| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
|
Interact CardioVasc Thorac Surg 2009;9:925-931. doi:10.1510/icvts.2009.211219 © 2009 European Association of Cardio-Thoracic Surgery
Lung function evaluation before surgery in lung cancer patients: how are recent advances put into practice? A survey among members of the European Society of Thoracic Surgeons (ESTS) and of the Thoracic Oncology Section of the European Respiratory Society (ERS)
a Service de Physiologie et d'Explorations Fonctionnelles, Pôle de Pathologie Thoracique, Nouvel Hopital Civil, Hopitaux Universitaires de Strasbourg, BP426, Strasbourg Cedex 67091, France Received 7 May 2009; received in revised form 22 July 2009; accepted 21 August 2009
*Corresponding author. Tel.: +33 (0)3 88 69 55 08 79.
Key Words: Lung cancer; Lung surgery; Guidelines; Survey In recent years, an abundant literature related to preoperative evaluation of lung cancer patients has been published. Therefore, the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) agreed to form a task force with the aim of developing new guidelines and recommendations to evaluate the fitness of lung cancer patients undergoing radical treatment. One of the first priorities of the task force members was to assess the state-of-the-art of functional evaluation and perioperative treatment of these patients. A multiple-choice survey covering several aspects of this subject was designed and administered online. This survey aimed at assessing how the recent advances in preoperative evaluation of lung function have been put into practice. More specifically, we focused on the cardiologic evaluation before lung resection, the role of diffusing capacity of the lung for carbon monoxide (DLCO) in predicting complications, and the interpretation of split function studies. We asked the physicians to specify the role of exercise tests in their algorithms, and how high-tech or low-tech exercise tests are selected in their current practices. The perioperative management of patients was also considered, with questions aimed at investigating the indications for physiotherapy and rehabilitation, and the criteria for admission in intensive care units (ICU). Eventually, since several studies showed there is a positive impact of specialization and volume on the results of surgical cancer treatment, physicians were invited to give their opinion on the qualification of the surgeon as well as the specialization of the centers required to manage lung cancer patients.
A web-based questionnaire was designed by the 14 experts of the ERS/ESTS Task Force. All members of the ESTS and of the Oncology group of the ERS were invited to respond from December 2007 to April 2008 using a commercially available, online survey designer (www.surveymonkey.com). The questionnaire consisted of 47 questions covering the various issues addressed by the task force. In this article, we focused on preoperative assessment and patients' care management, which were covered by 32 questions.
The number of respondents to the 32 questions of this survey ranged from 179 to 265 (6.8% and 17.9% of the 1485 successfully delivered E-mails, respectively). This survey reflects the practice of physicians from 38 countries (87% of European countries). Interpretation of these data should of course take into account who provided the responses. This survey reflects mainly the practice of surgeons who accounted for 72% of respondents (including 7% of general surgeons), chest physicians accounting for 27% of respondents. Respondents worked for the most part in academic hospitals (72%), but also in community-based hospitals (20%), and in private hospitals (7%) (Fig. 1). Responses from physicians working in academic hospitals did not differ significantly from those of physicians working in community-based or in private hospitals. However, it is likely, given the low response rate, that this survey is biased towards physicians and surgeons interested in the functional assessment before lung cancer surgery, and may not reflect all the ESTS and ERS members' opinion.
Is the preoperative work-up standardized, and who performs it? It is worth noting that almost half of physicians have a multidisciplinary approach to the preoperative work-up, as recommended in guidelines [1, 2]. Nonetheless, for one-third of the respondents of this survey, the preoperative work-up is still performed by chest physicians alone (Table 1). Another interesting result is that more than half of physicians performed a standardized functional evaluation before lung cancer surgery. However, only one-third of respondents follows published recommendations. The latter point suggests that published guidelines might be outdated, may conflict with the physicians' own experience and opinion, or cannot be implemented in some centers because of the lack of availability of technical resources, or because of economic and logistic issues. Whatever the reasons, this also indicates that more research is needed to improve, validate and implement recommendations.
