Big data was on display at the Society of Thoracic Surgeons’ annual meeting last week in Fort Lauderdale, Florida. Whether it was the National Cancer Database, the STS Databases, or SEER-Medicare Database, cardiothoracic surgeons are tackling common problems by analyzing cohorts of thousands of patients.
With the accessibility of the Public Use Files (PUF), all a surgeon needs is an appropriate question, an adequately trained statistician, and off they go!
The opioid epidemic has been front page news this year, as dependence and abuse continue to rise. An abstract titled, “Factors Associated With New Persistent Opioid Use After Lung Resection” analyzed 3026 opioid naive patients over a 4 year period for factors that may lead to dependence after an operation. Using the Truven Health MarketScan database, they found that 1 in 7 of these patients continued to fill opioid prescriptions greater than 90 days postoperatively. Patients having their resection via thoracotomy were almost twice as likely to become dependent, as compared to those resected thorascopically.
Understandably, we want our patients to recover comfortably and be able to return to routine daily life as soon as possible. It is our responsibility to monitor opioid medication use, prescribe in an appropriate fashion, and make sure these addictive medications are used only when necessary. As lead author Alexander Brescia, MD explained, “new persistent opioid usage is an iatrogenic postoperative complication.” All surgeons must begin treating it as such, and help curb this epidemic.
The next hot topic in the world of general thoracic surgery was outcomes after esophageal resection. This tends to be an issue of discussion year after year. With the exception of the extreme-high volume centers such as University of Michigan and University of Pittsburgh, most institutions don’t have enough internal volume to adequately evaluate esophageal cancer outcomes. The National Cancer Database (NCDB) provides an excellent opportunity to ask questions that can only be answered by analyzing several thousand patients at once.
There were several reports looking at overall outcomes and comparing minimally invasive to open approaches, but what happens to those patients who refuse esophagectomy all together? Dr. Sebron Wood Harrison attempted to answer this question with his study “Consequences of Refusing Surgery for Esophageal Cancer.”
The NCDB does not document specifically why a patient refuses to have an esophagectomy, but it does keep track of when a physician recommends the procedure and the patient does not follow that advice. Dr. Harrison was able to evaluate 708 such patients. When compared to patients that followed through with their physician’s advice and underwent esophagectomy, those who refused had a 30% decrease in median survival. While we can’t answer why the patients are refusing, this study did analyze who was refusing. Older patients, females, and non-white patients were the most likely to refuse. Is it because of lack of patient education? Distrust of physicians? Inadequate access to a thoracic surgeon? Future studies may answer this question.
There are clearly limitations to each database due to lack of granularity and reporting bias, but if the right question is asked to the right database, the results can be intriguing and help guide future treatment algorithms.
Dr. Brian Mitzman is a senior thoracic surgery fellow at the University of Chicago. He has an interest in refining minimally invasive approaches to advanced oncologic problems, and loves to teach anyone with a desire to learn. Twitter: @BrianMitzman
