November 16, 2001

High volume boosts survival rate at VICC

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This chart illustrates the three-year survival rate of Vanderbilt-Ingram patients diagnosed with lung cancer at stages where surgery is typically a component of therapy. Vanderbilt’s survival rate is consistently higher, in large part due to differences in treatment regimen between community hospitals and academic centers that do a large number of lung surgeries each year. (Illustration by Matt Gore.)

High volume boosts survival rate at VICC

When it comes to complicated cancer surgery, the old adage “practice makes perfect” may well hold true.

Evidence is mounting that patients with lung cancer who undergo lung surgery as part of their treatment are more likely to survive if treated at a facility with the greatest experience in performing these surgeries. The same holds true for patients with esophageal cancers, according to several studies published in the medical literature.

Vanderbilt’s thoracic surgeons perform well over 500 chest surgeries each year, more than any other practice in Tennessee and more than most programs in the Southeast. Among those are more than 100 lung cancer surgeries and more than 40 esophageal cancer surgeries annually. Both figures put Vanderbilt-Ingram Cancer Center squarely in the “high-volume center” category.

“It is important for patients to understand that lung cancer is a disease that is best treated by specialists,” said Dr. John R. Roberts, Ingram Assistant Professor of Cancer Research, chief of Thoracic Surgery and a member of Vanderbilt-Ingram’s multi-disciplinary thoracic cancer team.

“It is a complex disease, but we have many promising new therapies and combinations of therapy now that were unavailable just a few years ago. We remove at least one cancer every week from patients who were told they were ‘incurable.’ Even if the cancer truly is incurable, that does not mean it is untreatable.”

The most recent study supporting the idea that quality of lung cancer surgery correlates with the experience of the institution is a study published in the New England Journal of Medicine earlier this year by investigators at Memorial Sloan-Kettering Cancer Center.

Senior author Colin Begg and his colleagues looked at 2,118 patients diagnosed and treated for early-stage non-small-cell lung cancer. They examined survival rates at 30 days, two years and five years after surgery.

The researchers found that the average five-year survival was 38 percent, but survival ranged from 33 percent at hospitals that perform eight or fewer of these procedures to 44 percent at centers that perform between 67 and 100 such surgeries.

In addition, mortality in the period 30 days after surgery was twice as high at the lowest volume centers than at the highest volume centers (6 percent vs. 3 percent).

At Vanderbilt, three-year survival for Stage 1 lung cancer is 77 percent, compared to 55 percent nationally (data from the National Cancer Database).

The difference is even wider for Stage 2 and Stage 3A cancers. For Stage 2, Vanderbilt’s three-year survival rate is 93 percent, compared to a national average of 34 percent. For Stage 3A, Vanderbilt’s three-year survival is 49 percent, compared to 16 percent nationally.

Roberts attributes much of that difference to a difference in treatment regimen between community providers and an academic center that performs a high number of lung cancer surgeries each year.

“Early stage cancer is best treated with surgery alone,” Roberts said. “In more advanced stages, the standard in the community is to do chemotherapy and radiation alone, whereas here, we typically follow chemotherapy and radiation with surgery.

“It’s also important for patients to know that because of our level of experience, we are willing to provide surgery to older or frailer patients who are not considered surgical candidates elsewhere.”

A lung cancer patient at Vanderbilt also faces a lower-than-average risk of post-surgery complications as reflected by perioperative mortality data, Roberts said.

At Vanderbilt, perioperative mortality after removal of a lung lobe is 0.4 percent, compared to a national average of 2.67 percent, Roberts said. Vanderbilt’s perioperative mortality for lung removal is in line with data for high-volume centers reported in the New England Journal of Medicine study, at 3.2 percent, compared to a national average of 6.75 percent.

For esophageal cancers, the association between better outcomes and experience of the treating facility has been reported several times, including in 1999 in the Journal of the American Medical Association, in 2000 in the Journal of Thoracic and Cardiovascular Surgery and early this year in Cancer.

In these three studies, for example, perioperative mortality after esophagectomy ranged from between 12 percent and 17 percent in low-volume centers to between 3 percent and 5 percent in high-volume centers. Vanderbilt’s perioperative mortality rate for esophagectomy stands at about 2 percent.

The treatment of cancer is advancing so quickly, patients are well advised to obtain a second opinion and investigate what is available to them on clinical trials at nationally recognized cancer centers, experts including the National Cancer Institute say.

This is especially true for lung cancer, where advances are being made rapidly, Dr. David Carbone, Ingram Professor of Cancer Research, told a group of lung cancer survivors and their families gathered recently at Vanderbilt for “Living with Lung Cancer” workshop.

Dr. Mathew Ninan, assistant professor of Cardiovascular and Thoracic Surgery, agreed.

“The odds for beating lung cancer depend on proper initial staging and assessment,” Ninan said. “Simply put, your first chance is your best chance. So it is important that patients choose their provider wisely.”

Several effective chemotherapies are available now that did not exist just a few years ago. In addition, a new class of “biologic agents” that specifically target cancer cells are being developed for a number of tumors, including lung cancer, Carbone told the workshop participants.

The Vanderbilt-Ingram Cancer Center, as the only NCI-designated Comprehensive Cancer Center in Tennessee, offers about 150 of the most promising new therapies for cancer through clinical trials, including between 20-30 open or pending trials for lung cancer at any one time.

In addition, Vanderbilt-Ingram is the only Specialized Program of Research Excellence in Lung Cancer in the Southeast. This distinction by the NCI supports a multi-disciplinary initiative in cutting-edge research in lung cancer that is considered quickly “translatable” to patient care. There are only six specialized programs in lung cancer in the United States.