Cardiologic evaluation Few guidelines provided detailed recommendations about the cardiologic evaluation before lung resection [1, 2]. This shortcoming likely explains some results of this survey, such as the divergent opinion about recommendation of β-blockers before lung surgery (29% recommend them in patients with known coronary disease, 31% in patients with known or suspected coronary disease, and 35% respondents never recommend them) and the high rate (55%) of systematic use of echocardiography (Table 2). The ERS/ESTS task force [3] concluded that patients with ischemic heart disease generally do not benefit from newly prescribed perioperative β-blockade, but that β-blockers should be continued in patients who are already taking them and may be beneficial as new therapy in very high-risk patients. Echocardiography should be obtained only when valvular disease, left ventricle dysfunction or pulmonary hypertension is suspected, but should not be done systematically. Another significant result is the under-use of cardiac indexes. Cardiac risk for lung resection can be stratified through validated indexes based on simple items, such as the patient's history, physical examination and electrocardiogram [4–6]. The British Thoracic Society (BTS) and the American College of Chest Physicians (ACCP) [1, 2] recommend the use of ACC/AHA guidelines [5] and the ERS/ESTS task force recommend the revised cardiac risk index (RCRI) index [3]. However, two-thirds of participants do not use these indexes, which also define when the patient should be referred to the cardiologist. Eventually, high-technology exercise tests are prescribed by most participants (75% of surgeons and 57% of physicians) to assess concomitantly the cardiac and the pulmonary status of their patients, additional cardiologic tests being prescribed only if a coronary disease is detected. A lower proportion of surgeons (17%) and physicians (36%) always prescribe additional cardiologic tests to patients undergoing cardiopulmonary exercise test (CPET).
Lung function tests Despite results of recent studies demonstrating that diffusing capacity is important in predicting postoperative complications, even in patients with a normal forced expiratory volume in one second (FEV1) [7, 8], DLCO is assessed in all patients only by one-third of respondents (Table 3). Most physicians (57%) assess DLCO only in patients with compromised lung. This seems somewhat inconsistent with the subsequent responses showing that 74% of participants think DLCO is a strong predictor of outcomes. Consequently, the position of DLCO needs to be clearly defined in the future guidelines.
The use of split function studies is well established in current practice. However, two points of interpretation are less known: segment counting is recommended rather than scintigraphic techniques before lobectomy, and ventilation and perfusion scintigraphy are equivalent in predicting predicted postoperative (ppo) lung function [9, 10]. Unsurprisingly, for 77% of respondents, the main role of exercise tests is to avoid lung resection in patients who perform below a specific cut-value (Table 4). This clearly underlines the weight of this test in the decision to operate or not. Physicians also use this test in less ‘validated’ indications: to discriminate a high-risk population who will be sent to the ICU after the procedure (49%) or to whom preoperative rehabilitation will be proposed (28%). Exercise tests are prescribed by 24% of physicians in all patients before lung cancer surgery.
Most respondents prescribe integrated cardiopulmonary assessment (CPET) after calculation of ppo values, following BTS or ACCP guidelines. Only a quarter of them use high-tech exercise tests before split function studies, following recommendations by Bolliger and Perruchoud [11]. However, cut-off values used by physicians differ from those recommended by Bolliger and Perruchoud, since only 20% of respondents perform exercise tests if FEV1 and DLCO are lower than 80%. Exercise tests appear to be proposed to patients with severely compromised lung function, the most used cut-off values being around 40% of predicted for both FEV1 and DLCO. This likely explains that only 10–30% of patients have a high-tech exercise test according to the majority of respondents, even though these tests are available in 75% of their centers. The high variability of practice in exercise tests may be partly due to a lack of availability of CPET in some centers, but also emphasizes the current debates about indications of high-technology tests. Low-technology exercise tests usually are part of current practice, as demonstrated by the very low percentage of respondents who never perform them (6.5%) (Table 5). However, these tests are prescribed in very different situations, e.g. in patients with ppoFEV1 or ppoDLCO values lower than 40% (33%), as a screening test in patients with FEV1 or DLCO lower than 80% (28%), or as an alternative to CPET (20%). The 6-min walk and the stair climbing test are the most frequently prescribed low-technology tests, the shuttle walk test being used by only 6% of physicians. Interestingly, low-technology tests belong to the first stage screening for 24% of surgeons, but only for 9% of chest physicians. In addition, 42% of surgeons choose stair climbing, compared to 13% of chest physicians. Chest physicians prefer the 6-min walk test. This test is prescribed by 56% of chest physicians, but only by 24% of surgeons. It is worth noting that the 6-min walk test is widely used whereas its association with postoperative outcome after lung resection is highly controversial [12–14]. The recent literature on the stair climbing test [15] appears to be favorably received since 64% of respondents think this test could predict lung cancer outcome, despite standardization is regarded as insufficient by 75% of surgeons and 92% of chest physicians. Taken as a whole, these results underline the need to clarify both indications and limits of low-technology exercise performed before lung resection.
