National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma

Our plain-English summary of National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma, by V. Verma, C.A. Ahern, C.G. Berlind, et al (Journal of Thoracic Oncology, 2017).

The study

• Authors: V. Verma, C.A. Ahern, C.G. Berlind, W.D. Lindsay, S. Sharma, J. Shabason, M.J. Culligan, S. Grover, J.S. Friedberg, C.B. Simone
• Journal: Journal of Thoracic Oncology
• Published: 2017;12(11):1704-1714
• Cited by: 66 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Introduction: Controversy exists regarding the optimal surgical technique for malignant pleural mesothelioma (MPM). We evaluated national practice patterns and outcomes of MPM treated with extrapleural pneumonectomy (EPP) versus lung-sparing extended pleurectomy/decortication (P/D).

Methods: The National Cancer Database was queried for patients with newly diagnosed MPM undergoing EPP or P/D. Multivariable logistic regression ascertained clinical factors independently associated with P/D receipt. Kaplan-Meier analysis was used to evaluate overall survival (OS) between cohorts; multivariable Cox proportional hazards modeling was used to evaluate factors associated with OS. Survival was then evaluated between propensity-matched populations.

Results: Overall, 1307 patients (271 undergoing EPP [21%] and 1036 undergoing P/D [79%]) met the criteria. Patients receiving P/D were older (p = 0.028), whereas those undergoing EPP were more likely to live in a rural area (p = 0.044), live farther from the treating facility (p = 0.039), and receive treatment at an academic center (p = 0.050). There were no differences between cohorts in 30-day readmission or mortality (all p > 0.05). The median OS times in the EPP and P/D groups were 19 versus 16 months, respectively (p = 0.120); no differences were observed after propensity matching (p = 0.540).

Conclusions: In this largest analysis of its kind to date, findings from this contemporary cohort demonstrate that P/D comprised most surgical procedures for MPM. Procedure type was influenced by sociodemographic and geographical factors, without observed differences in survival or postoperative mortality and readmission rates between techniques.

Copyright © 2017 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

In plain English

This study used the US National Cancer Data Base to compare two operations for malignant pleural mesothelioma. One was extrapleural pneumonectomy (EPP), a lung-sacrificing operation. The other was lung-sparing extended pleurectomy/decortication (P/D). The authors reviewed 1,307 patients from the 2004-2012 database file: 271 (21%) had EPP and 1,036 (79%) had P/D. The study did not examine asbestos exposure. Older patients and urban residents were more likely to have P/D. EPP was more common for rural patients, those living farther from the hospital, and those treated at academic centers. Median overall survival from diagnosis was 19 months in the EPP group and 16 months in the P/D group, not a statistically significant difference (p=0.120). After propensity matching, a statistical method of pairing similar patients, both groups had a median of 19 months (p=0.540). Thirty-day readmission (7% vs 5%) and 30-day death rates (5% vs 5%) did not differ significantly. The authors concluded that the findings support either operation as a viable option. They noted that a retrospective study cannot control for treatment-selection biases and that surgical definitions lack standardization.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a national cancer registry (National Cancer Data Base), with multivariable regression, Kaplan-Meier survival analysis and propensity score matching
• Who was studied: 1,307 patients in the United States with newly diagnosed malignant pleural mesothelioma (2004-2012 database file): 271 (21%) underwent EPP and 1,036 (79%) underwent lung-sparing extended P/D. Patients with metastatic (M1) disease, palliative care, improper staging, or other or unknown surgery types were excluded.
• Exposure: No asbestos or fiber exposure was studied. The comparison was between two types of surgery: extrapleural pneumonectomy (EPP) and lung-sparing extended pleurectomy/decortication (P/D).
• Main results:
  • Overall survival was measured from the date of diagnosis to the date of death or last contact, not from the date of surgery.
  • Older patients were more likely to undergo P/D (p=0.028), as were urban patients (p=0.036). EPP was more likely for rural patients (p=0.044), those living farther from the facility (p=0.039), those treated at academic centers (p=0.050), and those treated in the Pacific and West North Central regions (p<0.05).
  • 3-year overall survival was 26.5% (95% CI 21.4%-32.7%) in the EPP group vs 19.9% (17.5%-22.7%) in the P/D group. 5-year overall survival was 9.9% (6.2%-15.9%) vs 11.1% (9.1%-13.7%). Median overall survival was 19 vs 16 months (p=0.120), not statistically significant.
  • After propensity matching (241 EPP and 441 P/D patients), there was no statistical difference in overall survival: median 19 vs 19 months (p=0.540).
  • 30-day readmission was 7% in the EPP group and 5% in the P/D group (p=0.292). 30-day mortality was 5% vs 5% (p=0.999).
  • In the propensity-matched population, 30-day readmission was 8% vs 5% (p=0.370) and 30-day mortality was 5% vs 3% (p=0.322).
  • In the whole cohort, after adjustment, worse overall survival was associated with older age, male gender, urban residence, treatment at a community center, and non-metastatic stage IV disease. Better survival was associated with chemotherapy and higher total radiation dose. Type of surgery was not statistically significant.
• The authors' conclusion: The authors concluded that most operations in this dataset were lung-sparing extended P/D, and that sociodemographic and geographical factors were associated with which operation patients received. They found no apparent differences in survival, postoperative mortality or readmission between the techniques, which in their view supports either technique as a viable treatment option.
• Limitations the authors state:
  • As a retrospective study, it cannot control for biases in who received which treatment.
  • Surgery types were defined from database codes, and neither operation is universally standardized, especially extended P/D. Miscoding and interpretation bias are possible.
  • Some lung-sparing cases may have been more palliative than definitive in intent, which might have artificially lowered P/D survival.
  • Performance status is not coded, so the link between chemotherapy and survival may reflect which patients were given chemotherapy.
  • Only Commission on Cancer-accredited facilities contribute data, so findings may not represent the whole US population.
  • The database does not record surgical margin status, pulmonary function tests or salvage therapies, any of which could affect survival.
  • Many histology values were unknown or not otherwise specified, which may affect the propensity matching and survival analyses.
  • Propensity matching cannot account for all confounders and did not include socioeconomic parameters.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pneumonectomy, Pleural Mesothelioma, Extrapleural Pneumonectomy (EPP), Pleurectomy/Decortication (P/D), Overall Survival.

Related studies

• National Cancer Database Report on Pneumonectomy Versus Lung-Sparing Surgery for Malignant Pleural Mesothelioma — Z.M. Abdelsattar, S.A. Saddoughi, et al. (2018)
• Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study — T. Treasure, L. Lang-Lazdunski, et al. (2011)
• Treatment of malignant pleural mesothelioma with chemotherapy preceding versus after surgical resection — V. Verma, C.A. Ahern, et al. (2019)
• Facility volume and postoperative outcomes for malignant pleural mesothelioma: A National Cancer Data Base analysis — V. Verma, C.A. Ahern, et al. (2018)
• A systematic review of lung-sparing extirpative surgery for pleural mesothelioma — E. Teh, F. Fiorentino, et al. (2011)
• Second surgery for recurrence of malignant pleural mesothelioma after extrapleural pneumonectomy — L. Politi, G. Borzellino (2010)

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