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Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resection
Micaela L Collins1,2, Gregory L Whitehorn1,2, Shale J Mack1,2
1Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pa.
Objectives:
Although sublobar resections have gained traction, wedge resections vary widely in quality. We seek to characterize the demographic and facility-level variables associated with high-quality wedge resections.
Methods:
The National Cancer Database was queried from 2010 to 2018. Patients with T1/T2 N0 M0 non-small cell lung cancer 2 cm or less who underwent wedge resection without neoadjuvant therapy were included. A wedge resection with no nodes sampled or with positive margins was categorized as a low-quality wedge. A wedge resection with 4 or more nodes sampled and negative margins was categorized as a high-quality wedge. Facility-specific variables were investigated via quartile analysis based on the overall volume and proportion of high-quality wedge or low-quality wedge resections performed.
Results:
A total of 21,742 patients met inclusion criteria, 6390 (29.4%) of whom received a high-quality wedge resection. Factors associated with high-quality wedge resection included treatment at an academic center (3005 [47.0%] vs low-quality wedge 6279 [40.9%]; P < .001). The 30- and 90-day survivals were similar, but patients who received a high-quality wedge resection had improved 5-year survival (4902 [76.7%] vs 10,548 [68.7%]; P < .001). Facilities in the top quartile by volume of high-quality wedge resections performed 69% (4409) of all high-quality wedge resections, and facilities in the top quartile for low-quality wedge resections performed 67.6% (10,378) of all low-quality wedge resections. A total of 113 facilities were in the top quartile by volume for both high-quality wedge and low-quality wedge resections.
Conclusions:
High-quality wedge resections are associated with improved 5-year survival when compared with low-quality wedge resections. By volume, high-quality wedge and low-quality wedge resections cluster to a minority of facilities, many of which overlap. There is discordance between best practice guidelines and current practice patterns that warrants additional study.
Insights
High-quality wedge resections in lung cancer patients improve 5-year survival. Quality varies widely, with high-quality procedures concentrated in a few specialized centers, indicating a need to address practice pattern disparities.
Area of Science:
- Thoracic Surgery
- Surgical Oncology
- Pulmonary Medicine
Background:
- Sublobar resections, including wedge resections, are increasingly utilized for early-stage non-small cell lung cancer.
- However, the quality of wedge resections can vary significantly, impacting patient outcomes.
- Understanding factors associated with high-quality procedures is crucial for improving surgical care.
Purpose of the Study:
- To identify demographic and facility-level factors associated with high-quality wedge resections for early-stage non-small cell lung cancer.
- To compare survival outcomes between high-quality and low-quality wedge resections.
- To analyze the distribution of high-quality and low-quality wedge resections across healthcare facilities.
Main Methods:
- Analysis of the National Cancer Database (2010-2018) for patients with resectable T1/T2 N0 M0 non-small cell lung cancer (≤2 cm).
- Definition of high-quality wedge resection (≥4 nodes sampled, negative margins) versus low-quality (0 nodes sampled or positive margins).
- Investigation of facility-level variables using quartile analysis based on procedure volume and quality.
Main Results:
- A total of 21,742 patients were included; 29.4% received high-quality wedge resections.
- Treatment at an academic center was associated with higher rates of high-quality wedge resection (47.0% vs 40.9%, P < .001).
- High-quality wedge resections demonstrated improved 5-year survival (76.7% vs 68.7%, P < .001) compared to low-quality resections.
- The majority of both high-quality and low-quality wedge resections were performed at a minority of facilities.
Conclusions:
- High-quality wedge resections are linked to significantly better 5-year survival rates.
- Both high-quality and low-quality wedge resections are concentrated in a limited number of healthcare facilities.
- A notable discrepancy exists between established best practice guidelines and current clinical practice patterns for lung cancer wedge resections.