Scoring systems Several multifactorial scoring systems and predictive models have been published recently with the objective of providing a standardized risk assessment to compare outcomes across different hospitals. In this survey, almost 75% of physicians do not use them, either because they are too difficult to calculate (52%) or because they were felt not to add any information (18%) or being inaccurate and not useful (4%). The role and limitations of these systems for selection purposes still need to be clarified to limit their improper use in surgical lung cancer patients. Aim and indication of physiotherapy and rehabilitation Physiotherapy, as usually delivered in a multidisciplinary rehabilitation context, is not widely reported in literature [16]; nonetheless, 80% of respondents have declared to refer their patients to both pre- or post-surgery, in order to decrease the risk of postoperative atelectasis (75%), decrease the risk of postoperative respiratory insufficiency (72%), facilitate postoperative bronchial toilette (72%), improve functional exercise capacity (57%), improve long-term quality of life (47%), and improve immediate postoperative pulmonary volumes (40%). Hence, physicians assign substantial benefit to pulmonary rehabilitation, that is highly probable but not firmly established in surgical patients with lung cancer [17, 18]. In particular, specific characteristics of patients (i.e. underlying comorbidities and/or functional status) who are likely to benefit from rehabilitation course still need to be elucidated.Admission to ICU after surgery Patients with pneumonectomy necessitate admission to ICU according to 80% of respondents. Opinions differ regarding admission of patients with lobectomy or minor resection: most respondents (53%) said patients may be transferred to the surgical ward in stable cardiorespiratory condition after a short stay in a high dependency unit/intermediate care unit (HDU/IntCU); 37% of respondents said patients should be admitted in HDU/IntCU for at least 24 h, whereas 12% of respondents felt patients should be admitted in ICU for at least 24 h. Recently, published recommendations by the ERS/ESTS task force [3] are that in an emergency situation, patients requiring support for organ failure (i.e. ventilatory mechanical assistance) should be admitted to ICU. Patients undergoing complex pulmonary resection, those with marginal cardiopulmonary reserve and those with moderate to high risk should be admitted to HDU. Among the numerous outcomes proposed by the questionnaire and the physicians themselves, measurement of long-term impairment of quality of life was the highest priority for 89% of respondents. Indeed, the commonly used outcomes, especially pulmonary function assessment, are poorly correlated with symptoms and quality of life after lung resection [19, 20]. This interest in quality of life assessment should encourage initiation of research projects in this area. Other responses included the need of home care after discharge (55%), how hospital costs are influenced by a complicated postoperative period (33%), long-term psychological impairment after surgery (33%), and the expected period of inability to work for medical reasons after surgery (31%).Who should treat thoracic patients and where these patients should be treated? There is a clear consensus asserting that lung cancer patients should be treated in specialized centers and that minimum criteria should be met to allow a hospital to permit lung cancer surgery. In addition, there is an agreement on the need of a European official organization to develop and verify credentials to guarantee the patients to be operated under high quality surgical standards. The only constraint emphasized by the respondents is that the official organizational body should be representative of the profession (Fig. 2).
This survey provides a snapshot of the opinions of 200 physicians with a great commitment to treating lung cancer, although it does not describe in detail the current practice of the preoperative assessment of lung cancer patients. The responses to the questionnaire help define the lack of consensus in some areas as well as difficulties in putting existing recommendations into practice. The results of this survey warrant the revision of published guidelines or the development of new ones to provide clinicians with clear, updated, and pragmatic recommendations [21, 22]. Indeed, information derived from this analysis was taken into consideration during preparation of the ERS-ESTS guidelines for evaluating fitness for radical treatment of lung cancer patients [3]. This questionnaire is planned to be repeated after the publication of the ERS/ESTS guidelines [3] to assess their impact on clinical practice.
The authors wish to thank Eveline Internullo, who implemented the questionnaire in the survey designer.
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
Top
Questionnaire design
Respondents
