collect more nodes and also just do a better surgery. It may be that these patients are more accurately staged and are more likely to receive the best guidance for post-operative therapy. And we can easily envision that there is a significant value in removing cancer-involved lymph nodes, rather than relying on post-surgical treatments to cure them.

My surgeon friends also explain, however, that their efforts are only a fraction of the process of nodal yield. Like a pitcher-catcher battery, the overall assessment of results after surgery depends on how well the pathologists do their job of retrieving lymph nodes from the tissue they’re given and how meticulously they look for cancer in the nodes they find. In fact, a study from the University of Tennessee in Memphis and just published in the Journal of Clinical Oncology now offers clear evidence that expertise and meticulous care by the pathologist has a significant impact.

The authors had noted that many patients they saw in Memphis appeared to be understaged because of less than expert surgical care and/or interpretation of the pathology material submitted. The deficiencies of surgery by many people who are doing lung cancer resections has been studied and are well known, but the contribution of the pathologist’s role to staging has been less clear. So the people who did this study used internal controls, in which the results from the initial pathology from 73 patients who underwent routine pathologic examination then had their pathology material processed by a more detailed process by an expert pathologist and assistant.

The expert pathologist was able to collect an additional 514 lymph nodes from the lung tissue of 66 of the 73 patients (90%), with cancer in 56 (11%) of those nodes. Among 50 who were considered node negative after initial evaluation, six (12%) patients were actually found to have positive lymph nodes after more accurate evaluation; 3 additional patients had previously undetected satellite tumor nodules. Altogether, in eight of the 73 patients (11%), the patient was “up-staged” by the addition of this new information.

While it’s always discouraging to learn that a cancer is more advanced than initially suspected, this more accurate staging would likely be the difference between a recommendation for adjuvant chemo or not, and for a more accurate assessment of prognosis. In addition, we might imagine that for some of them, this more accurate prognosis with revision of treatment recommendations could possibly be the difference between curative post-operative therapy or a patient not getting that recommendation and treatment.

All in all, this work further emphasizes the theme that expertise and meticulous care matter and can easily lead to important differences in treatment recommendations…and likely also help to explain why we so often find that patients treated by people with more expertise do better.



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